5-2 Final Project Milestone Two: Draft
Sophia Peters
Southern New Hampshire University
Pathophysiology for Nurses
Mark Ouellette, MSN, FNP-C
24 July 2022
Introduction: Pathophysiology & Clinical Manifestations
The individual selected for this and subsequent milestones is Clark Middleton. He was born in 1957 in Briston, Tennessee and passed away in 2020 at a Los Angeles hospital. Clarke Middleton was an actor, writer as well as advocate for persons with disability. He was commonly referred to as an actor with a cause. Clark Middleton was diagnosed with arthritis at the age of 4 and underwent various surgeries that attempted to rectify his condition. He did an interview that summarized his life and how doctors told him that he would not survive in any winter weather because of the juvenile rheumatoid arthritis. However, he managed to live a fulfilling life with great success in his career.
Pathophysiology
Rheumatoid arthritis is a systemic disease, it can affect various parts of the body. Inflammation of the synovial tissue lining normally causes proliferation of the tissues (Adami & Saag, 2019). This is referred to as Pannus. It then invades the bone surfaces as well as the cartilages. Erosion of the cartilages subsequently leads to destruction of the joints. However, the causative agents of chronic inflammation have not yet been discovered. One of the functions of the immunity system of the body is to identify and differentiate local and foreign tissues. However, in the case of Rheumatoid Arthritis, it becomes impossible for the immune system to differentiate foreign tissues (Adami & Saag, 2019). These attacks the synovial as well as connective tissues. Pathophysiology of RA can be summarized through dysregulated inflammation, presentation of antigens and activation of T-cells. All these are mediators in the inflammatory process (Gibofsky, 2022). RA alters normal physiology when the immune system of the body attacks the lining of the joints, leading to inflammation of the bones.
Clinical Manifestations
One aspect that should be known about the clinical manifestations of RA is that they should be present in more than one joint. For instance, RA is manifested by pain in more than one joint, which may be the hands, knees or writs. In addition to pain, these joints may as well be subjected to painful inflammations. The joints may either be stiff or tender. When palpated, the joints of an RA patient normally feel bouncy (Gulati et al., 2018). RA also involves difficult in moving the joints. This is the reason why there is a significant difficult in mobility of patients that have Rheumatoid Arthritis.
History
Historical Variations in Pathophysiology
Technically, Juvenile Rheumatoid Arthritis (JRA) is a type of arthritis that onsets before one clock 16 years of age (Chabanov et al., 2018). It is also persistent for a period of more than 3 weeks and is the most likely rheumatoid disease that can affect children. JRA is the subject to causation of various long term and even short-term disabilities. According to Chabanov et al., (2018), there are three categories used to describe JRA. These are European League Against Rheumatism, American College of Rheumatology and the European League Against Rheumatism. Rheumatoid Arthritis dates back to 1500BC when a condition similar to RA was mentioned. It was later discovered that RA is chronic and progressive and is involved in the tendon sheaths which ended up causing damage on the bone and cartilage (Al-Rubaye et al., 2017).
RA has four distinctive stages. The first stage is known as synovitis. This is where the synovial membrane becomes inflamed, and this causes inflammation in the joints (Al-Rubaye et al., 2017). This is what causes pain during mobility. The second stage is where the inflammation spreads to the joint cavity space. This causes damage of the cartilage (Al-Rubaye et al., 2017). In the third stage, there is formation of pannus in the synovium (Al-Rubaye et al., 2017). This results to deformities of the joints. The final stage is the terminal stage and is characterized by reduction of inflammation of the joint tissue, meaning the joint has been completely decimated. This stage is arrived at due to inadequate or complete lack of medical care in the prior stages.
RA is not a curable condition. However, there are methods that can be used in the management of the condition. These include early identification and instigation of the requisite interventions. This is where patient care technologies come in handy. Patient technology is useful in the management of the condition because it facilitates collection of data that will guide the intervention phase of the disease. These technologies include Electronic Health Records, wearable health devices and smartphones laced with the necessary applications.
Stressors
The physiological stressors that are likely to affect the course of rheumatoid arthritis is the presence of contributors to inflammation (Mititelu, 2020). Notable aspects of the patient that can be targeted in mitigating the progression of the disease is the physical activity level and eating habits. Diets high in sugar, consumption of alcohol, and a sedentary lifestyle or too much strain can lead to the aggravation of the inflammatory processes that are a main marker of the disease. Other stressors include environmental factors such as increased cold which can lead to the aggravation of inflammation. Such patients are advised to stay warm especially during the cold seasons to avoid flare ups in joint pains and other presentations that limit physical activity.
The presence of the stressors is likely to increase the extent of damage to the joints and the synovium that is affected. There is also a likelihood in increased flare-ups and the progression to chronic limitation in movement due to structural deformity and pain. Identification of possible stressors is useful in formulating prevention measures such as dietary modification and avoidance of alcohol.
Adaptive Physiological Mechanisms
The main notable adaptive response to the assault that results from the inflammation is the presence of joint deformities. The damage to the synovial covering of the tendons leads and joint cartilage leads to deformities and chronic limitation in movement. The presence of the joint deformities complicates the treatment process. It makes it harder to control the progressive joint damage due to the distorted planes of movement.
Plan of Care (PIE)
Planning
The mission statement in this case scenario is to ensure pain management within two weeks and reduce the limitation in physical activity in one month.
Concerns
A major concern in this case is the presence of pain. The constant sensation of pain in the affected joints limits movement. Optimal management aims at reduction in pain to ensure physical activity that helps reduce the inflammation.
There is also the concern of chronic inflammation and progressive damage to the joints. The overall outcome of the patient is dependent on how well the process of inflammation is managed to ensure prevention of long-term conformational changes.
An important concern in the treatment process is the level of knowledge of the family and the care givers on the management of the disease in the home setting. It is crucial in shaping the health education that is provided throughout the treatment process and before discharge.
Short term goals
In order for the interventions to be successful, it is important that goals are set. These goals will be both short term and long-term goals. The short-term goals are intended to be achieved within 1 month while the long-term interventions will be achieved from 6 months. The first short term goal for JRA will be pain relief. One factor that really affects patients with JRA is pain. JRA affects the joints. The joints become inflamed and this causes a severe chronic pain associated with the infection (Al-Rubaye et al., 2017). This pain demeans the quality of life as well as exposed the patient to constant pain relieve medicine which may cause further healthcare concerns.
Another short-term goal for the intervention is to control inflammation. As discussed by Al-Rubaye et al., (2017), the initial stages of JRA is associated with inflammation of smaller joints around the knees, fingers as well as the hands. With progression of the disease, the inflammation spreads to the knees, elbows, hips and shoulders. In some cases, some internal organs such as the liver and lymph nodes also become inflamed (Al-Rubaye et al., 2017). This inflammation becomes severe and causes pain and discomfort.
Long Term Goals
The first long term goal is to inhibit progressive damage that is caused by the disease. This progressive damage is usually caused by increasing signs and symptoms associated with the disease. With inhibition of progressive damage, the individual is capable of resuming normal function albeit with limited ability.
The second long term goal is to reduce disease activity and, in the process, induce clinical remission. Reduction of the disease activity means engaging in interventions that will help curb spreading of the disease to other joints which have yet to be affected or those that have minimal effects from the disease. This will consequently lead to clinical remission, which is a decline in the signs and symptoms associated with the disease.
Nursing Concerns
One nursing concern affiliated with JRA is compromised family coping. Shaw et al., (2017) identified compromised family coping as inadequate information about the dynamics of JRA. When the family has limited understanding on the dynamics of JRA, then there are bound to be complications that will limit attainment of the short term and long-term objectives. Inadequate information about JRA may cause the family to be somewhat overprotective of the child.
In JRA, self-care is a very important aspect that may lead to a quicker reduction of the symptoms as well as pain. This, however, may become difficult to attain. Therefore, self-care deficit is another nursing concern. Self-care deficit is associated with chronic pain and discomfort as well as impairment of the musculoskeletal system (Shaw et al., 2017).
Patient Technologies
Various technological equipment is critical for the management of JRA. These technologies have various capacities such as clinician-derived data as well as patient-derived data (William & Kaleb, 2018). Clinician-derived data can be obtained from increased use of Electronic Health Records. Maarseveen et al., (2021) identify that EHRs can be used to capture and store observational data obtained by rheumatologists. This data will be crucial in analysis of how well the interventions are working. In addition, the data will also be useful in the determination of whether the short-term and long-term goals are actually attainable.
Patient-derived data will be obtained from smartwatches, smartphones and other wearable devices. According to William & Kaleb (2018), these devices can be used in clinical management because of their ability to transmit clinical data to the health care professionals. With this in mind, they are better placed to ensure that they actually monitor the patients and determine self-care activities and their efficacy. They can also be used to instigate behavioral changes such as increase in physical activities.
Interventions
JRA has various interventions that have all proven effective. These interventions can either be pharmacologic interventions, physical activity or medical management interventions. However, this care plan will incorporate the use of physical activities and medications for the pharmacologic interventions. Physical therapy is arguably the most proficient intervention applied by various health care professionals in the management of JRA. Physical therapy intends to keep the child more active in either sports or other physical activities such as jogging. Physical therapy is crucial in the attainment of both short-term and long-term care plans. It is crucial in the maintenance of motion within the affected joints (Mudano et al., 2019). When motion is maintained, it helps inhibit the spreading of the inflammation. Consequently, this helps in the enhancement of muscle strength, and it will consequently induce remission. Some of the safety concerns associated with physical therapy include use of qualified personnel as well as avoidance of activities that may cause injury.
Another intervention relative to this condition is health education. Health education involves highlighting the roles of the patient in managing the disease. For instance, the nurse will educate the patient on dietary practices, adherence to medication as well as dynamics of rest and exercise (Srinivasalu & Riebschleger, 2019). The intervention also involves prognosis of JRA as well as future expectations. For the efficacy of this intervention, the nurses involve the parents, guardians or care givers of the child. There is no significant safety associated with patient education. However, a prominent factor that should be considered is the accuracy of the information passed across.
Medication
Pharmacologic management of JRA utilizes various medicine which include Nonsteroidal Anti-Inflammatory Drugs (NSAIDs), Corticosteroids, and Disease-Modifying Antirheumatic drug (DMARD). NSAIDs are particularly useful in the management of pain and inflammation. They work by inhibiting the synthesis of cyclooxygenase by interfering with functioning of the prostaglandin (Shi et al., 2021). The dosage should be accurately disseminated in order to avoid violation of various patient safety aspects. One safety aspect associated with NSAIDs is the substantial risk of Disseminated Intravascular Coagulation. This calls for cautionary practices and monitoring early manifestations of DIC.
DMARDs on the other hand are sort of a secondary relief when NSAIDs seem not be working to the expected standards. DMARDS can be administered through biologic measures such as IVs or non-biological, through pills. DMARDS are also crucial in the attainment of both the short-term and long-term goals. However, there are some safety concerns associated with DMARDs especially the development of infections that become difficult to manage. However, Shi et al., (2021) proposed testing the children of infections before the interventions are commissioned.
Patient Care Technology
As discussed earlier, the patient technology applicable in this segment is wearable devices, smartphones and smartwatches. These devices will transmit information regarding the level of physical activity. Here, the health care professional will be able to offer evidence-based advice regarding the efficacy of the practices. Electronic Health Records will be useful in management of medication. The health care provider will be capable of instigating the necessary dosage to as to avoid medication errors as well as adverse drug interactions.
Evaluation
Evaluation will be conducted as a means to determining whether or not the goals identified in the plan of care has been attained. The evaluation will be based on five attainments. These attainments are relief of pain. The patient should be capable of explaining the pain, potentially with the use of a pain scale. A response of between 0 to 3 on the pain scale will be an indicator that the interventions were effective. Above that, then the intervention needs to be reevaluated. The second evaluation rubric will be the ability of the patient to effectively participate in physical activities. When they are capable of participating in the activities, then it means that the interventions have managed to curb pain.
One of the goals of the plan of care was to inhibit progressive damage and reduce disease activity. These goals will be evaluated through assessment of whether or not the strength and functioning of the body parts that had been compromised. By the end of the plan of care, the compromised body part needs to have maintained or increased its ability to perform its dedicated function without much difficulty.
The final segment of the evaluation will be based on the understanding of the patient on the dynamics of JRA. This segment will be done in concert with the parents, caregivers or guardians. It will involve identification of whether or not the patient has fully comprehended the disease in terms of its prognosis, medications, risk factors as well as interventions. With complete understanding of these aspects, it is possible that the patient will be more judicious in the management of the condition. They will also be able to make the necessary lifestyle modifications to this condition.
References
Adami, G., & Saag, K. G. (2019). Osteoporosis Pathophysiology, Epidemiology, and Screening in Rheumatoid Arthritis. Current Rheumatology Reports, 21(7). https://doi.org/10.1007/s11926-019-0836-7
Al-Rubaye, A. F., Kadhim, M. J., & Hameed, I. H. (2017). Rheumatoid Arthritis: History, Stages, Epidemiology, Pathogenesis, Diagnosis and Treatment. INTERNATIONAL JOURNAL OF TOXICOLOGICAL AND PHARMACOLOGICAL RESEARCH, 9(02). https://doi.org/10.25258/ijtpr.v9i02.9052
Chabanov, D., Tsintzas, D., & Vithoulkas, G. (2018). Levels of Health Theory With the Example of a Case of Juvenile Rheumatoid Arthritis. Journal of Evidence-Based Integrative Medicine, 23, 2515690X1877799. https://doi.org/10.1177/2515690x18777995
Dixon, W. G., & Michaud, K. (2018). Using technology to support clinical care and research in rheumatoid arthritis. Current Opinion in Rheumatology, 30(3), 276–281. https://doi.org/10.1097/bor.0000000000000485
Gibofsky, A., MD. (2022, April 14). Epidemiology, Pathophysiology, and Diagnosis of Rheumatoid Arthritis: A Synopsis. AJMC. Retrieved July 12, 2022, from https://www.ajmc.com/view/ace017_may14_ra-ce_gibofsky1_s128
Gulati, M., Farah, Z., & Mouyis, M. (2018). Clinical features of rheumatoid arthritis. Medicine, 46(4), 211–215. https://doi.org/10.1016/j.mpmed.2018.01.008
Maarseveen, T. D., Maurits, M. P., Niemantsverdriet, E., van der Helm-van Mil, A. H. M., Huizinga, T. W. J., & Knevel, R. (2021). Handwork vs machine: a comparison of rheumatoid arthritis patient populations as identified from EHR free-text by diagnosis extraction through machine-learning or traditional criteria-based chart review. Arthritis Research & Therapy, 23(1). https://doi.org/10.1186/s13075-021-02553-4
Mititelu, R. R., Pădureanu, R., Băcănoiu, M., Pădureanu, V., Docea, A. O., Calina, D., ... & Buga, A. M. (2020). Inflammatory and oxidative stress markers—mirror tools in rheumatoid arthritis. Biomedicines, 8(5), 125. https://www.mdpi.com/2227-9059/8/5/125
Mudano, A. S., Tugwell, P., Wells, G. A., & Singh, J. A. (2019). Tai Chi for rheumatoid arthritis. Cochrane Database of Systematic Reviews. https://doi.org/10.1002/14651858.cd004849.pub2
Shaw, Y., Bradley, M., Zhang, C., Dominique, A., Michaud, K., McDonald, D., & Simon, T. A. (2020). Development of Resilience Among Rheumatoid Arthritis Patients: A Qualitative Study. Arthritis Care & Research, 72(9), 1257–1265. https://doi.org/10.1002/acr.24024
Shi, C. L., Zhang, Y., Zhang, Z. Y., Zhou, J., & Tang, X. M. (2021). Comparative Efficacy and Safety of Non-Steroidal Anti-Inflammatory Drugs in Patients With Juvenile Idiopathic Arthritis: A Systematic Review and Network Meta-analysis. Indian Pediatrics, 58(2), 162–168. https://doi.org/10.1007/s13312-021-2155-0
Srinivasalu, H., & Riebschleger, M. (2019). Medical education in pediatric rheumatology—unique challenges and opportunities. Clinical Rheumatology, 39(3), 643–650. https://doi.org/10.1007/s10067-019-04746-4