Nurse practitioner Dana Murdock, RN, explains the treatment pyramid for RA. Education is a key to patients’ participation in control of the disease.

Patricia Patterson

Awareness is key to rheumatoid arthritis

Rheumatoid arthritis (RA) is a fickle disease. Its cause is unknown, and no one can predict its course. It may attack suddenly or, more often, creep in slowly, showing only vague symptoms such as fatigue and weakness. Then it may dis- appear completely, recur episodically, or progress steadily. When active, RA alters joint tissue.

But with education and good health management, the disease can be con- trolled. Patients can live active lives with minimal joint damage and disabil- ity and relief from pain and inflamma-

tion caused by the disease. Numerous effective drugs are availa-

ble. Proper rest, physical therapy, and orthopedic devices also help control the disease. For more serious cases, joint reconstruction and replacement with prostheses can prevent further destruc- tion, correct deformity, and relieve pain.

The RA patient who comes to the OR for any type of surgery may have pain, inflammation, and a complicated medi- cal history, including anemia and com- bined drug therapy. Rheumatoid ar-

614 AORN Journal, October 1980, Vol32, No 4

thritis attacks not just the joints but the entire body. Awareness of the nature of the disease and the patient’s status and current treatment helps the OR nurse plan proper intraoperative care.

The RA patient should be receiving ongoing care. If he is on gold salt therapy, he probably will be seen weekly. At the Arthritis Clinic a t the University of Colorado Health Sciences Center, Denver, we talked to two nurse practitioners about how they manage chronic care of patients with uncompli- cated cases and those on gold therapy and d-penicillamine. Myrna Denholm, RN, and Dana Murdock, RN, described the continuing care of RA patients. When patients s tar t coming to the clinic, they are seen by physicians for four or more visits. After referral from the physician, the nurse practitioner manages their care as well as provides patient education classes.

The key to treatment is control, not cure. And the key t o control is patient education. The nurses conduct classes for patients to develop a solid base of information for their care. First, pa- tients learn about the basic facts of the disease-that it is chronic, systemic, complex, and can destroy joints. They also learn that they must be conscien- tious in following a treatment program that may involve a variety of measures. The clinic’s treatment pyramid is intro- duced (Fig 1).

The nurses inform patients about quackery-the so-called “cures” adver- tised in supermarket tabloids and the old wives’ tales passed on by well- intentioned friends and relatives. Mur- dock commented tha t “quackery is probably the largest problem we have to face from the general public.”

Denholm added, “They also have fears whether the disease will be pro- gressive and crippling. We give them in- formation about the percentages of pa- tients who fall into the three categories

of the disease. In general, about 35% will have monocyclic disease (one inci- dent with no recurrence); 50% will have polycyclic disease (a series of episodes and remissions); and 15% will have progressive, crippling disease that de- stroys joints in a short time.

“The average patient will be in the polycyclic group, with peaks and valleys probably for the rest of their lives,” she said. “We t ry to encourage them to stay with our education and treatment pro- gram so we can prevent as much defor- mity and promote as much comfort as possible.”

Classes also include information on physical therapy, drug therapy, ortho- pedic measures, and the value of rest. Differences between rheumatoid ar- thritis and degenerative joint disease are presented.

In the fourth session, after the group has gotten to know each other, a social worker guides them in a discussion of the five stages of loss, adapted from the work of Elisabeth Kubler-Ross. The five stages are denial, rage or anger, bar- gaining, depression, and acceptance. “They talk about anxieties and their hostile feelings,” Murdock said.

The nurses believe that the patient who has a thorough understanding of his disease is more likely to stay with the treatment program. He will be more inclined to cooperate in the series of treatments that may have to be tried to control his condition. The knowledge will help him tolerate the frustration of living with a chronic disease and the attempts to find a treatment program appropriate to his problems. The rest of the treatment plan must rest on this foundation of patient education.

Therapy must be based on realistic goals, which Robert W Lightfoot, Jr, MD, suggests are relief of symptoms, prevention of joint destruction, and a modified lifestyle.’ Rest, physical ther- apy, and drugs are the main elements of

AORN Journal, October 1980, Vol32, No 4 615

Experimental drugs and procedures

Reconstructive Immunosuppressive surgery drugs

Gold D- Oral therapy penicillamine steroids

Nonsteroidal Intra- Nonnarcotic Orthopedic Antimalarial anti- articular analgesics devices agents inflammatory steroids drugs

B A S I C P R O G R A M

Physical Occupational Salicylates Nutrition Psycho- Education: Rest: patient local therapy therapy logical family systemic support

Fig 7. A pyramid showing treatments for rheumatoid arthritis used at the Arthritis Clinic, University of Colorado Health Sciences Center, Denver,

disease management. Rest seems to bring relief from acute

flareups, but the patient must under- stand what proper rest entails in his particular case. Dr Lightfoot advises that a two- to four-hour rest period helps combat early afternoon fatigue typical for RA patients. For severe, acute exacerbations, complete bed rest may be necessary.2

“You have to individualize the rest pattern for each patient,” Denholm said. “We encourage pacing or control- ling the routine through the day to al- ternate rest with activity. In an occupa- tion where there is stress on the same joints all the time, patients tend to have permanent joint damage. They need to be relieved during the day.”

“Most patients feel they have to be active at some time during the day,” Murdock added. Otherwise, they tend to have more of the “gelling” effect-the

joint stiffness that makes it hard to get moving. They have to be active to avoid discomfort. Hot and cold applications and paraffin may also be used to relieve pain and inflammation.

Physical therapy for RA balances rest and exercise. The patient is directed to perform a complete range of motion at least twice a day. Emphasis is on iso- metric and isotonic exercise, not stren- uous, resistive exercises that can ag- gravate inflammation. Gentle exercise, joint-saving techniques, and proper po- sition during rest can assist in control- ling joint contractures. The patient is instructed to rest in a position as near as possible to the anatomic. Splinting can also assist in relieving pain and pre- venting def~rmi ty .~

A variety of drugs is used to ease symptoms of RA. Therapy usually be- gins with conservative salicylate treatment and progresses up the heirar-

616 AORN Journal, October 1980, Vol32, No 4

Patient’s descriptions of ho w they feel provide important data. Here Myrna Denholm, RN, talks to a patient during his weekly clinic visit.

chy until the symptoms respond. Each drug has side effects.

Aspirin is the first-line treatment, used in large doses for its antiinflam- matory effect. The dosage is increased to mild toxicity, then decreased to a toler- able level. Tinnitus and gastrointesti- nal distress are the common side effects, and patients are cautioned to take their aspirin during meals or use antacid as a prophylactic.

Nonsteroidal antiinflammatory drugs (NSAIDs) may be used in place of aspirin because they generally have fewer gas- trointestinal side effects, but Dr Light- foot reports they are seldom more effec- t i ~ e . ~ The new agents include fenoprofen (Nalfon), ibuprofen (Motrin), naproxen (Naprosyn), sulindac (Cliniril), and tolmetin sodium (Tolectin). If more ag-

gressive treatment is needed, aspirin or NSAIDs may be continued while gold salts-the next most potent agent-are administered. Gold is given in a cumula- tive fashion and may take about three months of weekly injections to reach full effect.

Gold benefits about seven of ten pa- tients who are treated early in the dis- ease. Two of ten patients will not be able to tolerate it, and one of ten will not benefit. Gold therapy has three main side effects-skin rash and potential damage to the kidneys and bone mar-

If the patient does not respond to aspi- rin, NSAIDs, or gold, the physician will probably prescribe d-penicillamine. Like gold, results may not be felt for several months. Gold is discontinued

AORN Journal, October 1980, Vol32 , No 4 617

Range of motion is an important part of the regular assessment for RA patients, since it provides an index to the status of pain

and inflammation.

6 18 AORN Journal, October 1980, Vol32, No 4

before penicillamine is started, since gold will be chelated by penicillamine, neutralizing the effect.6 Bone marrow depression is the most serious side effect and may be life-threatening. Israeli A Jaffe, MD, strongly recommends non- refillable prescriptions, with hemo- tologic reports obtained before a new prescription is issued. “Complete blood count, including platelets, should be done every two weeks for the first six months and monthly thereafter,” he ad- vises.’

Intraarticular and systemic cortico- steroids may be included in the drug treatment regimen. At the Arthritis Clinic, joint injections of steroids are in- cluded in the second level of therapy, with the NSAIDs, nonnarcotic anal- gesics, and/or antimalarial agents. The injections are found to be most ben- eficial when one joint or tendon sheath is inflamed out of proportion to the rest of arthritis activity. No more than three injections per joint per year are recom- mended since more frequent use can ac- celerate cartilage and joint destruction.

The oral steroids are part of the third treatment level, accompanying the gold salts and d-penicillamine. Arthritis ex- perts differ about the place of the sys- temic corticosteroids in drug therapy. They agree, however, that the decision to use them should be carefully weighed with each patient’s condition and life situation.

Immunoregulatory agents such as those used in cancer chemotherapy may be used in advanced cases. Examples a re azathioprine and cyclophos- phamide. Rheumatoid a r thr i t i s is thought to be related to a disruption in the immune system, and these drugs may stimulate the system to control the disease. No one is yet sure how or why this works. The drugs are toxic to the bone marrow, causing leukopenia and thrombocytopenia. Other side effects may include nausea and vomiting, a

rash, and hepatitis. Minor tranquilizers such as diazepam

(Valium) and chlordiazepoxide hy- drochloride (Librium) are prescribed for some patients.

How does the OR nurse plan when a rheumatoid arthritis patient is coming to surgery? She takes the same com- prehensive, well-informed approach that is used in the patient’s total treat- ment. A review of the patient’s history and assessment of his present condition provide clues for a n intraoperative care plan that considers protection of joints, prevention of skin breakdown, and possible side effects from medica- tions. She understands that depression, anxiety, and feelings of loss often ac- company chronic disease.

Betty Guthery, RN, an OR nurse specializing in orthopedics at the Uni- versity of Colorado Health Sciences Center, joined Denholm and Murdock in offering suggestions for perioperative nursing care. The three agreed it is best if an OR nurse can see the patient before he comes to the OR suite, whether on the unit or in the orthopedic clinic. The patient is the best source of information about his condition, including joint in- volvement.

“I think it’s almost imperative that OR nurses know which joints are prob- lems for the patient,” Murdock said. She advised doing a range-of-motion as- sessment the night before surgery or be- fore the patient is premedicated. “I’ve had some patients who’ve had serious problems with a joint after it was im- properly positioned during surgery. If a joint seems resistant, don’t move it.” If they suffer ill effects from positioning, patients may fear future surgery, re- membering how uncomfortable they were previously.

In the Arthritis Clinic, Denholm and Murdock use active and passive range of motion to check their patients’ joints, and they ask them where they have

AORN Journal, October 1980, Val 32, No 4 619

The nurse exercises extra care in positioning joints of RA patients. Here an arthritic elbow is placed in the position of comfort.

pain and stiffness. Inflammation and discomfort rise and fall from day to day. Before surgery, it is important to ask the patient where there are contrac- tures, nodules, and limits to the range of motion.

“The first thing I notice is how they’re walking down the hall,” Denholm said. Their gait and ease of movement indi- cate their status. And their facial ex- pression is an important clue to how they’re feeling.

Guthery advised OR nurses to be aware of the same factors they would consider in positioning any patient. Damage to peripheral nerves and ves- sels is a threat to any surgical patient, as is skin breakdown over bony promi- nences. With RA patients, there are the additional problems of compromised

joints, and vasculitis may predispose them to skin breakdown. Rheumatoid nodules, which may occur in tissue over pressure areas, require protection against further damage. Nodules may occur over the olecranon, patella, scapu- lar area, the back of the head, the but- tocks, and the knuckles.

Guthery and Bev Peratino, RN, OR head nurse, demonstrated positioning for an elbow with a flexion contracture. The arm is placed in a position of com- fort, padded, and taped. If there are finger deformities, those joints should be padded, too.

The neck is protected during position- ing for intubation since there may be arthrit ic involvement of the first through third cervical vertebrae.

Cushioning of pressure points is espe-

620 AORN Journal, October 1980, Vol32, N o 4

Other nursing care suggestions Whether he is having joint surgery or another procedure not directly related to the disease, the RA patient has special needs. These are other suggestions:

0 Find out the patient‘s goal for nursing care in the OR. Although your goal might be that he will be free from infection, his major concern may be protecting a joint.

0 Determine if other personnel will need instruction in caring for the patient. For example, transport personnel will need to know which joints are involved, so they can move the patient properly.

0 Find out the number and location of metal joint implants. Current can cause burns if the electrosurgical grounding pad is placed too near a metal prosthesis.

0 Communicate to recovery room nurses which joints are affected and if the patient has prostheses, so they can include this in their care plan.

0 Most of all, realize that RA patients are a population with special needs.

cially important for RA patients if they tend to be thin. Guthery said she is care- ful to provide the extra padding. In the supine position, used for hip and knee replacement procedures, the sacrum re- ceives the most pressure and is pro- tected with foam padding. The other pressure points are the back of the head, shoulders, elbows, and heels.

The lateral position is the most dif- ficult for patient protection, Guthery believes. The lower side of the body is considered to be compromised because there is pressure on the shoulder, arm, hip, and leg as these areas are com- pressed against the table by the body’s weight. Padding is needed, not only for these compromised areas, but also be- tween the knees and ankles. The upper arm must be supported and the patient stabilized by tape or safety straps in the lateral position.

Providing emotional support before surgery is important. RA patients may come to the OR depressed. Loss of func- tion and the frustration of living with a chronic disease may deepen the depres- sion patients often feel before surgery. Murdock noted that before a joint re- placement surgery, patients who have had previous joint replacements are likely to be depressed. “I attribute it to the theory of loss developed by Kubler- Ross,” she said. Before a joint replace- ment, a patient may be experiencing one of these feelings because “this is another joint they have lost,” Murdock explained. They may experience these feelings even though they express satis- faction after the surgery because the pain is relieved and mobility is im- proved.

The patient may have had to cope with other types of loss as well. They may have had to retire from their job, curtail activity, and perhaps give up the independence of living in their own home.

Care of RA patients is complex and multifaceted. By understanding the disease process, the OR nurse can con- tribute to the whole program of care.

Notes 1. Robert W Lightfoot, Jr, “Treatment of rheu-

matoid arthritis,” in Arthritis and Allied Conditions, ed. Daniel J McCarty (Philadelphia: Lea & Febiger, 1979) 514.

2. lbid. 3. lbid, 515. 4. lbid, 517. 5. Gold Treatment in Rheumatoid Arthritis (New

York: Arthritis Foundation, 1977). 6. Lightfoot, “Treatment of rheumatoid arthritis,”

517. 7. Israeli A Jaffe, “Penicillamine treatment in

rheumatoid arthritis,” in Arthritis and Allied Condi- tions, ed. Daniel J McCarty (Philadelphia: Lea & Febiger, 1979) 371.

8. Lightfoot, “Treatment of rheumatoid arthritis,” 517.

AORN Journal, October 1980, Vol32, No 4 62 1