Rheumatoid arthritis (RA) is a chronic inflammatory autoimmune disease that affects the lining of the joints (synovium), resulting in pain, swelling, and stiffness. Symptoms occur bilaterally and in multiple joints. The hands, wrists, and feet are most commonly affected, though any joint is susceptible to RA. Additionally, the chronic inflammation caused by RA has the potential to damage other tissues, including the skin, eyes, lungs, and heart.
In this article:
- Overview
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Disturbed Body Image
- Impaired Physical Mobility
- Impaired Sitting/Standing
- Risk for Falls
Overview
It is believed that RA develops due to an environmental trigger (smoking, pollution, viruses) in genetically susceptible people. The body’s immune system responds erratically and produces RA autoantibodies, causing joint pain and other symptoms.
Juvenile idiopathic arthritis (JIA), formerly known as juvenile rheumatoid arthritis, can occur in children prior to 16 years of age and is the most common form of arthritis in this age group. The goals of care remain the same as with RA. Early recognition and treatment offer the best chance of long-term remission.
RA is characterized by periods of flares and remissions. Although they may be difficult to predict, flares can be kept to a minimum with proper treatment, and long-term damage to the joints can be prevented or lessened.
Nursing Process
RA is often managed by a specialist called a rheumatologist. Nurses best support patients with RA by educating them on the disease process, the importance of adhering to their medication regimen, pain control, and preventing extra-articular complications.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section, we will cover subjective and objective data related to rheumatoid arthritis.
Review of Health History
1. Assess the patient’s general symptoms.
RA develops slowly for most patients, and fever, weakness, and malaise may occur before joint symptoms. Specific manifestations of RA include:
- Painful, tender, warm, and swollen joints on both sides of the body
- Stiffness, especially in the mornings or after long periods of inactivity that may last for hours
- Decreased range of motion
If RA progresses to other organs, the patient may report:
- Dryness, pain, or redness of the eyes or changes in vision
- Dry, inflamed gums or mouth irritation
- Respiratory symptoms
- Nerve damage
2. Determine the patient’s nonmodifiable risk factors.
The exact cause of RA is unknown, but researchers believe a significant genetic component exists. Women and individuals with a first or second-degree relative with RA are also at a higher risk.
3. Review the patient’s medical history.
Infectious agents have been identified as causes of RA. Examples include:
- Epstein-Barr virus
- Rubella virus
- Periodontal disease
4. Identify modifiable risk factors that may increase the risk of RA.
Cigarette smoking is the most significant risk factor for RA. A diet high in red meat and sodium and low in fiber also seems to increase the risk. The risk for RA also increases for patients with a BMI > 25. The patient’s occupation may also be a contributing factor, as exposure to asbestos, textile dust, and silica is associated with RA.
5. Inquire about the patient’s ability to perform ADLs.
Joint pain and swelling may hinder the patient’s ability to dress, perform personal hygiene, or ambulate.
Physical Assessment
1. Assess the musculoskeletal status.
RA’s defining trait is joint involvement. Inflammation of the affected joints manifests as pain, swelling, and reduced range of motion (ROM). Palpate joints for tenderness and perform passive ROM to assess for stiffness. Note that stiffness usually improves with activity in RA. Certain joints that may be difficult to palpate, such as the hips, neck, and shoulders, may present with pain with motion.
2. Inspect for visual deformities.
Many patients will present with deformities of the fingers and hands, such as ulnar deviation, boutonniere deformity, and swan-neck deformities. The knees may accumulate fluid and synovium. Hammertoes may be seen in the feet.
3. Monitor for extra-articular involvement.
RA can affect the skin, heart, lungs, eyes, and several other organs. The nurse should remain aware of symptoms such as cardiac abnormalities, shortness of breath, infections, nerve pain, and eye changes, among others. Rheumatoid nodules are another extra-articular finding that develops under the skin and on organs. They are firm and usually painless.
Diagnostic Procedures
1. Send blood samples for laboratory testing.
Three categories of laboratory testing are useful for diagnosis or monitoring disease activity:
- Inflammatory markers become elevated in relation to disease activity.
- Erythrocyte sedimentation rate (ESR)
- C-reactive protein (CRP) level
- Hematologic parameters are monitored for disease activity and treatment effectiveness.
- Complete blood count (CBC)
- Immunologic parameters are autoantibodies present in many patients with RA.
- Rheumatoid factor (RF) assay
- Antinuclear antibody (ANA) assay
- Anti−cyclic citrullinated peptide (anti-CCP) antibody
Note: RF is not specific to RA as it is found in other connective tissue and autoimmune disorders. Anti-CCP is the test used for the clinical diagnosis of RA.
2. Review diagnostic criteria.
The 2010 European Alliance of Associations for Rheumatology (EULAR)/American College of Rheumatology (ACR) classification system is a score-based algorithm that diagnoses RA on the following four factors:
- Involvement of joint
- Serology results (RF and anti-CCP)
- Acute-phase reactant results (CRP and ESR)
- Patient’s self-reported duration of symptoms (< 6 weeks or ≥ 6 weeks)
3. Consider imaging scans of the joints.
In RA, plain X-rays are the preferred imaging approach. Magnetic resonance imaging (MRI) offers a more accurate assessment and earlier lesion detection than radiography, though is more expensive. Ultrasonography (US) can identify cysts and effusions in difficult-to-reach joints, such as the shoulder and hip, or in obese patients. US is also used to guide injections, aspiration, or biopsies.
4. Consider joint aspiration.
Joint aspiration of synovial fluid is not required for all patients, but it can be used to make a definitive diagnosis or rule out other conditions, such as gout.
5. Determine the patient’s disease activity score.
The nurse can utilize a disease activity measurement tool that calculates the patient’s current RA disease activity as low, moderate, or severe. The measure includes the number of tender joints and swollen joints and the current CRP level. This score is used to assess the effectiveness of treatment until remission (if possible) is reached.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section, you will learn more about possible nursing interventions for a patient suffering from rheumatoid arthritis.
Managing Acute Flares
1. Administer medications as ordered.
There is no cure for RA. The goal of RA treatment is to reduce disease progression and activity and manage symptoms. Early administration of disease-modifying antirheumatic drugs (DMARDs) is crucial to delay or prevent joint damage. Methotrexate is the most common DMARD. Corticosteroids are given to manage flares, and some patients require long-term low doses to control symptoms. Nonsteroidal anti-inflammatory drugs (NSAIDs) are frequently used to control pain and swelling.
2. Instruct on pain management.
Medications are used to control pain, and they may include the above-mentioned medications as well as acetaminophen, tramadol, and opiates. Advise the patient on nonpharmacologic pain methods such as heat or cold application, massage, acupuncture, and exercise.
3. Consider surgical options.
Some patients may choose a surgical approach to manage severe joint damage or loss of function. Surgical options include:
- Removal of the synovium (synovectomy)
- Removal of the tendon sheath (tenosynovectomy)
- Tendon realignment
- Joint replacement (arthroplasty)
- Joint fusion (arthrodesis)
4. Manage fatigue.
Fatigue is a common and debilitating symptom of RA and its complications (anemia, heart disease). The nurse can encourage energy conservation techniques during flares, such as prioritizing sleep, taking breaks during tasks, and exercising, even though it may seem counterintuitive.
Preventing Flares and Complications
1. Educate on lifestyle modifications.
Managing stress, eating a healthy diet, quitting smoking, and maintaining a healthy weight are recommended to reduce RA flares.
2. Monitor for infections.
DMARDs and corticosteroids used to manage RA work by suppressing the immune system, making the patient more susceptible to infections. The disease itself also increases the risk of infection. Advise on recommended vaccinations (patients on a TNF inhibitor must avoid live vaccines), and preventing infection through handwashing, mask-wearing, and avoiding large crowds. When the patient has an active infection, DMARDS may be temporarily paused.
3. Educate on complications.
DMARDS, corticosteroids, NSAIDS, and the disease process itself carry risks. Anemia, pulmonary conditions, coronary artery disease, malignancy, and osteoporosis are just a few complications the patient may encounter.
4. Educate on flare recognition.
Educate the patient that increased joint pain, swelling, stiffness, and fatigue are signs of an RA flare. Flares can last a few days to several weeks. The patient can attempt nonpharmacologic methods like rest or heat to reduce symptoms, but an increase in medication may be necessary, and contacting their provider is advised.
5. Review the patient’s quality of life.
Depression is a potential complication of RA due to disability, chronic pain, and poor quality of life. The nurse may need to refer the patient to a mental health professional or support group to cope.
Preserving Joint Health
1. Recommend adaptive equipment.
Patients with RA may lose joint mobility and strength required to complete ADLs. Adaptive equipment such as electric jar or can openers, large or angled utensils, dressing aids, shower chairs, doorknob covers, and more can make everyday tasks easier.
2. Refer the patient to a physical or occupational therapist.
A physical therapist can create a therapeutic exercise program tailored to the patient with joint damage, pain, and decreased ROM. Occupational therapists teach patients how to decrease tension and stress on the joints and suggest adaptive equipment and home modifications. They may also recommend splits or orthotic devices.
3. Educate on joint protection.
Avoiding joint overuse or improper movement is important to preserve joint health. Instruct on the following:
- Good body posture
- Limiting joint use during flares
- Modifying tasks as needed
- Appropriate use of splints and braces
Nursing Care Plans
Once the nurse identifies nursing diagnoses for rheumatoid arthritis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section, you will find nursing care plan examples for rheumatoid arthritis.
Chronic Pain
Tissues become inflamed, causing damage to joints and chronic pain and stiffness in patients who have RA.
Nursing Diagnosis: Chronic Pain
Related to:
- Joint damage
- Inflammation
As evidenced by:
- Verbalization of pain
- Stiffness
- Fatigue
- Guarding behavior
- Erythema and swelling of the joints
- Decreased range of motion
Expected outcomes:
- Patient will verbalize relief or control of pain.
- Patient will be able to participate in activities and perform self-care.
- Patient will verbalize two strategies to control pain.
Assessment:
1. Assess the location of the pain.
The primary complaint of patients suffering from RA is chronic pain and stiffness of the joints. Nurses can keep track of tender and swollen joints using a Disease Activity Score calculator.
2. Assess the effects of pain on activities and ADLs.
Assess when the pain and stiffness occurs and if it interferes with the patient’s ability to perform ADLs, hobbies, and exercise.
Interventions:
1. Recommend firm mattresses and supportive pillows.
Soft sagging mattresses and soft pillows prevent the maintenance of proper body alignment, placing further stress on the affected joints and preventing restful sleep.
2. Consider alternative therapies.
Massage, acupuncture, meditation, and more can help reduce cortisol levels, the stress hormone, which in turn reduces inflammation.
3. Recommend warm, moist heat.
Heat promotes muscle relaxation and mobility, decreases pain, and relieves morning stiffness. Methods such as using paraffin gloves and whirlpool baths will provide sustained heat to reduce pain and improve the range of motion (ROM) of affected joints.
4. Administer medications appropriately.
NSAIDs are given to reduce inflammation and ease pain. Diclofenac, a common topical NSAID, can be applied directly to the joints. Steroids may be prescribed during flares to reduce inflammation and to slow joint damage.
5. Ensure adherence to a DMARD.
Disease-modifying antirheumatic drugs (DMARDs) are used to treat RA and slow disease progression. These drugs reduce systemic inflammation and the incidence of flares.
Disturbed Body Image
Patients who suffer from RA will experience swelling, changes in the shape of their hands and feet, weight gain or loss, and walking difficulties. These physical changes may affect their self-esteem.
Nursing Diagnosis: Disturbed Body Image
Related to:
- Inability to perform usual tasks
- Impaired mobility
- Altered self-image perception
As evidenced by:
- Joint deformities
- RA nodules
- Negative self-talk
- Change in lifestyle and ability to perform roles
- Withdrawal from social involvement
- Attempt to hide body parts
- Sense of isolation
Expected outcomes:
- Patient will verbalize acceptance of joint deformities.
- Patient will formulate realistic plans for the future.
- Patient will demonstrate positive lifestyle changes.
Assessment:
1. Note withdrawn behavior, denial, or over-concern with body changes.
These behaviors may suggest emotional exhaustion or maladaptive coping methods, requiring more in-depth intervention or psychological support.
2. Assess how the patient views themselves in their usual lifestyle functionality.
Identifying how the illness affects their self-perception and interactions with others will determine the need for further intervention and counseling.
Interventions:
1. Encourage verbalization of concerns about the disease process and future expectations.
Listening to the patient’s concerns regarding their experiences with the illness and what they expect to happen in the future will provide an opportunity to identify fears and misconceptions so that they may be addressed appropriately.
2. Acknowledge their feelings of grief, anger, or loss.
Constant pain is wearing, and feelings of anger, irritability, and resentment are common. Listen and let the patient express their thoughts without fear of judgment.
3. Involve the patient in planning their care and in scheduling their activities.
Involving the patient in the treatment process will enhance feelings of competency and self-worth, encouraging independence and participation in therapy.
4. Give positive reinforcement for accomplishments.
Providing positive feedback will allow the patient to feel good about themselves, reinforce positive behavior, and enhance self-confidence.
5. Refer to counseling or support groups as needed.
Counseling professionals such as psychiatric clinical nurse specialists, psychologists, or support groups may be needed for ongoing support to deal with any feelings of loss or difficulty coping with a chronic disease.
6. Recommend treatment for RA nodules.
RA nodules usually aren’t painful but may be a source of embarrassment for the patient. Steroid injections or surgery can shrink or remove them, though they will often come back.
Impaired Physical Mobility
Rheumatoid arthritis may cause deformities in the affected joints, making movement difficult. The joints most often affected by RA are in the fingers, hands, wrists, ankles, feet, knees, shoulders, and elbows.
Nursing Diagnosis: Impaired Physical Mobility
Related to:
- Skeletal deformity
- Intolerance to activity
- Decreased muscle strength
- Contractures
As evidenced by:
- Reluctance to attempt movement
- Limited ROM
- Stiffness and pain
- Slow, uncoordinated ambulation
- Use of assistive devices
Expected outcomes:
- Patient will maintain or increase the strength and function of the affected joints.
- Patient will participate in recommended physical therapy.
- Patient will maintain joint function with the absence of contractures.
Assessment:
1. Assess and monitor the degree of joint inflammation.
The activity or exercise level depends on the inflammatory process’s progression or resolution.
2. Evaluate the patient’s ability to perform ADLs safely and effectively.
Restricted movement influences the capacity to perform ADLs. Safety with ambulation and self-care is a priority.
3. Assess ROM of joints.
This assessment provides baseline data and monitoring of the effectiveness of the plan of care.
Interventions:
1. Cluster care and promote rest.
Clustering related tasks instead of spacing them out over time will allow the patient to have longer periods of rest. As fatigue is common in RA, adequate rest is important.
2. Encourage exercise.
Exercising maintains and improves joint function, muscle strength, and stamina. Inadequate exercise leads to joint stiffening and poor bone health. If exercise is painful, assist the patient with ROM exercises.
3. Encourage the patient to maintain proper posture.
Keeping an upright posture with proper joint alignment can help prevent contractures and maintain mobility.
4. Delegate tasks.
Some tasks, such as cleaning the house or maintaining the yard, may become too painful or unsafe. The patient may need to delegate or hire others to perform tasks.
5. Recommend PT/OT.
Physical therapy can prolong mobility and strength through appropriate exercise. Occupational therapists can provide tools like eating utensils or toothbrushes with larger grips to aid in the patient’s performance of tasks independently.
Impaired Sitting/Standing
Patients with rheumatoid arthritis can experience issues with balance and mobility, affecting sitting and standing due to joint deformities, weakness, limited range of motion, and pain.
Nursing Diagnosis: Impaired Sitting/Standing
Related to:
- Poor posture
- Inflammatory process
- Joint pain
- Joint tenderness
- Joint stiffness
- Joint deformities
- Limited range of motion
- Decreased muscle strength
As evidenced by:
- Difficulty adjusting position
- Difficulty maintaining postural balance
- Difficulty flexing one or both hips
- Difficulty flexing/extending one or both knees
Expected outcomes:
- Patient will demonstrate improvement in range of motion.
- Patient will demonstrate proper use of assistive and adaptive devices.
Assessment:
1. Inspect the affected joints.
The joints of the hips, knees, and feet affected by RA are most likely to contribute to impaired sitting or standing. The nurse may observe deformities like bunions or hammertoes in the feet. Pain may result from bearing weight. The knees may appear swollen with an accumulation of fluid or synovium. RA affecting the hips is unlikely to be obvious, but the patient may report pain with movement or a limited range of motion with abnormal flexion, abduction, and external rotation of the hip joint.
2. Assess the effects on the patient’s ADLs and quality of life.
Impaired ability to stand or sit can affect how the patient completes tasks and may prevent them from driving, participating in hobbies, or exercising, which can diminish their quality of life.
3. Observe the patient sitting, standing, and walking.
Assess for abnormalities in their posture when sitting and standing or in their gait when ambulating.
Interventions:
1. Remind the patient to prevent periods of prolonged immobility.
Inactivity worsens stiffness in RA. Remind the patient to shift positions frequently and move their joints to encourage the flow of synovial fluid.
2. Recommend seating.
The patient should choose supportive chairs or seating that maintain their posture. Power lift reclining chairs can assist the patient in moving from a seated to a standing position.
3. Encourage exercise.
A lack of physical activity worsens joint mobility. Exercise is crucial to enhance muscle strength and reduce pain and stiffness.
4. Suggest the use of adaptive devices.
The patient may greatly benefit from splits, braces, or orthotics to assist with arch support or pain in the feet or knees.
Risk for Falls
The disease process and symptoms of rheumatoid arthritis increase the risk of falls.
Nursing Diagnosis: Risk for Falls
Related to:
- Inflammatory process
- Joint pain
- Joint tenderness
- Joint stiffness
- Fatigue
- Poor balance
- Postural instability
- Limited range of motion
- Decreased muscle strength
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms, as the problem has not occurred yet, and nursing interventions are directed at prevention.
Expected outcomes:
- Patient will remain free from falls.
- Patient will demonstrate interventions that reduce the risk of falls.
Assessment:
1. Conduct a comprehensive fall risk assessment.
A risk fall assessment helps determine the risk of falls based on additional factors like the patient’s age, history of falls, living environment, comorbidities, and medication use.
2. Assess the patient’s gait and mobility.
RA causes joint stiffness and deformities that often impact movement. Identify concerns related to posture, balance, and range of motion that are a safety risk.
Interventions:
1. Manage fatigue.
Fatigue is often a common and debilitating symptom of autoimmune diseases, including RA, and can contribute to falls. Advise on strategies to manage fatigue, such as getting adequate sleep, prioritizing the most important tasks, and taking breaks.
2. Refer the patient to physical therapy.
A physical therapist can help plan an individualized program to improve mobility and reduce the risk of falls. Balance exercises, tai chi, and strength training are recommended to fend off falls.
3. Ensure environmental safety.
Ensure the safety of the environment by removing clutter, installing handrails or grab bars near stairs or in the bathroom, and keeping rooms well-lit.
4. Instruct the patient on the proper use of assistive devices.
If the patient requires walking aids like a cane or walker, ensure they are properly adjusted to their height and are used correctly.
References
- Rheumatoid arthritis. Mayo Clinic. https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/symptoms-causes/syc-20353648. Accessed on Dec. 31, 2022
- Rheumatoid arthritis. NHS. https://www.nhs.uk/conditions/rheumatoid-arthritis/. Accessed on Dec. 31, 2022
- Doenges, M. E., Moorhouse, M. F. (1993). Nurses’s Pocket Guide: Nursing Diagnoses with Interventions (4th Ed.). F.A. Davis Company.
- M Ranatunga, S. K. (2023, September 5). Rheumatoid arthritis (RA) treatment & management: Approach considerations, pharmacologic therapy, considerations for specific patient presentations. Diseases & Conditions – Medscape Reference. Retrieved March 2024, from https://emedicine.medscape.com/article/331715-treatment#showall
- Rheumatoid Arthritis. Cleveland Clinic. https://my.clevelandclinic.org/health/diseases/4924-rheumatoid-arthritis. Accessed on Dec. 31, 2022
- Rheumatoid Arthritis: Causes, Symptoms, Treatment and More. Arthritis Foundation. https://www.arthritis.org/diseases/rheumatoid-arthritis. Accessed on Dec. 31, 2022
- Rheumatoid arthritis – Diagnosis and treatment – Mayo Clinic. (2023, January 25). Top-ranked Hospital in the Nation – Mayo Clinic. Retrieved March 2024, from https://www.mayoclinic.org/diseases-conditions/rheumatoid-arthritis/diagnosis-treatment/drc-20353653
- Rheumatoid arthritis (RA): Causes, symptoms & treatment FAQs. (2022, February 18). Cleveland Clinic. Retrieved March 2024, from https://my.clevelandclinic.org/health/diseases/4924-rheumatoid-arthritis
