6 Rheumatoid Arthritis Nursing Care Plans

Your RA patient is dealing with pain, stiff joints, fatigue, and the weight of a chronic disease that flares without warning. Your job is to control the pain, protect joint function, keep them moving, and teach them to manage the disease at home. Here are the six priorities that should drive the plan.

What is Rheumatoid Arthritis?

Rheumatoid arthritis (RA) is a chronic, systemic, autoimmune inflammatory disease. The immune system attacks the synovial membranes, which proliferate and destroy the joint, producing pain, swelling, stiffness, ankylosis, and deformity. The cause is unknown. The current thinking is that a virus or other trigger sets off an immune response that becomes chronically activated and turns on the body's own tissues. Because it is a whole-body disease, RA reaches beyond the joints and can involve other organ systems, including the skin and eyes. Expect spontaneous remissions and unpredictable exacerbations.

Nursing Care Plans & Management

The issues you will manage most often are pain, sleep disturbance, fatigue, altered mood, and limited mobility. A newly diagnosed patient needs solid disease education to make daily self-management decisions and to cope with a lifelong condition.

Nursing Problem Priorities

1. Manage pain and discomfort with appropriate pain interventions.
2. Promote joint mobility and prevent deformity through range-of-motion exercises, joint protection, and assistive devices.
3. Teach self-care: medication adherence, joint protection, and energy conservation.
4. Watch for complications such as inflammation, joint erosion, and systemic involvement, and collaborate with the team.
5. Support emotional well-being and address the impact of chronic pain and functional loss.
6. Coordinate referrals to rheumatology and occupational therapy for specialized care.

Nursing Assessment

Assess for the following subjective and objective data:

• Joint pain, stiffness, and tenderness
• Fatigue
• Morning stiffness lasting more than 30 minutes
• Family history of RA or other autoimmune disease
• Visible joint swelling, redness, or warmth
• Limited range of motion in affected joints
• Deformities or rheumatoid nodules
• Joint tenderness on palpation
• Imaging showing joint erosion or change in affected joints
• Positive rheumatoid factor (RF) or anti-cyclic citrullinated peptide (anti-CCP) antibodies
• Elevated erythrocyte sedimentation rate (ESR) or C-reactive protein (CRP)

Assess for factors related to the disease:

• Tissue distension from fluid accumulation and inflammation, joint destruction
• Skeletal deformity
• Pain and discomfort
• Activity intolerance and decreased muscle strength
• Changes in ability to perform usual tasks
• Increased energy expenditure and impaired mobility
• Long-term degenerative disease process
• Inadequate support systems

Nursing Diagnosis

After assessment, you form a diagnosis that fits the patient in front of you, based on your clinical judgment. Diagnostic labels organize care, but in real clinical settings your judgment and the patient's priorities shape the plan more than the label does.

Nursing Goals

The client will:

• Report relief or control of pain.
• Appear relaxed, sleep and rest, and participate in activities.
• Follow the prescribed medication regimen.
• Use relaxation skills and diversional activities as part of pain control.
• Maintain a position of function with absent or limited contractures.
• Maintain or increase strength and function of affected and compensatory body parts.
• Demonstrate techniques that allow resumption of activities.
• Verbalize increased confidence in dealing with illness, lifestyle changes, and limitations.
• Form realistic goals for the future.
• Perform self-care consistent with individual ability.
• Demonstrate lifestyle changes to meet self-care needs.
• Identify personal and community resources for assistance.
• Maintain a safe, growth-promoting environment.
• Verbalize understanding of the condition, prognosis, and potential complications.
• Develop a self-care plan with lifestyle modifications consistent with mobility and activity limits.

Nursing Interventions and Actions

1. Managing Pain Relief

RA pain comes from tissue distension as fluid accumulates, from the inflammatory process itself, and from joint destruction that limits mobility and feeds more pain.

Assess reported pain, noting location and intensity on a 0 to 10 scale, plus precipitating factors and nonverbal cues. This drives your pain management plan and tells you whether it is working.

Track the duration, not the intensity, of morning stiffness. Duration reflects disease severity more accurately.

Provide a firm mattress or bedboard and a small pillow, and elevate linens with a bed cradle as needed. Soft, sagging mattresses and large pillows throw off body alignment and stress affected joints. A bed cradle takes pressure off inflamed joints.

Let the patient assume a position of comfort in bed or in a chair, and promote bedrest as indicated. In severe disease or acute flare, total bedrest may be needed until objective and subjective improvement shows, to limit pain and joint injury.

Use pillows, sandbags, trochanter rolls, splints, and braces to rest painful joints in a neutral position. Splints reduce pain and joint damage, but prolonged inactivity costs joint mobility and function, so monitor their use.

Encourage frequent position changes. Help the patient move in bed, supporting affected joints above and below and avoiding jerky movements. This prevents fatigue and stiffness and stabilizes the joints.

Recommend a warm bath or shower on arising or at bedtime, and apply warm, moist compresses to affected joints several times a day. Check the water and compress temperature first. Heat relaxes muscle, improves mobility, and relieves morning stiffness, but heat sensitivity may be blunted and skin injury can occur.

Provide gentle massage to promote relaxation and reduce muscle tension.

Teach stress management: progressive relaxation, biofeedback, visualization, guided imagery, self-hypnosis, controlled breathing, and Therapeutic Touch. These give a sense of control and support coping.

Involve the patient in diversional activities suited to their situation to refocus attention and support self-esteem.

Medicate before planned activity and exercise as indicated to reduce muscle tension and spasm so the patient can participate.

Administer medications as indicated. See Pharmacologic Management.

Assist with physical therapies such as paraffin gloves and whirlpool baths for sustained heat that reduces pain and improves range of motion.

Apply ice or cold packs when indicated. Cold relieves pain and swelling during acute episodes.

Instruct in the use of a transcutaneous electrical nerve stimulator (TENS) unit if ordered, and monitor the effect. A constant low-level electrical stimulus blocks pain transmission.

2. Enhancing Physical Mobility

Impaired mobility in RA comes from inflammation and joint damage that limit movement, disuse and atrophy that cut muscle strength, and skeletal deformity that restricts motion.

Assess and continuously monitor joint inflammation and pain. Activity level depends on how the inflammatory process is progressing or resolving.

Maintain bedrest or chair rest when indicated, and schedule activity with frequent rest periods and uninterrupted nighttime sleep. Systemic rest is mandatory during acute flares and important in all phases to reduce fatigue and build strength.

Assist with active, passive, and resistive range-of-motion exercises and isometrics when the patient is able. This maintains joint function, muscle strength, and stamina. Too little exercise stiffens joints; too much damages them.

Encourage upright, erect posture when sitting, standing, and walking to maximize joint function and mobility.

Encourage activities of daily living such as hygiene, dressing, and self-feeding. ADLs the patient can do should be encouraged to maximize function.

Provide safety measures: raised chairs and toilet seats, handrails in the tub, shower, and toilet, proper use of mobility aids, and wheelchair safety. These prevent falls and injury.

Reposition frequently with adequate staff. Demonstrate and assist with transfer techniques and mobility aids such as a walker, cane, and trapeze. This relieves tissue pressure, promotes circulation, supports independence, and proper technique prevents shearing skin abrasions.

Position with pillows, sandbags, and trochanter rolls, and support joints with splints and braces to promote joint stability and minimize contractures.

Use a small, thin pillow under the neck to prevent neck flexion.

Provide foam or alternating-pressure mattresses to reduce pressure on fragile tissue and lower the risk of decubitus.

3. Enhancing Body Image and Self-Esteem

Visible deformity, functional loss, and the chronic course of RA hit body image and self-esteem hard and can drive emotional distress and social isolation. Emotional support and counseling belong in the plan.

Note withdrawn behavior, denial, or over-concern with body changes, which may signal emotional exhaustion or maladaptive coping that needs deeper intervention.

Encourage the patient to talk about concerns over the disease and future expectations so you can surface and correct fears and misconceptions.

Encourage a balanced diet, but make clear that no special diet cures RA, and stress weight control. Excess weight adds stress to joints.

Find out how the patient views self in usual lifestyle roles, including sexual function, to determine the need for further counseling.

Explore how the patient thinks their significant other views their limitations. Verbal and nonverbal cues from an SO strongly shape self-image.

Acknowledge and accept feelings of grief, hostility, and dependency. Constant pain wears people down, and anger is common. Acceptance tells the patient these feelings are normal.

Set limits on maladaptive behavior and help the patient identify positive coping behaviors to maintain self-control.

Involve the patient in planning care and scheduling activities to build a sense of competence and encourage participation.

Assist with grooming as needed, since appearance supports self-image.

Give positive reinforcement for accomplishments to build confidence.

Administer antianxiety and mood-elevating drugs as indicated, which may be needed with severe depression until coping skills develop.

Refer to psychiatric counseling, a psychiatric clinical nurse specialist, psychiatrist, psychologist, or social worker. Patient and SO may need ongoing support for a long-term, debilitating disease.

4. Promoting Independent Self-Care

Independent self-care means the patient takes an active role: sticking to medication schedules, using self-help strategies for pain, using assistive devices, and tapping support and resources.

Establish the usual level of functioning (0 to 4) before onset or flare and the changes now anticipated. The patient may continue usual activities with adaptations.

Assess barriers to self-care, and identify and plan environmental modifications to prepare for greater independence.

Maintain mobility, pain control, and the exercise program to support physical and emotional independence.

Allow enough time to complete tasks to the fullest extent of ability, and build on individual strengths. Extra time builds self-confidence and self-worth.

Consult occupational therapy to match assistive devices to the patient, such as a buttonhook, long-handled shoehorn, reacher, or hand-held shower head.

Arrange a home-health evaluation before discharge with followup afterward. This identifies problems tied to the current level of disability and supports coordinated team care.

Arrange consults with other agencies such as Meals on Wheels, home care, and nutrition services for patients who need added support at home.

5. Initiating Patient Education and Health Teachings

RA patients often have gaps in understanding the causes, symptoms, treatment options, self-care, and symptom monitoring. Home maintenance can also become difficult and may need modification or outside help.

Determine the level of physical functioning using Functional Level Classification 0 to 4. This sets the degree of support required. A level 0 patient performs usual ADLs (self-care, vocational, avocational) fully, while a level 4 patient is limited in all of these and does not participate.

Evaluate the home environment for the patient's ability to care for self, and whether the layout can stay or must change.

Determine financial resources and identify support systems such as extended family, friends, and neighbors. Available resources affect problem-solving and the choice of solutions.

Develop a plan for a clean, healthful environment, such as sharing household repairs and tasks among family or by contract service, so needs are met on an ongoing basis.

Identify sources for needed equipment such as lifts, elevated toilet seats, and a wheelchair, before discharge.

Coordinate a home evaluation by occupational therapy and rehab to identify adaptive equipment and ways to modify tasks.

Connect the patient with community resources such as visiting nurses, homemaker service, social services, and senior groups to support staying at home.

Review the disease process, prognosis, and future expectations so the patient can make informed choices.

Teach the signs of adverse drug effects: tinnitus, gastric intolerance, GI bleeding, and purpuric rash. Prolonged maximal aspirin doses can cause overdose. Tinnitus usually signals high therapeutic blood levels; if it occurs, the dose is usually decreased by 1 tablet every 2 to 3 days until it stops.

Discuss the patient's role in disease management through nutrition, medication, and a balanced program of exercise and rest. The goal is to suppress inflammation in joints and other tissues to preserve function and prevent deformity.

Help plan a realistic, integrated schedule of activity, rest, personal care, drug administration, physical therapy, and stress management. Structure defuses the anxiety of managing a complex chronic disease.

Identify an appropriate exercise program: swimming, stationary bike, or nonimpact aerobics. This raises energy and alertness and limits functional loss. Customize it to the joints involved and the patient's condition.

Stress continued medication management. Drug benefit depends on correct dosing; aspirin must be taken regularly to sustain a therapeutic blood level of 18 to 25 mg per dL.

Recommend enteric-coated or buffered aspirin, or nonacetylated salicylates such as choline salicylate (Arthropan) or choline magnesium trisalicylate (Trilisate). Taken with food, these minimize gastric irritation and bleeding risk. Nonacetylated products have a longer half-life and need less frequent dosing.

Suggest taking NSAIDs with meals, milk products, or antacids, and at bedtime. This limits gastric irritation, and a bedtime dose eases sleep and decreases early-morning stiffness.

Stress reading product labels and avoiding OTC drugs without medical approval. Many cold remedies and antidiarrheals contain hidden salicylates that raise overdose risk.

Review the value of a balanced diet high in vitamins, protein, and iron to support tissue repair.

Encourage the obese patient to lose weight and supply weight-reduction information. Weight loss reduces stress on joints, especially the hips, knees, ankles, and feet.

Provide assistive-device options: a wheeled dolly or wagon for moving items, pick-up sticks, lightweight dishes and pans, a raised toilet seat, and safety handlebars. These cut the force on joints.

Discuss energy-saving techniques such as sitting instead of standing to prepare meals or shower, which prevents fatigue and supports independence.

Teach correct body position and posture at rest and during activity: keep joints extended rather than flexed, wear splints for the prescribed periods, avoid holding one position too long, keep the hands near the center of the body during use, and slide rather than lift objects when possible. Good body mechanics must become part of daily life to reduce joint stress and pain.

Review frequent skin inspection and meticulous skin care under splints, casts, and supports, and demonstrate proper padding to prevent breakdown.

Discuss the need for medical followup and lab studies (ESR, salicylate levels, PT). Aspirin prolongs PT and raises bleeding risk, so therapy needs frequent assessment to stay effective and avoid overdose.

Provide sexual and childbirth counseling as needed. Many RA patients are in their childbearing years and need support and medical input, and information on positions and techniques can help personal relationships.

Connect the patient with the Arthritis Foundation and similar resources for support that promotes recovery.

6. Administering Medications and Pharmacologic Support

RA drug therapy centers on disease-modifying antirheumatic drugs (DMARDs) to slow progression and reduce joint inflammation, with NSAIDs and corticosteroids for pain and inflammation. Biologics target specific parts of the immune system and are added for moderate to severe RA that does not respond to other treatment.

Salicylates, such as aspirin (ASA: Acuprin, Ecotrin, ZORprin), give an anti-inflammatory and mild analgesic effect that decreases stiffness and increases mobility. ASA must be taken regularly to sustain a therapeutic blood level and has the lowest toxicity index of the commonly prescribed NSAIDs.

Nonsalicylate NSAIDs, including ibuprofen (Advil, Motrin), naproxen (Aleve, Naprosyn), sulindac (Clinoril), piroxicam (Feldene), fenoprofen (Nalfon), diclofenac (Voltaren), ketoprofen (Orudis), ketorolac (Toradol), and nabumetone (Relafen), control mild to moderate pain and inflammation by inhibiting prostaglandin synthesis.

Glucocorticoids, such as prednisone (Deltasone), methylprednisolone (Depo-Medrol), and dexamethasone (Decadron), modify the immune response and suppress inflammation.

DMARDs, including methotrexate (Rheumatrex), hydroxychloroquine (Plaquenil), sulfasalazine (Azulfidine), gold compounds, auranofin (Ridaura), azathioprine (Imuran), and leflunomide (Arava), reduce pain and swelling and lessen symptoms rather than eliminating them. Arava (FDA-approved in 1998) was the first oral drug shown to slow RA progression and joint damage.

COX-2 inhibitors, such as celecoxib (Celebrex) and rofecoxib (Vioxx), interfere with prostaglandin production like NSAIDs but are less likely to harm the stomach lining or kidneys, and may be combined with other medications.

Biologics, etanercept (Enbrel) and infliximab (Remicade), are the first genetically engineered arthritis drugs. These injectable anti-TNF compounds block inflammation and rapidly cut pain and joint swelling. Enbrel is self-injected twice a week and may be combined with methotrexate. Remicade is given IV at 1- to 3-month intervals. Because of concerns about immune suppression, Enbrel is recommended only for patients who cannot tolerate methotrexate or who failed to respond to at least two other DMARDs.

Tetracyclines, such as minocycline (Minocin), combine anti-inflammatory and immune-modifying effects with the ability to block metalloproteinases tied to joint destruction, with notable benefit in research studies.

D-penicillamine (Cuprimine) may control the systemic effects of RA synovitis and scleroderma when other therapies fail. A high rate of side effects (thrombocytopenia, leukopenia, aplastic anemia) demands close monitoring. Give it between meals, since food, antacids, and iron impair absorption.

Antacids and gastric protectants, misoprostol (Cytotec) and omeprazole (Prilosec), are given with NSAIDs to minimize gastric irritation and reduce GI bleed risk.

Codeine-containing medications are generally avoided given the chronic nature of RA, but short-term use may be needed during an acute flare to control severe pain.