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january 30/vol16/no20/2002 nursing standard 45

C O N T I N U I N G P R O F E S S I O N A L D E V E LO P M E N T

Autoimmune diseases

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Rheumatoid arthritis

The aim of this article is to provide nurses with anoverview of the information required to providecomprehensive care for patients with rheumatoidarthritis. After reading this article you should beable to:■ Explain the disease process in rheumatoid arthritis.■ Describe the clinical presentation of this condition.■ Identify and discuss the objectives of care

management.■ Describe how psychological and social function

can be affected by rheumatoid arthritis.■ Outline the functions of a nurse-led clinic.■ Explain the role of the multidisciplinary team in

the management of patients with rheumatoidarthritis.

Rheumatoid arthritis (RA) is an autoimmune sym-metrical inflammatory arthritis of unknown cause.It is hypothesised that various factors, includinginfection, stress and trauma might act as initiatingfactors in people with a genetic disposition (Arthur1998). RA is characterised by inflammation of thesynovium (a substance that lines the joints andtendon sheaths of the body) and increased syn-ovial exudate, which result in thickening of thesynovium and joint swelling. The condition ischaracterised by a symmetrical small joint poly-arthritis involving the hands and feet, but largerjoints can also be affected.

The autoimmune response initiates an immunecomplex, which activates the inflammatory process.Inflammation is usually a self-limiting event, which

continues until the antigen is destroyed. However,in RA, the immune complexes are not deactivatedand the continuation of the inflammatory responsecan result in severe joint destruction. In RA theimmune reaction commences in the joint, wherethe synovial lining of the capsule becomesinflamed and congested with T lymphocytes, B cells,macrophages and plasma cells (Firestein 1994). Thiscauses proliferation of the synovial membrane,which erodes the bone, resulting in altered function.Local signs of inflammation include redness, heat,swelling and pain. The systemic nature of inflam-mation can result in extra-articular features, suchas fatigue, anaemia and weight loss. Systemicmanifestations of RA are outlined in Box 1.

RA affects approximately one million people inthe UK (Hill and Ryan 2000). The prevalence is1:200 women and 1:600 men (Le Gallez 1996),although the distribution among the sexes is moreeven over the age of 60. RA occurs globally,with severe presentations evident in NorthernEurope (Lawrence 1994).Patterns of presentation The most commonform of presentation occurs typically in the fourthor fifth decade of life and manifests as an insidious

Epidemiology

Introduction

Aims and intended learning outcomes

NS125 Ryan S, Oliver S (2002) Rheumatoid arthritis. Nursing Standard. 16, 20, 45-52. Date of acceptance: December 7 2001.

AuthorSarah Ryan RGN, is NurseConsultant Rheumatology,Staffordshire RheumatologyCentre, Haywood Hospital,Stoke on Trent. Tel: 01782556201. Susan Oliver RGN,MSc, is Clinical Nurse Specialistin Rheumatology, NorthernDevon Healthcare Trust.

SummaryRheumatoid arthritis is themost common form ofinflammatory joint disease inthe UK, affecting about onemillion people (Hill and Ryan2000). The authors discussthe patterns of presentation,clinical features and nursingmanagement of this condition.

Key words■ Arthritis and rheumatism■ Multidisciplinary teams■ Nursing: care■ Nursing: role

These key words are basedon subject headings from theBritish Nursing Index. Thisarticle has been subject todouble-blind review.

In brief

Rheumatoid arthritis 45-52

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Practice profile 27

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List the manifestations andclinical presentation of apatient with RA. Draw anoutline map of the body andlabel the joints you think might be affected.

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46 nursing standard january 30/vol16/no20/2002


Autoimmune diseases

onset of symmetrical small joint polyarthritis, affect-ing the metacarpophalangeal (MCP) and proximalinterphalangeal (PIP) joints in the hands and themetatarsophalangeal (MTP) joints in the feet(Cushnaghan and McDowell 1999). As the diseaseprogresses, other joints might also be affected,including the wrists, elbows, shoulders, cervical spine,ribs, temporomandibular joints, knees and ankles. Aninitial presentation and diffuse swelling is more com-monly seen in older persons. RA can also present ina monoarticular form affecting larger joints such asthe shoulders or knees. The symptoms might be con-fined to these areas or become more generalisedaffecting other joints.Clinical features The American RheumatismAssociation’s revised criteria for the classificationof RA provide guidance on diagnosis (Box 2).Common clinical features include:■ Pain – often the first symptom experienced by

the patient, it can vary in its intensity and loca-tion on a daily basis. Pain is often accompaniedby early morning stiffness, which can rangefrom a few minutes to several hours and is anindicator of disease activity. Joint pain isassessed by direct palpation of the joints andcan assist in the assessment of disease activity.

■ Joint inflammation – can be periarticular (inthe area around a joint) or intra-articular(within a joint). Symmetrical swelling of theMCPs and PIPs is typical of RA. The featuresdisplayed in the hands are often a reflection ofthe patient’s overall condition, which could beearly, late or progressive. Tendons are alsosheathed with synovium and in extensortenosynovitis swelling occurs over the dorsumof the wrist. Rupture occurs more commonlyin extensor tendons than flexor tendons.

■ Reduced joint function.■ Muscle weakness – can be an early feature of

RA and might lead to marked muscular atrophy.■ Extra-articular features including subcuta-

neous nodules.

Laboratory investigations can inform the diagno-sis and progression of RA, although the diagnosisis often established from the clinical history andexamination.Rheumatoid factor The rheumatoid factor (RF)is an immunoglobulin complex of immunoglobulinG (IgG) and immunoglobulin M (IgM). It is presentin approximately 70-90 per cent of patients with RAand can be absent in the first three to six monthsfollowing diagnosis (Hill and Ryan 2000). Patientswith RA who have this complex are classified asbeing seropositive. A titre of 1:32 is classified as

weakly positive and a ratio of 1:64 and aboveindicates more active disease (Hill and Ryan2000). RF is present in at least 1 per cent of thenormal UK population and is not diagnostic ofRA when other clinical features of the conditionare absent (Hill and Ryan 2000).Acute phase reactants Non-specific indicators ofinflammation include the erythrocyte sedimentationrate (ESR) and the C-reactive protein (CRP). Bothmarkers can be used to monitor disease activity inRA. The normal range of ESR is 4-20mm/h formales and 10-25mm/h for females. Infection,myeloma and age can raise the ESR. The normalrange of a CRP is 0-9mg/l. A consistently raisedCRP is associated with severe disease.Radiographs X-rays of the hands and feet oftenreveal evidence of the condition, including softtissue swelling around an affected joint andenlargement of the joint cavity. As the conditionprogresses, periarticular osteoporosis and articu-lar erosions with loss of joint space can occur. Thepresence of erosions is an indicator of poor prog-nostic outcome. Factors associated with severedisease and subsequent poor outcome include:■ Presence of extra-articular features.■ Radiological evidence of erosions.■ Rheumatoid factor positive.■ Uncontrolled polyarthritis.Synovial fluid examination The synovial mem-brane secretes synovial fluid. The aspiration andsubsequent examination of the fluid can aiddiagnosis. The number of white blood cells pres-ent can indicate whether it is a non-inflammatory,inflammatory or infective condition.

The management of RA is focused on relievingpain, modifying the level of disease activity andmaintaining optimal functional ability for eachindividual. A dedicated multidisciplinary teamcan provide a wide range of support for patients,their families and the primary healthcare teams(Box 3), resulting in an effective ‘triangle of care’(Fig. 1). All members of the team are activelyinvolved in education to enhance care for RApatients.

Specialist knowledge and skills are required toidentify the key issues arising from each individ-ual’s needs and perceptions of RA. The patient’sinitial needs might vary depending on:■ The length of illness before attending the

department.■ Severity of the disease.■ Previous knowledge of RA.■ Perceptions of ‘illness’.■ The individual’s normal coping strategies.

Management

Investigations

■ Anaemia■ Subcutaneous nodules■ Entrapment neuropathies –

median nerve involvement■ Sjogren’s syndrome (an

immunological disorder characterised by deficientmoisture production of thelacrimal, salivary and otherglands, resulting in abnormaldryness of the mouth, eyes and other mucousmembranes)

■ Lymphadenopathy (any disorder characterised by alocalised or generalisedenlargement of the lymphnodes or vessels)

■ Pericarditis■ Felty’s syndrome

(hypersplenism)■ Vasculitis■ Episcleritis (inflammation

of the outermost layers ofthe sclera)

Box 1. Systemic manifestations of RA

■ Morning stiffness in andaround the joints lasting atleast one hour

■ Arthritis in three or morejoint areas with swellingand fluid

■ Arthritis of hand joints■ Symmetrical arthritis(All the above must be presentfor at least six weeks)

■ Subcutaneous nodules■ Radiological changes■ Positive rheumatoid factor

(Arnett et al 1988)

Box 2. Revised criteria forthe classification of RA



Autoimmune diseases

■ Level of financial and social support.It is important that adequate time is allocated toassess each patient on an individual basis and thatcare management addresses his or her specificneeds.

Patient education Patient education and self-management programmes provide a framework forpatients to become the key decision makers in theircare. The aim of patient education is to empowerpatients and improve their health status by changingnegative health behaviours (Hill 1998). Patient edu-cation should be the earliest intervention as there islittle point in prescribing medication, advocatingchanges in lifestyle, or suggesting other interven-tions if patients have no concept of the diseaseprocess and how a team approach can promoterehabilitation. Initially, this should be undertaken ona one-to-one basis, tailoring information and sup-port to the patients’ needs, health status and thelevel of pain control at diagnosis, as well as theirability to assimilate information. With the patient’sconsent, partners and carers should be included inthe educational programme.

Research has highlighted difficulties in provid-ing information for patients and identified thatinformation recall immediately after a clinic

appointment is limited (Cameron 1996). It isessential that written information should alwayssupport any advice given. Providing writteninformation (or the use of audiovisual aids)means that relatives are able to review the infor-mation and gain a better understanding of theconsequences of the disease process. Patienteducation programmes (PEPs) should be providedin tandem with the regular support and educa-tion each patient receives. PEPs involve smallgroups of between five and ten patients, whoattend regular sessions over a period of one ortwo weeks. These programmes should includeinformation on:■ The disease process – aetiology, symptoms,

blood tests and investigations.■ Medication – disease modifying antirheumatic

drugs (DMARDs), steroids and biologics.■ Pain management – analgesia, non-steroidal

anti-inflammatory drugs (NSAIDs), joint injec-tions, as well as managing fatigue and pro-moting relaxation.

■ Exercise and joint protection.■ Complementary therapies.■ Nutrition.■ Goal-setting, self-help support groups and manag-

ing a flare (an increase in physical symptomatology,for example, pain, swelling and fatigue).

■ Podiatry. See Hill (1998) for additional information onpatient education programmes.

Medication A range of pharmacological inter-ventions is used in the management of RA.Patients might be prescribed medication for paincontrol, DMARDs, which are sometimes referred toas slow-acting antirheumatic drugs (SAARDs), bio-logics, such as anti-tumour necrosis factor alphatreatments, and intravenous, oral or depot injec-tions of corticosteroids.

The management of patients with RA receivinglong-term treatment for their disease relies onthe principles of informed consent (Dimond2001a and b). Patients should have an opportu-nity to discuss their medication and the potentialrisks and benefits of treatment. This adviceshould be supported with written information.Research has identified drug treatment and sideeffects as an area of significant concern forpatients with RA (Bath et al 1999).

Fig. 1. Triangle of care

Write notes on how you wouldexplain the disease process to apatient with RA. Imagine apatient who has been newlydiagnosed with RA, how would youbegin to assess his or her education needs?

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Patient and family

Primary care team Rheumatology team

■ Enhances patient and family empowerment

■ Provides a seamless service

Medical■ Diagnosis■ Prescribe pharmacological

treatments■ Physical assessment■ Referral to other members of

team or specialist support■ Regular review – general

medical and functional■ Monitor level of disease control

Nursing ■ Education■ Advice on pain management ■ Drug information■ Treatment monitoring■ Review of functional ability■ Social/psychological support■ Nutrition and skin integrity■ Telephone helpline support■ Symptom management

using goal setting

Physiotherapy■ Functional assessment: range

of movements, gait analysis■ Exercise regimens – water

and land-based■ Pain relief■ Improving mobility using goal

setting ■ Walking aids

Occupational therapy■ Joint assessment, protection

and splinting■ Assessment and advice on

need for energy-saving aids ■ Home assessment; assessment

of daily activities of living■ Pain management, relaxation■ Work assessment and

redeployment advice

Psychologist■ Psychological assessment■ Support in coping with grief,

denial, poor self-esteem andpain management

■ Theoretical expertise inpsychological aspects ofchronic disease

Podiatry■ Assessment of foot function

and deformities that restrict gait■ Pain relief■ Adaptation of shoes■ General chiropody advice

Dietician■ Assessment of nutritional

need and intake■ Improving nutritional intake

Box 3. Multidisciplinaryroles

Write down the informationand advice you would give toa patient who is experiencingmoderate systemic and localpain due to RA.

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Pain Pain is a cardinal feature of RA and is themost significant symptom of the disease. Mostpatients with RA need to rely on regular painrelief. Chronic uncontrolled pain can quicklylead to a cycle of sleeplessness, fatigue, loss ofappetite and depression (Hill and Ryan 2000).This can result in a loss of perceived control overthe disease and the ability to adequately controlpain. However, analgesia alone is not the answerand the psychological aspects of pain manage-ment should be considered simultaneously withpharmacological preparations. Health professionalsshould spend time learning to understand thepatient’s perspective on health, illness and anyother social issues that might reduce his or herability to focus on pain control. Distraction andrelaxation techniques can be used to supportthe pharmacological interventions and helppatients to explore the multifaceted aspects ofpain management. Pain management Regular non-opioid analgesiacan be advocated for the relief of mild to mod-erate pain. Pharmacological options for painrelief are outlined in Box 4. It is important toensure that patients receive adequate educationto enable them to use a step-up or step-downapproach to pain relief.

The anti-inflammatory, antipyretic and anal-gesic properties of NSAIDs can help to reducepain and early morning stiffness. Once the disease

is being managed and pain management is wellestablished, the dose of analgesia and NSAIDscan sometimes be reduced. There are moderaterisks associated with the long-term use ofNSAIDs and patients need to be fully assessed ona regular basis. The development of a class ofNSAID called Cox II has demonstrated an abilityto reduce significantly the risk of gastrointestinalside effects in some patients (Emery et al 1999).The National Institute for Clinical Excellence (NICE2001) advocates the use of Cox II for patients athigh risk of developing serious gastrointestinalcomplications.

Local pain control can be achieved in somejoints with the use of:■ Ice packs on hot and painful joints.■ Topical application of NSAI creams. ■ Hot baths to reduce pain and joint stiffness,

especially in the morning.■ Splinting to protect the joints.Disease-modifying anti-rheumatic drugsDMARDs are used to suppress the diseaseprocess and prevent the development of ero-sions and deformities. Current opinion supportsearly and aggressive treatment with DMARDs(Brooks 1998). These drugs are toxic and requirefrequent monitoring to reduce the risk of toxici-ty (Box 5). Research has demonstrated the ben-efits of using combination therapy (two or moreDMARDs), and there is little evidence of anyadditional toxicity as a result of using combina-tion treatments (O’Dell and Scott 1999). The roleof the nurse in supporting patients on DMARDtreatment involves providing advice and litera-ture on the risks and potential benefits of spe-cific drug treatments. Nurses also need to ensurethat patients are assessed and reviewed beforeand after treatment, and all assessments andadvice should be carefully documented. Regularblood monitoring is required to assess the safetyand efficacy of the new treatment alongside ongo-ing support and education of the patient, especiallyas it takes several months before the benefits ofthe treatment become apparent. Primary health-care teams need to be informed of the patient’streatment plan so that they can monitor the effec-tiveness of treatment, assess side effects and mon-itor any changes in drug regimens.Biologics During the past decade, new therapeuticoptions termed ‘biologics’ have become available.These drugs act on altering the normal immuneresponse by blocking the normal inflammatoryprocess. Biologics block tumour necrosis factoralpha, a cytokine that is implicated in launchingan inflammatory response.

These drugs are now being administered in intra-venous (infliximab) and subcutaneous treatments

Non-opioid■ Paracetamol■ Aspirin

Compound analgesics ■ Co-codamol (8mg codeine phosphate/

500mg paracetamol)■ Co-proxamol (32.5mg dextropoxyphene

hydrochloride/325mg paracetamol)■ Co-drydramol (10mg dihydrocodeine/

500mg paracetamol)■ Tylex (30mg codeine phosphate/500mg

paracetamol)

Non-steroidal anti-inflammatory drugs■ Ibuprofen 200mg four times a day■ Diclofenac sodium 75mg three times a day ■ Cox II selective■ Meloxicam 15mg once daily■ Cox II specific■ Celecoxib 200mg twice daily

Opioids – used to relieve moderate tosevere pain■ Dihydrocodeine tartrate 30mg■ Tramadol hydrochloride 50mg

Box 4. Analgesia used for pain relief in RA



Autoimmune diseases

(etanercept). The management of patients receiv-ing these drugs requires specialist nursing expert-ise to ensure thorough screening of patients forinfection before treatment and to monitor thebenefits of treatment. Patients need to bescreened for infection as there is the potential forthe new biologic agents to increase the risk ofinfection – it is not advisable to commence thistreatment in patients with co-existing infection.

Research in this field is ongoing and knowledgegained has informed researchers targeting otherpotent cytokines implicated in the inflammatorycascade. Corticosteroids Corticosteroids have the potentialto reduce pain as a result of their anti-inflamma-tory effect, however, long-term treatment withsteroids in RA remains controversial (Hill and Ryan2000). Therefore, corticosteroids are used mainlyto achieve remission and symptom relief duringexacerbations of the disease.

Maintaining functional ability requires a multidisci-plinary approach to assessment and recognition ofdeterioration in a range of movements. The role ofthe physiotherapist in assessing patients and advis-ing them on appropriate exercise regimens iscrucial. Hydrotherapy – the use of warm water forexercise – is an important part of physiotherapyfor patients with RA. Patients generally find exer-cising in water relaxing and rewarding (Hill andRyan 2000). Hydrotherapy programmes should besupported by the patient’s own regular exerciseregimen. The benefits of exercise need to be rein-forced regularly as patients might find exercisingtime-consuming and boring. Exercise helps tomaintain general body endurance and musclestrength, and reduces the risk of a decreasedrange of movement and functional limitation.

The role of the occupational therapist in assess-ing the needs of patients is paramount in enhanc-ing their independence and quality of life. Jointsthat are painful, hot and inflamed are vulnerableto damage, and movement increases pain. Athorough assessment of hand function, generalmobility and the activities of daily living (ADL) willprovide information to guide the changes neededto enhance the ability of the patient to maintainthese activities. Using simple aids can often resultin a significant reduction in pain and time takento undertake tasks, and this can boost self-esteem.The occupational therapist provides: ■ Splints for the protection for damaged and

vulnerable joints.■ Practical skills on energy conservation, for exam-

ple sitting down to do the ironing, and pacing

(achieving a balance between exercise and rest).■ Assessment of the home environment for

safety and practical aspects of daily living, forexample, safe access to bathing and the useof kitchen equipment and stair lifts.

■ Information on positive coping strategies.■ Educational advice and support on the work

environment or redeployment.■ Review and regular assessment of ADL.

Patients with poor nutrition are at increased riskof tissue damage, muscle wasting and weightloss. This can sometimes be attributed to an exac-erbation of the disease. Many aspects of generalwellbeing are interconnected to other areasdiscussed in this article, including pain, functionand psychological status. In addition to theseissues, patients should have access to: ■ Psychological support from a trained psychologist.

General wellbeing

Management of functional ability

Reflect on how you might feelif you had RA. Think aboutthe effect this diagnosis wouldhave on your psychological andsocial functioning, and aspects ofwellbeing. Discuss with a colleague what youthink the nurse’s role should be in enablingpatients to address and manage this aspect oftheir condition.

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■ Hydroxychloroquine■ Azathioprine■ Cyclosporin■ Cyclophosphamide■ Leflunomide■ Methotrexate■ Gold salt (sodium aurothiomalate)■ Penicillamine■ Sulphasalazine■ Biologics

Side effects of all DMARDs■ Bone marrow suppression■ Increased risk of infection due to

immunosuppression■ Renal dysfunction■ Gastrointestinal effects – diarrhoea and

nausea■ Pulmonary – pneumonitis■ Cytotoxic cautions – infertility or potential

damage to unborn child/breastfeeding infant■ Skin reactions■ Loss of hair

Box 5. Disease-modifying antirheumaticdrugs and main side effects



Autoimmune diseases

■ Podiatry services. ■ Dietary advice from a dietician. ■ Equipment to enhance independence and reduce

fatigue, such as utensils, chair raisers and bath aids.■ Information on support groups, agencies and

benefits available.■ A telephone helpline service.

The responsibility of the multidisciplinary team isto provide an open and caring environment forindividuals to discuss and seek guidance onvarious complementary therapy options. There isinadequate research evidence to support the long-term benefits of complementary therapies or pos-sible interactions with other medication. However,the therapeutic benefit of touch together with thepatient’s perception of regaining ‘control’ overtheir disease using complementary therapies hasbeen recognised as having a positive effect (Ersser1995). It is essential that the therapy is provided bya competent practitioner (Rankin-Box 1995).

People with RA experience alterations in theirsocial and occupational roles. Patients havereported lost relationships, disrupted leisureactivities and limitations in employment (Yelin etal 1987). The unpredictability of symptoms interms of pain, stiffness and fatigue, and the con-sequences of ongoing disease places a psycho-logical burden on individual patients and theirfamilies. Maycock (1988) refers to living with RAas ‘a tightrope between freedom and a life sen-tence’. Nurses involved in the management ofpatients with RA need to address psychologicaland social function within a holistic care assess-ment to provide a comprehensive managementplan for each patient.Altered body image Body image refers to theway in which an individual feels about his or herbody in terms of appearance and function, andhow he or she believes others regard his or herbody (Pigg et al 1985). Altered body imageexists when coping strategies (individual orsocial) to address changes in body reality, idealor presentation are overwhelmed by injury, dis-ease, disability or social stigma (Price 1998).

There are many reasons why a person livingwith RA might experience alterations to his orher body image. The disease process has adverseeffects on the structure and function of joints,muscles, tendons and ligaments. Most patientswill experience a certain degree of muscle wast-ing. Severe disease is accompanied by the pres-

ence of subcutaneous nodules often affectingthe upper limbs and ulna deviation of the fingerjoints. Such changes to the structure of the jointsand muscles will affect the range of movementand function. Patients might also be affected bythe visibility of the treatment regimen, includingthe use of oral steroids, which alter the distribu-tion of body fat. Even the use of a wrist splint tosupport functional activity might confer topatients that they are different and thus influ-ence their perceptions of their body image.

During assessment the nurse needs to take noteof how patients refer to and use their body. If neg-ative terminology is used, for example: ‘...thesehands are no good for anything’ then furtherexploration will be required to assess the impacton psychological and social function. Negativeperceptions of body image can lead to social with-drawal and subsequent isolation. The manage-ment of body image problems is outlined in Box 6.

Sexuality Sexuality is an under-researched area.Blake et al (1987) found that feelings of unattrac-tiveness, loss of partner interest and absence ofsexual drive were as prevalent among people with-out illness as they were in patients with RA. Wherepatients with RA differed was that they experi-enced a greater loss of sexual satisfaction overtime; physical symptomatology cited as causativefactors included joint pain and fatigue. In an auditof RA outpatients, Ryan et al (1996) found that 69per cent of patients with RA perceived that theircondition had adversely affected their sexual rela-tionship and they attributed this to pain, reducedjoint function and the effects of medication. LeGallez (1996) found that patients reported feweropportunities to engage in sexual activity and foundfatigue a prohibiting factor. Many patients haveexpressed a desire to discuss sexuality with healthprofessionals (Blake et al 1987, Ryan et al 1996).

All aspects of sexuality must be addressed on anindividual patient basis. Following an initial assess-ment, a management plan should be devised. Thismight include advice on planning sexual activity,using pillows to support joints, having a hot bathand taking analgesia before commencing sexualactivity. Aromatherapy oils can promote relax-ation and different positions can be adopted to

Psychological and social factors

Complementary therapies

■ Focus on positive aspects ofadaptation to improve thepatient’s confidence andreinforce that the patienthas successfully adoptedcoping strategies in otherareas of care management

■ Adapted equipment can beused to improve independence (for example,a long-handled comb)

■ Meet with other patients tolearn how they haveovercome similar problems

■ Understand how the manipulation of drug treatment can influencebody image (for example,methotrexate-inducedalopecia is often related tothe dose)

■ Involve patients in an education programme toimprove self-efficacy inmanaging the condition.Hawley (1995) identifiedthat pain, depression, self-efficacy, coping abilitiesand self-management activities improved followingattendance on a patienteducation programme

■ Refer patients to a psychologist where appropriate

■ Involve other health professionals to assist withhand function

Box 6. Management ofaltered body image

Before reading on, writedown what information andguidance you would give to apatient who asked for your helpregarding difficulties with sexualintercourse as a result of pain and limitationof movement in the joints.

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Autoimmune diseases

avoid unnecessary strain on the joints. Patientsshould be encouraged to attend an educationprogramme to learn how to cope with reducedself-esteem, the effects of medication on bodyimage, and so on. Appropriate patient literaturecan be obtained from the Arthritis ResearchCampaign and referral to specialist organisationsshould be accessible for all patients.Depression It has been estimated that depres-sion affects between 21 and 34 per cent ofpatients with RA (Creed et al 1990), althoughthe true incidence might be a lot higher.Depression can impair psychological, social andvocational function (Parker and Wright 1995).Features of depression include alteration inappetite and sleep pattern, loss of interest andenjoyment in life, lack of drive and motivation,and agitation and restlessness (Hill and Ryan2000). Patients will often require a combinationof antidepressant therapy and counselling. Work Many patients with RA discontinue workwithin ten years of developing the condition(Meenan et al 1981). Both the patient and his or herfamily will require psychological support through thisperiod of adaptation. Appropriate agencies, such asthe disability employment adviser, can provide infor-mation regarding retraining and financial assistance.Family When a family member has a chronic ill-ness such as RA, the family unit can be affected –it might become stronger, or the pressure mighthave a negative impact on the roles taken withinthe unit (Affleck et al 1988). It is important toinvolve the family in the patient’s care assessmentand management, so that family members canlearn to recognise and interpret the clinical symp-toms and support the individual in self-manage-ment. For example, undertaking regular exercisecan become a social activity for all the family. Thiscan also provide a useful opportunity to discussthe level and type of support the family is willingand able to provide, and to ensure that it is inaccordance with the patient’s perceived needs.

Professional (UKCC 1992) and political agendas(DoH 1999, 2001) support nurses in using theirexpertise to enhance care and improve serviceprovision. Rheumatology specialist nurses haveled the way in providing nurse-led clinics (Hill

1992). The nurse-led service promotes independ-ence and empowers patients to manage theircondition effectively (McCabe et al 2000) (Fig. 2).The role of nurses at these clinics includes:■ Assessing disease activity and functional ability.■ Recording evidence-based assessments.■ Reviewing pain management. ■ Providing ongoing education.■ Administering soft tissue or intra-articular joint

injections.■ Providing an opportunity to review patients’

and relatives’ anxieties.■ Implementing a patient-focused plan to

address problems identified.■ Monitoring drug efficacy and side effects.■ Reducing the need for emergency admissions.■ Liaising with other healthcare professionals,

including primary healthcare teams.■ Supporting patients with changes in treatment

and offering advice. ■ Offering education and research opportunities in

collaboration with other healthcare professionals.■ Providing additional support through a telephone

helpline service.■ Offering psychosocial support, advice and referral

to other agencies.■ Providing information on coping styles.The assessment of disease activity and functionalability is often undertaken in nurse-led clinics,although there is an element of overlap with otherteam members. This assessment process must be avalid and reliable method of recording changes.There are various validating assessment tools formeasuring swollen and tender joints, functional

Nurse-led clinics

Fig. 2. Aspects of care and assessment in a nurse-led clinic

Reflect on and make a list of theprofessional issues you thinkshould be considered beforesetting up a nurse-led clinic?

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Pain

Skin integrity

Nutrition

Self-esteem

Medication Health beliefs

Social support

Role in society

Personal care

Mobility

FatigueStiffness

Body image and sexual issues

Patientempowerment

Education

Support



Autoimmune diseases

ability and activities of daily living for patients withRA (Box 7). It is vital that nurses have an in-depthknowledge of the assessment tools used, includinginformation on the strengths and weaknesses ofdata collected, and whether they reflect thepatient’s perceptions of change (Oliver 2000).

The holistic nature of nurse clinics enablespatients to receive a wide range of support. Inrecent years, nurses have extended their expertiseto administer joint injections. This role mightenhance the therapeutic relationship betweennurses and patients, reducing the need for furtheroutpatient clinic appointments and promotingearlier pain relief. However, administering jointinjections must be considered in the context ofenhancing patient care (Wright 1995). The pro-vision of a telephone helpline service acts as anadditional ‘safety net’ for patients and healthprofessionals. The service provides access, sup-port and guidance on disease problems, drugtreatments and psychological needs.

Patients with RA require access to a team of healthprofessionals who can guide, support and empow-er patients to manage their condition effectivelywithin a negotiated care framework. By working in

partnership with patients the main objective ofmaintaining physical and psychological functionand independence can be addressed

Conclusion

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Bath J et al (1999) Patient perceptions ofrheumatoid arthritis. Nursing Standard.14, 3, 35-38.

Blake D et al (1987) Sexual quality of lifeof patients with arthritis compared toarthritis free controls. Journal ofRheumatology. 14, 3, 570-576.

Brooks P (1998) Rheumatology: recentadvances. British Medical Journal.June, 316, 1810-1812.

Cameron C (1996) Patient compliance:recognition of factors involved andsuggestions for promoting compliancewith therapeutic regimes. Journal ofAdvanced Nursing. 24, 2, 244-250.

Creed F et al (1990) Measurement ofpsychiatric disorder in rheumatoidarthritis. Journal of PsychosomaticResearch. 34, 1, 79-87.

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Reflect on patients in yourarea of practice who have hadchronic conditions and make alist of some of the issues that arecommon to them. Based on whatyou have read, highlight three issues that areunique to patients diagnosed with RA.

TIME OUT 7

Now that you have completedthe article, you might like towrite a practice profile.Guidelines to help you are onpage 55.

TIME OUT 8

■ Arthritis Research Campaign,Copeman House, St Mary’s Court,St Mary’s Gate, Chesterfield,Derbyshire S41 7TD

Useful address

■ The Health AssessmentQuestionnaire (Fries et al1980)

■ The Arthritis ImpactMeasurement Scales(Meenan et al 1980)

■ Functional Assessment Tool(Oliver 2000)

■ Modified Disease ActivityScore (Prevoo et al 1995)

Box 7. Tools for assessingpatients with RA

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