The Standards of Care of a Patient with Rheumatoid Arthritis - Essay Example

?The Standards of Care of a Patient with Rheumatoid Arthritis Introduction. This paper is to evaluate the different standards of care available for treatment of Rheumatoid Arthritis (RA) with particular reference to a 40 year old female with painful feet with changes to their gait. The typical pattern of joint and soft tissue swelling suggests that the patient is following an aggressive and polyarticular course. She was diagnosed for RA 16 weeks ago. Rheumatoid arthritis (RA) is an inflammatory disorder leading to a chronic destructive polyarthritis. Proliferation of the synovial membrane and uncontrolled persistent inflammation are the characteristic features of RA which manifest as a symmetric arthritis affecting several small and large joints. Other symptoms include fatigue, articular stiffness, anorexia and fever. Complaint of pain and limited lifestyle are the characteristic features of the onset of the disease. If left untreated, the inflammation will result in serious life threatening conditions during its progression. Morbidity, progressive disability and hastened mortality feature the untreated disease conditions. As a result, it entails serious economic implications for both the patients and their families as well as society as the affected people are unable to continue in their employment with the same efficiency as before with their normal functioning of their palms, feet and gait seriously affected and progressively disfigured and disabled (Cush, Weinblatt, & Kavanaugh, 2010). According to National Audit Office, there are around 580,000 people afflicted with RA with additional 26,000 new cases every year. The disease affects people of age between 40 to 60 years with women who are three times more likely to be affected than men. The patient referred herein for treatment also happens to be a woman aged 40. This being an auto-immune disease, affects small joints of the hand and feet. If severe, it reduces life expectancy by 6-10 years as a result of co-morbidity through cardio-vascular diseases or side effects from treatment (Home & Carr, n.d.) The disease reduces the affected person’s work life by five years. Its annual cost to the U.K. economy is estimated to be between ? 3.8 and ? 4.75 billion (NationalAuditOffice, 2009). There are many institutions engaged in the care of RA with their own guidelines for treatment. British Society for Rheumatology (BSR, (n.d)),NHS (NHS, n.d.), National Rheumatoid Arthritis Society (NRAS) (NRAS, n.d.), The Society of Chiropodists and Podiatrists (SCPOD, n.d.), The Musculoskeletal Services Framework (DeptOfHealth, 2006), NSF long-term conditions (DeptOfHealth, Department of Health, 2005), 18 week commissioning pathway (DeptOfHealth, Department of Health, 2006) and Podiatry rheumatic care associations (PodiatryRheumaticCareAssociation, n.d.) are the major sources of standards of care for RA conditions. They are complementary to one another and it is worthwhile referring to all of them while dealing with the patient affected by RA. Brief outline of care Two of the inevitable symptoms RA are joint pain and stiffness that manifest in the foot and ankle in the early stages. These symptoms also change during the course of progression of the disease (Helliwell, 2006). Since rheumatoid arthritis is not curable, the aim of care is to relieve symptoms and improve quality of life for the patient. Although multidisciplinary approach is resorted to, therapeutic interventions are the responsibility of rheumatoid specialist professionals. The patient involvement and empowerment are desirable for a successful outcome with the patient coping up with the course of treatment and lifestyle adaptations (Alexander, Fawcett, & Runcinman, 2006). For control of pain, analgesics such as paracetamol/aspirin, compound analgesics such as cocodamol to NSAIDs can be administered. Since NSAIDs are associated with gastrointestinal side-effects, cyclo-oxygenase (Cox) II group of NSAIDs are recommended so that side effects are at minimal levels. (Alexander, Fawcett, & Runcinman, 2006).Since muscle power of the RA patient is lessened, variable height bed, raised or ejector chair and raised toilet can be made available for the patient. Walking sticks or elbow crutches can aid the patient to maintain mobility by avoiding weight loads on the affected joints. Diet should be designed in such a way as to maintain nutrition due to anorexia or difficulty in drinking or eating from utensils though the occupational therapist can prescribe custom made utensils. Since patient is prone to develop anaemia due to chronic inflammatory condition, iron supplements and other medication therapy are required (Alexander, Fawcett, & Runcinman, 2006). A qualitative analysis as per GALS locomotor screening system is desirable. Gait analysis is done following referral from podiatrist who would require plantar pressure measurement. Physician can also request gait analysis to assist in explaining to the patient foot mechanics regarding persistent unresolved tribalis posterior tenosynovitis on a finding that foot is pronoated. Observational gait analysis is a description of human walking (Alexander, Fawcett, & Runcinman, 2006). Patient needs to undergo gait analysis. The walking pattern of a patient with rheumatoid arthritis becomes slow and modified to mitigate pain accompanied by altered muscle activity and stress distribution to the plantar region. When patients arrive at the clinic, observation of their gait cannot be fully achieved because of coverage of lower limbs and feet by their clothing and footwear (Helliwell, 2006). Standards of care The British Society for Rheumatology has issued has issued as many as 14 standards of care most of which are relevant to the present patient’s conditions. Kennedy et al (2005) have interpreted these standards. According to the standards, the patient must be seen for confirmation of diagnosis of RA within 12 weeks of referral from the general practitioner. In the involvement of a multi-disciplinary team for management of the disease, the patient should be encouraged to assume a leading role in the team. The patient should be given access to self management programmes, local support groups and other necessary information to manage her own disease. The patient should be given access to the multidisciplinary team consisting of general practitioner, consultant rheumatologist, consultant orthopaedic surgeon, trainee doctors, nurse specialist, physiotherapist, occupational therapist, dietician, podiatrist, orthotist, pharmacist and social worker. NSAIDs including COX II and biological agents should be administrated in conformity of NICE guidance The patient may be considered for biological therapy in accordance with NICE and BSR guidelines. And possible side-effects of therapy and other drugs including DMARDs should be watched by the multi-disciplinary team. (Kennedy, et al., 2005). NICE guideline state that newly diagnosed patient with RA should be offered a combination of disease modifying anti-rheumatic drugs (DMARDs) including methotrexate and at least one other DMARD along with short term glucocorticoids as the first-line treatment within 3 months of the onset of symptoms (PressRelease, 2009) In short, the BSR standards aim at early identification of persons afflicted with rheumatoid arthritis and later empowering them with efficient, cost effective and evidence-based clinical care. The standards set are at a minimal level and they also serve as a record of care given as part of clinical governance process at a rheumatology unit. These standards are subject to periodical review by the society (Kennedy, et al., 2005). The second most important standards of care can be found in NICE guidelines which the BSR also incorporate in its standards. NHS sponsored NICE clinical guideline79 was developed by the National Collaborating Centre for Chronic conditions. Guideline 79 refers to the management of rheumatoid arthritis in adults. The guidelines are for conditions prevailing in the NHS in England and Wales. The guidelines reflecting the views of NICE do not however place any restrictions on the discretion of healthcare professionals who may have to take appropriate decisions that can be different from what guidelines have provided for. The development of these guidelines was done by the National Centre for Chronic Conditions which set up a Guideline development group of eminent healthcare professionals. They in turn reviewed the evidence and made these recommendations as guidelines for management of RA. (NICE, 2009). The Department of Health has issued The Musculoskeletal Services Framework which is relevant to the patient’s conditions affecting her musculoskeletal system. The framework covers as many as 200 musculoskeletal conditions. Rheumatoid arthritis conditions are part of them. The framework does not replace the functions of the primary care professionals. It dispels certain myths about arthritis in general such as ‘the condition is not treatable, the patient should not exercise, only old people are prone, surgery can make the patient better, and only options are painkiller and surgery’. The framework says that some conditions of RA are to be treated proactively since it is necessary to have a tight control of the disease for an optimal level of treatment. This means that there must a regular evaluation of clinical indicators for progress of the disease thus minimising radiological progression and control of co-morbidities. (DeaprtmentOfHealth, 2006). Podiatrist who specialises in foot care can play a prominent role in the care of the present patient with foot problems. The Society for Chiropodists and Podiatrists has a guide for the benefits of podiatry to patient care. Podiatrists in the NHS and Private clinics treat patients with long-term conditions which include RA also. For the conditions the present patient is likely to be faced with, the podiatry would provide orthotic devices and footwear to mitigate the patient’s condition. The guide says 90% of the people with RA develop foot problems caused by the disease. Early podiatric intervention is essential for avoidance of future deterioration and in fact it can improve long term outcomes. The NICE recommends referral to a podiatrist for proper assessment and periodic review (TheSocietyOfChiropodistsAndPodiatrists, n.d ). The standards of care for people with Musculoskeletal foot health is a document of standards of care for musculoskeletal and rheumatological conditions issued by the Podiatry Rheumatic Care Association (PRCA). The foot health standards of care were developed by an expert working group in coordination with PRCA and funded by the Arthritis Research Campaign. The group met six times from April 2007 to January 2008 and developed these standards of care which include RA also. Professionals from various institutions had active roles in development of these standards. (PRCA, n.d ) Conclusion The patient will be largely benefitted by the treatment and management as per the above guidelines from different standards of care by being able to lead a better quality of life. The NICE guidelines and others are subject to amendments from time to time and hence the multi-disciplinary team should follow them closely for being implemented in the treatment regimen of the patient. References Alexander, M. F., Fawcett, J. N., & Runcinman, P. J. (2006). Nursing Practice: hospital and home:the adult. London: Elsevier Health Sciences. BSR. ((n.d), April 25). The British Society for Rheumatology. Retrieved 25 April 2011, from http://www.rheumatology.org.uk/ Cush, J. J., Weinblatt, M. E., & Kavanaugh, A. (2010). Rheumatoid Arthritis:Early Diagnosis and Treatment. New York: Professional Communications. DeaprtmentOfHealth. (2006). The Musculoskeletal Services Framework. DeptOfHealth. (2005). Department of Health. Retrieved April 25, 2011, from The National Service Framework for long term conditions: Avialble at accessed 25 April 2011 DeptOfHealth. (2006). Department of Health. Retrieved April 25, 2011, from The Musculoskeletal Services Framework: Avialble at accessed 25 April 2011 DeptOfHealth. (2006). Department of Health. Retrieved April 25, 2011, from Commissioning an 18 week patient pathway: Available at accessed 25 April 2011 Helliwell, P. (2006). The foot and ankle in rheumatoid arthritis : a comprehensive guide. London: Elsevier Health Sciences . Home, D., & Carr, M. (n.d.). Rheumatoid Arthritis : the role of early intervention and self-management. British Journal of Community Nursing , 14 (10), 432-436. Kennedy, T., McCabe, C., Sruthers, G., Sinclair, H., Chakravarty, K., Bax, D., et al. (2005). BSR guidelines on standards of care for persons with rheumatoid arthritis. Rheumatology , 44, 553-556. NationalAuditOffice. (2009). Services for people with rhematoid arthritis. London: The Sationery Office. NHS. (n.d., April 25). National Institute for Health and Clinical Excellence. Retrieved 25 April 2011, from http://www.nice.org.uk/ NICE. (2009). Rheumatoid Arthritis :The management of rheumatoid arthritis in adults. NRAS. (n.d., April 25). National Rheumatoid Arthritis Society. Retrieved 25 April 2011, from http://www.nras.org.uk/ PodiatryRheumaticCareAssociation. (n.d.). Podiatry Rheumatic Care Association. Retrieved April 25, 2011, from Standards Project: http://www.prcassoc.org.uk/standards-project PRCA. (n.d ). Standards of Care for people with Muculoskel;etal Foot health Problems. PressRelease. (2009). Press Release No 2009/12 New NICE Guidelines to help thousands of people with rheymatoid arthritis. p. Avialble at accessed 6 April 2011 . SCPOD. (n.d.). Feet for life. The Society of Chiropodists and Podiatrists : accessed 23 April 2011 TheSocietyOfChiropodistsAndPodiatrists. (n.d ). A guide to the benefits of podiatry to patient care. Read More