INTRODUCTION

Rheumatoid arthritis (RA) is a chronic, systemic inflammatory disorder that may affect many tissues and organs, but principally attacks flexible (synovial) joints. The process involves an inflammatory response of the capsule around the joints (synovium) secondary to swelling (hyperplasia) of synovial cells, excess synovial fluid, and the development of fibrous tissue (pannus) in the synovium. The pathology of the disease process often leads to the destruction of articular cartilage and ankylosis (fusion) of the joints. Rheumatoid arthritis can also produce diffuse inflammation in the lungs, membrane around the heart (pericardium), the membranes of the lung (pleura), and white of the eye (sclera), and also nodular lesions, most common in subcutaneous tissue. Although the cause of rheumatoid arthritis is unknown, autoimmunity plays a pivotal role in both its chronicity and progression, and RA is considered a systemic autoimmune disease. About 1% of the world's population is afflicted by rheumatoid arthritis, women three times more often than men. Onset is most frequent between the ages of 40 and 50, but people of any age can be affected. In addition, individuals with the HLA-DR1 or HLA-DR4 serotypes have an increased risk for developing the disorder. It can be a disabling and painful condition, which can lead to substantial loss of functioning and mobility if not adequately treated. It is a clinical diagnosis made on the basis of symptoms, physical exam, radiographs (X-rays) and labs, although the American College of Rheumatology (ACR) and the European League against Rheumatism (EULAR) publish classification criteria for the purpose of research. Diagnosis and long-term management are typically performed by a rheumatologist, an expert in joint, muscle and bone diseases.

Various treatments are available. Non-pharmacological treatment includes physical therapy, orthoses, occupational therapy and nutritional therapy but these do not stop the progression of joint destruction. Analgesia (painkillers) and anti-inflammatory drugs, including steroids, are used to suppress the symptoms, while disease-modifying antirheumatic drugs (DMARDs) are required to inhibit or halt the underlying immune process and prevent longterm damage. In recent times, the newer group of biologics has increased treatment options. Clinical trials have shown that consumption of fish oil reduces the number of swollen joints for people with rheumatoid arthritis provides a beneficial anti-inflammatory effect, and provides a protective effect for occlusive cardiovascular disease, for which people with RA are at risk. The name is based on the term "rheumatic fever", an illness which includes joint pain and is derived from the Greek word -rheuma (nom.), -rheumatos (gen.) ("flow, current"). The suffix -oid ("resembling") gives the translation as joint inflammation that resembles rheumatic fever. The first recognized description of rheumatoid arthritis was made in 1800 by Dr. Augustin Jacob Landr-Beauvais (17721840) of Paris. While rheumatoid arthritis primarily affects joints, problems involving other organs of the body are known to occur. Extra-articular ("outside the joints") manifestations other than anemia (which is very common) are clinically evident in about 1525% of individuals with rheumatoid arthritis. It can be difficult to determine whether disease manifestations are directly caused by the rheumatoid process itself, or from side effects of the medications commonly used to treat it for example, lung fibrosis from methotrexate or osteoporosis from corticosteroids. The incidence of RA is in the region of 3 cases per 10,000 populations per annum. Onset is uncommon under the age of 15 and from then on the incidence rises with age until the age of 80. The prevalence rate is 1%, with women affected three to five times as often as men. It is up to three times more common in smokers than non-smokers, particularly in men, 2

heavy smokers, and those who are rheumatoid factor positive. A study in 2010 found that those who drank modest amounts of alcohol regularly were four times less likely to get rheumatoid arthritis than those who never drank. Some Native American groups have higher prevalence rates (56%) and people from the Caribbean region have lower prevalence rates. First-degree relatives prevalence rate is 23% and disease genetic concordance in monozygotic twins is approximately 1520%. It is strongly associated with the inherited tissue type (MHC) antigen HLA-DR4 (most specifically DR0401 and 0404)hence family history is an important risk factor. The risk of first developing the disease (the disease incidence) appears to be greatest for women between 40 and 50 years of age, and for men somewhat later. RA is a chronic disease, and although rarely, a spontaneous remission may occur, the natural course is almost invariably one of persistent symptoms, waxing and waning in intensity, and a progressive deterioration of joint structures leading to deformations and disability.

OBJECTIVES
At the end of the first semester for the school year 2012-2013, in partial fulfillment for the prelim requirements of Nursing Care Management 106, I would be able to acquire a comprehensive knowledge on the concept of management of clients with Musculoskeletal Disorders particularly on the Rheumatoid Arthritis. We aim to complete this case study to help us discern a deeper understanding on all the factors contributing to the joint pain and other clinical manifestations of a patient with rheumatoid arthritis. Thus, we may be able to enhance our dexterity skills in the field of Nursing, and exercise our rational/verbal abilities and apply right attitude during the completion of the study.

Scope and Limitations

The scope of this case study is focused basically on the illness of the Patient whom we have chosen as the subject of interest because of his underlying conditions may contribute to our limited knowledge on the concept of Musculoskeletal Disorder Management. It is expected that our skills capabilities as Nursing Student are limited only through: Assessment, Study of Pathophysiology, Drug Study, Discharge Planning, Diet Analysis and Nursing Care Management of patient from time of Admission to Discharged and follow-up home visits.

DEMOGRAPHIC DATA
NAME: Mr. A ADDRESS: Brgy. Bal-ason Gingoog City AGE: 49 y/o HEIGHT: 57 WEIGHT: 50 kg GENDER: Male STATUS: Single NATIONALITY: Filipino RELIGION: Iglesia ni Cristo BIRTHDATE: January 12, 1966 BIRTHPLACE: Bal-ason Gingoog City DIAGNOSES: Rheumatoid Arthritis and Urinary tract infection (UTI) CHIEF COMPLAINT: Swelling and Pain at the lower extremities ROOM: Alley C HOSPITAL #: 283330 ADMISSION #: 3796 ATTENDING PHYSICIAN: Dr. Cezar DATE OF ADMISSION: 07/25/12 TIME OF ADMISSION: 12:35

DEVELOPMENTAL THEORIES
ERIK ERICKSONS PSYCOSOCIAL THEORY
He organized life into eight stages that extend from birth to death (many developmental theories only cover childhood). Then, since adulthood covers a span of many years, Erikson divided the stages of adulthood into the experiences of young adults, middle aged adults and older adults. While the actual ages may vary considerably from one stage to another, the ages seem to be appropriate for the majority of people.

Middle Adulthood: 35 to 55 or 65 Ego Development Outcome: Generativity vs. Self absorption or Stagnation Erikson observed that middle-age is when we tend to be occupied with creative and meaningful work and with issues surrounding our family. Also, middle adulthood is when we can expect to "be in charge," the role we've longer envied. The significant task is to perpetuate culture and transmit values of the culture through the family (taming the kids) and working to establish a stable environment. Strength comes through care of others and production of something that contributes to the betterment of society, which Erikson calls generativity, so when we're in this stage we often fear inactivity and meaninglessness. OBSERVATION: The patient belongs to this stage according to his age, his 49 years old so as Ive interviewed him during my duty at MOPH hes still single and never talk about any relationships, and there was a time that we asked him why hes just smiling and shrugging his shoulder. Maybe my patient is in stagnation stage because there is no sense of responsibility to the family because he doesnt have family the wife and children.

SIGMUND FREUDS PSYCHOSEXUAL THEORY

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According to Sigmund Freud, personality is mostly established by the age of five. Early experiences play a large role in personality development and continue to influence behavior later in life. Freud's theory of psychosexual development is one of the best known, but also one of the most controversial. Freud believed that personality develops through a series of childhood stages during which the pleasure-seeking energies of the id become focused on certain erogenous areas. This psychosexual energy, or libido, was described as the driving force behind behavior. Genital Stage Age Range: Puberty to Death Erogenous Zone: Maturing Sexual Interests During the final stage of psychosexual development, the individual develops a strong sexual interest in the opposite sex. This stage begins during puberty but last throughout the rest of a person's life. Where in earlier stages the focus was solely on individual needs, interest in the welfare of others grows during this stage. If the other stages have been completed successfully, the individual should now be well-balanced, warm and caring. The goal of this stage is to establish a balance between the various life areas.

OBSERVATION: The patient belongs to Genital stage because according to Freud the genital stage is in puberty up to death, so my patient maybe has a strong sexual interest to the opposite sex of course it is obvious because men has a strong libido than female.

ROBERT HAVIGHURSTS THEORY

From examining the changes in your own life span you can see that critical tasks arise 7

at certain times in our lives. Mastery of these tasks is satisfying and encourages us to on to new challenges. Difficulty with them slows progress toward future accomplishments and goals. As a mechanism for understanding the changes that occur during the life span. Robert Havighurst(1952, 1972, 1982) has identified critical developmental tasks that occur throughout the life span. Although our interpretations of these tasks naturally change over the years and with new research findings. Havighurst's developmental tasks offer lasting testimony to the belief that we continue to develop throughout our lives.

Developmental Tasks of Early Adulthood (Ages 4060) Assisting teenage children to become responsible and happy adults. Achieving adult social and civic responsibility. Reaching and maintaining satisfactory performance in ones occupational career. Developing adult leisure time activities. Relating oneself to ones spouse as a person. To accept and adjust to the physiological changes of middle age. Adjusting to aging parents.

OBSERVATION: The patient belongs to this stage according his age but the characteristics are not yet achieve because he dont have wife and children but he is responsible to himself and can adjust and accept the changes occurs in his age and also he can maintain satisfactory performance in the particular career.

JEAN PIAGETS COGNITIVE THEORY

He proposed that children's thinking does not develop entirely smoothly: instead, there are 8

certain points at which it "takes off" and moves into completely new areas and capabilities. He saw these transitions as taking place at about 18 months, 7 years and 11 or 12 years. This has been taken to mean that before these ages children are not capable (no matter how bright) of understanding things in certain ways, and has been used as the basis for scheduling the school curriculum.

Formal operational (11 years and up) Can think logically about abstract propositions and test hypotheses systematically. Becomes concerned with the hypothetical, the future, and ideological problems. OBSERVATION: The patient belongs to this stage, as what the meaning states above he can properly think logically regarding in an abstract and concrete thinking or propositions. Also have an idea of what are problems occur now a days and also in the future.

NURSING ASSESSMENT
PHYSICAL ASSESSMENT

Assessment Body Build, Weight Height

Normal Findings

Actual Findings

and Normal in proportion and has Height: 57 no deformities. Weight: 50 kg

Posture and Gait

Good posture and body gait

Cannot stand on his own and needs assistance because he cannot balance during ambulation.

Body and Breath odor

Has a body odor because he No unwanted body or breath never took a bath since he odor was admitted.

Signs of Distress

No distress noted

Patient

always

complains

pain in his knees and feet. And feels uncomfortable. Signs of Health or Illness Healthy appearance The patient now suffers pain and altered level of functioning. Attitude Cooperative Patient cooperates when we asked question to him. But when he wants to do something he wants do it by his own or with the help of her sister and he doesnt like me to help him.

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Affect/Mood

Appropriate to situation

Patient cooperates and active during our physical assessment. And answer only question when he likes it.

Quantity,

Quality

and Understandable, pace, exhibits association

moderate

Organization of Speech

Normal. Nothing alters in his thought speech or the he talk.

Relevance and Organization Logical of Thoughts

sequence,

makes The patient answer is relevant to the questions that are being asked.

sense, has sense of reality

Uniformity of skin color

Uniformity except in areas ex- Pale skin color. posed to the sun

Edema

No edema

Edema noted in knees and feet.

Skin Lesions

No freckles, No birthmarks, Abrasions in the hands and no abrasions or lesions legs.

Skin Moisture

Moisture in skin folds and the Moist in axilla and skin folds axillae during hot temperature. Slightly warm to touch. skin when it is

Skin Temperature Skin Turgor

Uniform, within normal range

Skin springs back to previous Patient state when pinched

pinched it doesnt return to its original state.

Scalp Hair Thickness Hair Texture Amount of Body Hair

Evenly distributed Thick hair Silky, resilient hair Variable 11

Presence of dandruff. Evenly distributed Normal Normal

Nail Plate Shape Texture Nail Bed Color

Convex curvature Smooth

Normal Normal

Highly vascular, pink, prompt Capillary refill is delayed, it return of pink color returns in 5 seconds.

Skull and Face Head Rounded, smooth nodule Eyes and Vision Eyebrows Hair evenly distributed, Normal skull symmetrical, Normal head shape. contour, no

symmetrical, skin intact Eyelid Skin intact, no discharges, no Intact skin. discolorations, symmetrical Eyelashes Equally distributed, slightly Normal

curved outward Conjunctiva Transparent, pink or red sometimes normal

appear white, shiny, smooth,

Lacrimal Gland Cornea

No edema or tearing Transparent, is touched shiny

No edema noted. and Normal

smooth, blinks when cornea

Pupils

Black color, equal size

Color black and has equal size.

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Near Vision

Able to read newsprint

Patient able to read without the use of glasses cant read in far distance.

Ears and Hearing Auricles Color is uniform, symmetric, Normal mobile, firm, pinna recoils when folded Nose and Sinuses Nares Symmetric and straight, no Normal discharges, no swelling, uniform color, not tender Lining of nose Mouth Lips Buccal Mucosa Uniform symmetrical Teeth and Gums Complete gums, teeth, moist, smooth, Complete teeth, slightly pink firm, no pink, soft, Dry lips and pale. Nasal septum in midline Normal

white tiny tooth enamel, pink gums. retractions Tongue Centrally located, pink in Normal

color, freely movable Palates, Uvula, Tonsils Light reflex Shape and Symmetry Symmetrical Normal pink, smooth, present no Normal, present gag reflex. gag

discharges,

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Spinal Deformities Inspect Neck Muscles

Spine vertically aligned Symmetrical centered with

Normal head Normal

Observe Head Movement

Coordinated, equal strength

smooth, Normal

movement with no discomfort,

Muscle

Size

is

symmetrical,

no Normal

contracture, normally firm Movement Smooth coordinated Limited body movement

movements, equal strength Joints No swelling, tenderness Swelling extremities. in the lower

GORDONS ASSESSMENT

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Function

Before Hospitalization Eats only 2 meals a day because he forgets to eat during night due of tiredness.

During Hospitalization

Interpretation

Nutrition

Wanted to drink soft drinks and wants to eat tahong and sardines. He doesnt like to eat the foods are being He loves to drink that by the carbonated drinks and prepared hospital. any salty foods. Low purine diet and full diet is being advised by the doctor.

Attending physician ordered low purine diet, because rich in purine will worsen the clients condition.

Elimination

Able to urinate & defecate normally twice everyday by himself and even without any assistance. Defecate usually in the afternoon after his work.

His sister assisted him when he wants to defecate but he only urinates at the bedside in the bedpan.

His condition does affect his elimination pattern due to pain in the lower extremities.

Sleeping

He has a regular sleep Abnormal sleeping Disturbed pattern and wake up pattern due to pain of the pattern. early in the morning due lower extremities. to his work. patient cannot sleep Normal sleep is 8-9 hrs. continuously during per day night.

sleep

Cognitive- Perceptual understand and able to understand He is cooperative Pattern comprehend well and can comprehend and responsive. well during interaction. 15

ANATOMY AND PHYSIOLOGY

Diarthodial joints are lined at their margins by a synovial membrane (synovium) with synovial cells lining this space. The lining cells synthesize protein as well as being phagocytic. Synovial fluid is transparent, viscous fluid. Its function is to lubricate the joint space and transport nutrients to the articular cartilage. Mechanical, chemical, immunologic, or bacteriologic damage may alter the 16

permeability of the membrane and capillaries to produce varying degrees of inflammatory response. Inflammatory joint fluids contain lytic enzymes that produce depolymerization of hyaluronic acid, which greatly impairs the lubricating ability of the fluid Analysis of synovial fluid plays a major role in the diagnosis of joint disease. A variety of disorders produces changes in the number and types of cells and chemical composition of the fluid. (e.g. gout uric acid crystals) Synovial fluid for RA is sterile, cloudy, and has an increased neutrophil count.

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