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The Journal for Nurse Practitioners
Volume 7, Issue 10,
, Pages 858-862, 870
Rheumatoid arthritis (RA) is a devastating illness that can have lifelong and potentially disabling consequences. Because the disease affects 1.29 million Americans, nurse practitioners (NPs) can expect to encounter a patient who suffers from this disease sometime during their career. Early diagnosis is crucial. The purpose of this article is to provide NPs an understanding of the clinical presentation and diagnosis, treatment options, and follow-up required for RA patients. With the current shortage of specialists to provide care to these patients, there will be increasing opportunities for NPs to partner with other health care providers to manage this patient population.
Clinical Presentation and Diagnosis
The NP, as a primary care provider, is typically the first person a patient sees after the onset of symptoms. Although pain is the most common motive to seek medical care, there can be many associated symptoms, and the patient can present at varying stages of the disease.3
Diagnosis is often based on the patient's history and clinical presentation.3, 4 When completing the health history, the NP should pay particular attention to the onset of symptoms as the inception of RA is usually subtle,
Early, aggressive, and effective treatment is imperative in the management of RA because the end result will be a significant reduction in the disease progression.2, 7 If left untreated, 20% to 30% of patients with RA will become permanently work-disabled within 2–3 years of diagnosis, causing major economic loss.4 Approximately 50% of individuals diagnosed with RA will have substantial functional disability after 10 years of diagnosis, which is 4–15 times greater than the general population.2
The historical approach to the management of RA was to maintain the patient on non-steroidal anti-inflammatory drugs (NSAIDs) for as long as possible, only to add more potent medications when the patient's disease had progressed.1, 4 The current approach to management is to initiate a disease-modifying, anti-rheumatic drug (DMARD) within 3 months of diagnosis.1, 4
Pharmacologic management should be under the direction of a rheumatologist. However, there will be occasions when the NP will be
The NP needs to assess the nutritional and dietary status of RA patients. Symptoms can be worse in people who are overweight as a result of increased strain on the joints. Eating a diet that is high in fiber, low in fat and sugar, and contains plenty of fruit and vegetables can help maintain a healthy weight and provide the body with needed vitamins and minerals.8 Patients with RA are at risk for developing osteoporosis, so it is especially important to consume a diet high in calcium and
The ACRSRA guidelines recommend that patient follow-up include ongoing evaluation for subjective and objective evidence of active disease.4 Assessment should include degree of joint pain, duration of morning stiffness and fatigue, presence of actively inflamed joints, and limitation of function. Loss or decrease in ROM, instability, misalignment, and deformity are evidence of disease progression.2 ESR and CRP elevation and evidence of disease progression on X-ray should also be assessed.2 NPs
Future Roles for the NP
The role of the NP will continue to grow with respect to RA. The emergence of chronic-disease management models will eventually encompass RA. NPs' training and expertise will guarantee them a role in managing this chronic disease.19
In the United Kingdom, NP rheumatology clinics have been proven to be feasible and cost-effective.19 Working in collaboration with the rheumatologists, these clinics have been able to provide comprehensive patient care and allow the rheumatologist to diagnose and
RA is a chronic disease that has the potential to cause significant distress and disability. The NP's role in management is invaluable and can be multifaceted. As a primary provider, the NP may be the first person the patient will see after the onset of symptoms. Diagnosis, referral to other providers, education, support, and follow-up are just some of the services the NP can provide. As the population ages, the need for providers proficient in RA management will increase, providing an
- A Golding et al.Rheumatoid arthritis and reproduction
Rheum Dis Clin North Am
Rheumatoid arthritis. Centers for Disease Control and Prevention Web site
- Mease PJ. Current clinical strategies for rheumatoid arthritis. Rheumatoid Arthritis: Meeting the Patient-Care...
- HR Smith
- JA Rindfleisch et al.
Diagnosis and management of rheumatoid arthritis
Am Fam Physician
- American College of Rheumatology Subcommittee on Rheumatoid Arthritis Guidelines
Guidelines for the management of rheumatoid arthritis. 2002 Update
- AN Lee et al.
Rheumatoid factor and anti-CCP autoantibodies in rheumatoid arthritis: a review
Clin Lab Sci
- S Bruce
Recent developments in the treatment of rheumatoid arthritis
J Pharm Pract
(2009)(Video) The role of patient organisations in rheumatology
- K Rennie et al.
Nutritional management of rheumatoid arthritis: a review of the evidence
J Hum Nutr Diet
There are more references available in the full text version of this article.
2019 EULAR recommendations for the generic core competences of health professionals in rheumatology
2020, Annals of the Rheumatic Diseases
The role of nurse practitioners in delivering rheumatology care and services: Results of a U.S. survey
2017, Journal of the American Association of Nurse Practitioners
Research articleDid the American Academy of Orthopaedic Surgeons Osteoarthritis Guidelines Miss the Mark?
Arthroscopy: The Journal of Arthroscopic & Related Surgery, Volume 30, Issue 1, 2014, pp. 86-89
The American Academy of Orthopaedic Surgeons (AAOS) 2013 guidelines for knee osteoarthritis recommended against the use of viscosupplementation for failing to meet the criterion of minimum clinically important improvement (MCII). However, the AAOS's methodology contained numerous flaws in obtaining, displaying, and interpreting MCII-based results. The current state of research on MCII allows it to be used only as a supplementary instrument, not a basis for clinical decision making. The AAOS guidelines should reflect this consideration in their recommendations to avoid condemning potentially viable treatments in the context of limited available alternatives.
Research articleAdjuvant argon-based cryoablation for joint-preserving tumor resection in patients with juxta-articular osteosarcoma around the knee(Video) Rheumatoid arthritis | NHS
Cryobiology, Volume 71, Issue 2, 2015, pp. 236-243
Opinion remains controversial as to whether joint-saving surgery could be safely performed in patients with juxta-articular osteosarcoma. The aim of this study was to assess the validity of adjuvant cryosurgery in joint salvage surgery.
We evaluated the oncological and functional outcomes of patients who underwent joint-sparing surgery in which argon-based cryoablation was employed to aid partial epiphysis-preserved tumor resection for osteosarcoma around the knee (7 in proximal tibia, 5 in distal femur).
The study included 12 patients (5 male, 7 female, mean age 15.8years (11–24). At a mean follow-up of 48.4months (38–61), lung metastasis occurred in three patients. Among these, one patient had died, one was alive with disease, and one had no evidence of disease after lobectomy. Histological examination of the resected specimens revealed no viable tumor at the osteotomy plane. There was no local recurrence in the residual epiphysis except one in soft tissue. The mean Musculoskeletal Tumor Society functional score was 92.7%.
Argon-based cryosurgery is a reliable method of sterilizing the tumor in the epiphysis thus allowing safe joint-saving tumor resection possible in patients with juxta-articular osteosarcoma.
Research articleSmoking cessation advice in limb reconstruction: An opportunity not to be missed
Injury, Volume 48, Issue 2, 2017, pp. 345-348
The adverse health effects of smoking are well known, including its effects on the musculoskeletal system. Limb reconstruction using external fixators is a high intensity process with high levels of patient contact time, complications and cost. The aim of this study was to examine smoking patterns in this group and in particular to assess trends in smoking cession.
Data was collected from 41 patients all undergoing treatment using circular frame external fixation, for a variety of pathologies, most commonly acute tibial trauma. A patient reported questionnaire was used. Data was collected over a six-month period.
In our population 56.1% of patients were smokers. During the study 47.8% patients stopped smoking and a further 39.1% decreased their smoking behaviour. 78.3% of patients could recall being given smoking cessation advice. In our group, 87% of patients were unaware of the effects of smoking on bone healing. Once made aware during discussion of proposed treatment, 73.9% stated that it was, in part, this knowledge that prompted them to positively change their smoking habits.
The results of this study show that advice regarding smoking cessation during limb reconstruction treatment can potentially have a positive impact on patients smoking habits. The effect of smoking should be linked to the patient pathology and discussed during the consent process.
Taking the time with the patient for this simple free intervention can have a positive impact on patient health, and potentially on the outcome of their current treatment, and is an opportunity not to be missed.
Research articleTrauma surgery by general surgeons: Still an option for proximal femoral fractures?
Injury, Volume 48, Issue 2, 2017, pp. 339-344
Surgery for proximal femoral fractures in the Netherlands is performed by trauma surgeons, general surgeons and orthopaedic surgeons. The aim of this study was to assess whether there is a difference in outcome for patients with proximal femoral fractures operated by trauma surgeons versus general surgeons. Secondly, the relation between hospital and surgeon volume and postoperative complications was explored.
Patients of 18 years and older were included if operated for a proximal femoral fracture by a trauma surgeon or a general surgeon in two academic, eight teaching and two non-teaching hospitals in the Netherlands from January 2010 until December 2013. The combined endpoint was defined as reoperation or surgical site infection. Multivariate analysis was used to adjust for patient and fracture characteristics and hospital and surgeon volume. Categories for hospital volume were>170/year (high volume), 96–170/year (medium volume) and <96/year (low volume).
In 4552 included patients 2382 (52.3%) had surgery by a trauma surgeon. Postoperative complications occurred in 276 (11.6%) patients operated by a trauma surgeon and in 258 (11.9%) operated by a general surgeon (p=0.751). When considering confounders in a multivariate analysis, surgery by trauma surgeons was associated with less postoperative complications (OR 0.746; 95%CI 0.580–0.958; p=0.022). Surgery in high volume hospitals was also associated with less complications (OR 0.997; 95%CI 0.995–0.999; p=0.012). Surgeon volume was not associated with complications (OR 1.008; 95%CI 0.997–1.018; p=0.175).
Surgery by trauma surgeons and high hospital volume are associated with less reoperations and surgical site infections for patients with proximal femoral fractures.(Video) The role of the rheumatology clinical nurse specialist
Research articleThe ABC risk score for patients with atrial fibrillation
The Lancet, Volume 388, Issue 10055, 2016, p. 1979
Research articleQuality Standards for Rheumatology Outpatient Clinic. The EXTRELLA Project
Reumatología Clínica (English Edition), Volume 12, Issue 5, 2016, pp. 248-255
In recent years, outpatient clinics have undergone extensive development. At present, patients with rheumatic diseases are mainly assisted in this area. However, the quality standards of care are poorly documented.
To develop specific quality criteria and standards for an outpatient rheumatology clinic.
The project was based on the two-round Delphi method. The following groups of participants took part: scientific committee (13 rheumatologists), five nominal groups (45 rheumatologists and 12 nurses) and a group of discussion formed by 9 patients. Different drafts were consecutively generated until a final document was obtained that included the standards that received a punctuation equal or over 7 in at least 70% of the participants.
148 standards were developed, grouped into the following 9 dimensions: (a) structure (22), (b) clinical activity and relationship with the patients (34), (c) planning (7), (d) levels of priority (5), (e) relations with primary care physicians, with Emergency Department and with other clinical departments, (f) process (26), (g) nursing (13), (h) teaching and research (13) and (i) activity measures (8).
This study established specific quality standards for rheumatology outpatient clinic. It can be a useful tool for organizing this area in the Rheumatology Department and as a reference when proposing improvement measures to health administrators.
En los últimos años, el peso específico de las consultas externas ha aumentado considerablemente. En la actualidad, la mayor parte de la atención reumatológica se lleva a cabo en esta área del hospital. Sin embargo, apenas existe documentación respecto a estándares de calidad asistencial.
Desarrollar, mediante consenso, estándares de calidad asistencial específicos para las consultas externas de reumatología.
El proyecto se llevó a cabo mediante metodología Delphi a 2 rondas. Se contó con la participación de un comité científico (13 reumatólogos), 5 grupos nominales (45 reumatólogos y 12 enfermeras especializadas) y un grupo de discusión formado por 9 pacientes. Se generaron de forma sucesiva diversos borradores hasta obtener un documento final que incluyó los estándares que recibieron una puntuación igual o superior a 7 en al menos el 70% de los participantes.
El documento consta de 148 estándares distribuidos en 9 áreas temáticas: a) estructura (22); b) actividad clínica y relación con los pacientes (34); c) planificación (7); d) niveles de prioridad (5); e) relación con atención primaria, con el servicio de urgencias y con otros servicios del hospital (20); f) proceso (26); g) enfermería (13); h) docencia e investigación (13), e i) cómputo de actividad (8).
Se han consensuado unos estándares de calidad asistencial que pueden ser útiles para organizar la actividad en las consultas externas de los servicios de reumatología y servir como marco de referencia a la hora de elevar propuestas de mejora a la gerencia del hospital o a otros estamentos de la administración.
Copyright © 2011 American College of Nurse Practitioners. Published by Elsevier USA All rights reserved.
- Take your pain medication on a schedule and as prescribed. ...
- Use a warm, moist compress to loosen up a stiff joint. ...
- Make it a priority every day to relax. ...
- Focus on things you enjoy.
- Join a support group. ...
- Exercise. ...
- Eat a healthy, balanced diet. ...
- Consider talking to a counselor.
- Primary care doctor. ...
- Rheumatologist. ...
- Physical and occupational therapists. ...
- Dietitian. ...
- Mental health professional. ...
- Podiatrist. ...
- Orthopedic surgeon.
- Weight loss. Excess weight puts extra stress on weight-bearing joints. ...
- Exercise. Regular exercise can help keep joints flexible. ...
- Heat and cold. Heating pads or ice packs may help relieve arthritis pain.
- Assistive devices.
Nursing consideration and implications are generally summed up as being what a nurse needs to know and do in a particular situation.
NSAIDs. According to the American College of Rheumatology and the Arthritis Foundation (ACR/AF), nonsteroidal anti-inflammatory drugs (NSAIDs) are one of the most effective OTC remedies for managing osteoarthritis pain. NSAIDs can help reduce both pain and inflammation.
Official answer. The newest drugs for the treatment of rheumatoid arthritis are the Janus kinase (JAK) inhibitors, which are FDA approved under the brand names Rinvoq, Olumiant, and Xeljanz.
There's no way to prevent RA, but you can lower your chances if you: Quit smoking. It's the one sure thing besides your genes that boosts your odds of getting RA. Some studies show it also can make the disease get worse faster and lead to more joint damage, especially if you're ages 55 or younger.
- Consultant rheumatologist. A consultant rheumatologist is a doctor who specialises in diagnosing and treating arthritis and related conditions.
- General practitioner (GP) ...
- Hand therapist. ...
- Neurologist. ...
- Occupational therapist. ...
- Orthopaedic surgeon. ...
- Orthotist. ...
A rheumatologist is an internist or pediatrician who received further training in the diagnosis (detection), and treatment of diseases that affect the muscles, bones, joints, ligaments, and tendons. These diseases can cause pain, swelling, stiffness, and potentially cause joint deformities.
Rheumatologists are specialists in arthritis and diseases that involve bones, muscles and joints. They are trained to make difficult diagnoses and to treat all types of arthritis, especially those requiring complex treatment. You may be referred to an orthopedist if you have a type of degenerative arthritis.
You'll need to keep up with your usual medical care, but some natural remedies might help relieve pain and stiffness from rheumatoid arthritis (RA). Many of them are simple, like using heat and ice packs. Others, like acupuncture, need a trained pro.
Once a diagnosis is made, the main treatment goals are to control disease activity and slow the rate of joint damage, in addition to minimizing pain, stiffness, inflammation, and complications.
Nurses keep track of their patients' health, provide medicine to them, take care of paperwork, help doctors diagnose patients, and provide advice, but their job doesn't stop here. As Study explains, they wear many hats throughout the working day, and meeting the emotional needs of their patients is one of them.
These are assessment, diagnosis, planning, implementation, and evaluation.
There are typically three different categories for nursing interventions: independent, dependent and interdependent.
A Rheumatology Nurse helps patients with rheumatic diseases that affect the joints and muscles, such as lupus, fibromyalgia, myositis, spondylitis, rheumatoid arthritis and Lyme disease.
A patient with gout should avoid foods high in PURINES. These include most red meats, organ meats (liver, kidneys, sweetbreads), alcohol (especially beer). 2.
Which of the following are usually the first choice in the treatment of rheumatoid arthritis RA )? ›
Methotrexate is usually the first medicine given for rheumatoid arthritis, often with another DMARD and a short course of steroids (corticosteroids) to relieve any pain. These may be combined with biological treatments.
What safety factor should the nurse teach parents about using a crib for an infant? Check the slats are less than 6 cm (2.4 in) apart. If parents are using an older crib, they should check that the slats are less than 6 cm (2.4 in) apart.