Treatment of the Patient with Arthritis and Side Illnesses

From the case study, the writer is aware that pain is a concern for Mary. She suffers from ‘pain in her knees’ and notices ‘redness and swelling over the knee joint.’ The redness and swelling Mary is experiencing is known as inflammation and is a common symptom of arthritis (Hinkle & Cheever, 2017). Mary’s diagnosis of arthritis is a concern because the pain, redness and swelling are presumably impacting on her ability to carry out activities of daily living (ADL) causing her to have diminished functional capacity. This is especially relevant because she lives in a 3rd floor apartment only accessed by a staircase which presents her housing situation as a current concern. The progression of the disease is also a concern as she feels the ‘same sensation spreading towards her hips, elbows and shoulders’. Mary’s BMI of 35 is another concern because obesity is known to exacerbate arthritis symptoms. A study by Kerkhoff et al., concluded that obesity had a negative influence on the outcome of patients treated with total knee arthroplasty. (Kerkhoff, et al., 2012) Total knee arthroplasty is a highly effective surgical treatment for progressive bone and joint destruction evoked by arthritis, who have not responded to medical management (Fournier, Hallock, & Mihalko, 2016, Stundner, et al., 2014). However, the impending procedure may be a cause of apprehension for Mary. This can be addressed through effective preoperative education for the patient. A psychosocial concern for Mary is a lack of supportive relationships, as she lives alone, and since retirement, she finds it hard to meet new people.’

Preoperative Behavior Intervention

In order to be prepared for her surgery, Mary needs to lose weight. With her current Body Mass Index (BMI) of 35 she is classified as class II obesity or severely obese (Euro.who.int, 2019). According to Fournier, Hallock, & Mihalko, “Preoperative lifestyle interventions can improve arthroplasty outcomes.” This is fortunate for Mary because obesity is a preoperative modifiable risk factor. Ryan, et al., highlighted in their study that women, aged 50 to 69 years, who were obese (BMI > 30), were ten times more likely to need knee replacements compared with non-obese women. This is because obesity causes joint loading which exacerbates the symptoms of arthritis (Ryan, et al., 2015). A Study conducted on the effect of obesity on elderly patients with knee osteoarthritis confirmed that weight loss improves arthritic symptoms and functional capacity and slows the progression of arthritis (Pera et al., 2016). Mary can lose weight by reducing her highly processed diet and alcohol intake and by increasing her exercise. Dietary modifications prove more effective than exercise alone in achieving weight loss, but a combination of the two is most effective (Fournier, Hallock, & Mihalko, 2016). As well as weight loss, proper nutrition will aid in Mary’s postoperative recovery, so it is important to encourage Mary to increase her intake of foods high in vitamins, protein and iron for tissue building and repair. (Hinkle, & Cheever 2017).

Obesity increases the risk of postoperative complications such as deep venous thrombosis (DVT), infection, and pulmonary embolism. It is not obesity alone that puts patients at risk for such complications but also the comorbidities that can often accompany obesity such as diabetes, coronary artery disease and liver disease. According to Fournier, Hallock, & Mihalko, patients with a BMI of 30-35 or >35 had a significantly higher risk of postoperative wound complication, rate of dislocation and fracture, revision surgery than those with a healthy BMI (Fournier, Hallock, & Mihalko, 2016).

A multidisciplinary team (MDT) approach can help Mary achieve her weight loss goals. For example, a dietitian can assist Mary in losing weight, in turn, decreasing her perioperative risks (Fournier, Hallock, & Mihalko, 2016). A tolerant attitude and support from the MDT, as well as a sense of autonomy in her own weight loss goals will increase Mary’s self-efficacy to lose weight and help her to achieve her preoperative goals (Pera, et al., 2016).

The incorporation of exercise into Mary’s life will help her achieve her weight loss goals, while also maintaining joint function and mobility. Swimming is a beneficial exercise for Mary because the water buoyancy limits pressure on her joints. Similarly cycling is a good option because it also reduces weight bearing and increases flexibility of the knee joint. Socially, Mary could meet new people in these exercise classes (Ryan, et al., 2015).

Preoperative Pain Management

Mary can manage her joint pain preoperatively with non-steroidal anti-inflammatory drugs (NSAID) such as ibuprofen. NSAID work to reduce pain, inflammation and stiffness. Oral NSAID are contraindicated in older people with renal failure, diabetes, cardiovascular disease or gastric problems, but it is not indicated that Mary suffers from any of these so she should be commenced on a low dose to control her symptoms. Mary should be prescribed a proton pump inhibitor with the NSAID to minimise the risk of developing a stomach ulcer (Ryan, et al., 2015). The effective use of NSAIDS will reduce pain, allowing Mary to exercise and subsequently achieve her weight loss goal. Hinkle & Cheever. 2017, highlight the importance of adequate pain management for the success of exercise programs However the writer notes that NSAID may be discontinued a week before surgery because of the risk of Mary developing a DVT (Hinkle & Cheever. 2017). Along with pharmacotherapy, Mary can use non pharmacological methods to manage her pain to ensure she is pain free and surgery ready. For example, she can put heat or ice on her knee to relieve the pain or use a walking stick to decrease the compressive load on her knee. The result of Mary achieving her preoperative goals of weight loss and pain management is that Mary will enjoy an improved quality of life and should see the benefits holistically.

It is not clear what specific type of arthritis Mary is diagnosed with, but based on her profile, the writer hypothesis that she is likely suffering from either rheumatoid arthritis (RA), osteoarthritis (OA), or psoriatic arthritis (PA). Rheumatoid arthritis is an autoimmune disease of unknown origin that affects 1% of the population worldwide and is more common in women than men. Swelling, warmth, erythema, lack of function, morning stiffness and symmetrical joint involvement accompany extra articular changes such as fever, weight loss, fatigue and anemia (Hinkle & Cheever. 2017). The presence of rheumatoid factor may help in Mary’s diagnosis of RA and would be discovered in the laboratory tests that were performed. However, the case study does not specify if Mary’s joint pain is bilateral or if she has any systemic manifestations of RA, so it is not certain if RA is the type of arthritis she is suffering from. Biologic or nonbiologic Disease Modifying Antirheumatic Drugs (DMARDS) and NSAID are treatments for RA which aim to decrease joint pain, swelling and joint deformity (Hinkle & Cheever. 2017).

Mary could also have PA, an inflammatory arthritis, because she has a history of plaque psoriasis. Psoriasis and psoriatic arthritis are both autoimmune inflammatory diseases. According to The New England Journal of Medicine, “Psoriatic arthritis occurs in up to 30% of people with psoriasis”. It starts in the skin and spreads to the joints and is symmetrical. NSAIDS and DMARDS such as Methotrexate and corticosteroids are used to control PA. Long-term treatment with DMARDS decreases the autoimmune destruction of the joints. If Mary is on immunosuppressants for her psoriasis and arthritis she may have to stop them prior to surgery because of risk of infection e.g methotrexate.

The etiology of OA is different to RA and PA in that, articular cartilage breaks down causing the eventual formation of osteophytes. These osteophytes narrow the joint space leading to decreased range of joint motion. Pain, stiffness and functional impairment are typical symptoms of OA. Conversely, osteoarthritis is a non-inflammatory degenerative disorder of the joints. Unlike RA, OA is limited to the affected joints and there are no systemic manifestations associated with the disease. The knee is predominantly affected in Mary’s case; however, the same sensation has started spreading to her hips, elbows and shoulders. OA commonly affects these weight bearing joints. The prevalence of OA is between 50% and 80% in older adults (Hinkle & Cheever, 2017). Therefore, Mary’s age predisposes her to OA. OA is also more common in women and people who are obese, and OA has a correlation with long term standing. As stated in the case study, Mary’s occupation meant she spent a lot of her time standing (Ryan, et al., 2015, Stundner, et al., 2014). Symptoms and pain associated with OA can be managed with lifestyle changes and NSAID, but not DMARDS because OA is not an autoimmune disease, meaning immunosuppressants would be ineffective.

RA, OA and PA all affect the individual’s mobility. After evaluating Mary’s current lifestyle, her presenting symptoms and critically analyzing the different types of arthritis, their etiology, symptoms and treatment, the writer concludes that she is predisposed to each type and so could be diagnosed with RA, OA or PA. Identify the gerontological considerations for Mary as she prepares for her surgery and for her future. Mary necessitates physical, social, emotional and cognitive support as she prepares for surgery and for her future. She will experience reduced mobility and therefore reduced Independence as she gets older. Discharge planning begins before surgery (Hinkle & Cheever, 2017), so now is the time to address issues relating to housing and social isolation.

Modified Housing

Mary must consider her housing options because her current home is no longer practical or fit for purpose as she now has arthritis, prepares for surgery and for her future. Options include staying at home and adapting the house to her needs, or moving to a more suitable, already adapted house, with or without additional care (Roy, et al., 2018). Kim, et al., found that most older adults prefer to stay in their own home for as long as possible (Kim, et al., 2014, Roy et al., 2018). Mary’s housing needs to be accessible, adaptable, safe and functional in order to support her emerging needs and independent living (Kim, et al., 2014). Her home is not adequate for her safety and management of the disease and the stairs is a physical barrier. The potential risk of Mary falling and injuring herself on the stairs, and the possibility of ending up in a long-term care facility is a gerontological consideration.

Mary has a decision to make whether to stay at home or relocate to more suitable housing such as a ground floor apartment. The involvement of the MDT is crucial in helping her make this decision and to cater for her additional needs. A social worker can offer her advice on what steps to take next such as applying for grants for home modifications and an occupational therapist can provide assistive devices to Mary such as walking aids and a shower chair in order to decrease weight bearing on the affected joints and make Mary more comfortable at home. The modification of Mary’s home would reduce difficulties she currently faces in performing ADL like, eating, washing, dressing, toileting, as well as more complex instrumental activities of daily living (IADL) like, grocery shopping, meal prep, getting to and from hospital appointments, and housework (Kim, et al., 2014). Based on Mary’s profile she may be eligible for potential services such as home care. Getting Mary home care services would help her perform ADLs and IADLs. There is potential for convalescence post discharge from hospital. The convalescence ensures Mary does not return to her home alone and receives additional rehabilitation. The high processed diet Mary currently consumes may be because of an inability to prepare food for herself. Meals on wheels could be introduced to protect Mary from malnutrition.

Social Isolation

Mary’s sense of self and social identity can transform because of a loss of autonomy. The writer knows from the case study that, Mary’s friends were predominantly work based and since she has retired, she finds it hard to meet new people. Psychosocial factors of aging such as loneliness and social isolation have been identified as significant risks to the quality of life of the geriatric population (McGraw 2015). A recent study showed that women are at a higher risk of social isolation than men, and that social isolation and loneliness are associated with a higher risk malnutrition among older people (Boulos, Salameh, & Barberger-Gateau, 2016).

Explanation for Mary to understand elective surgery (what it is and its benefits) and provide a concise plan for the preoperative preparation of Mary. Elective surgery is when patients have their admission and surgery at a predetermined and predictable time (Royal College of Surgeons in Ireland, Irish College of Anesthetists and Health Service Executive, 2011). There are many benefits to elective surgery including increased patient involvement and understanding of care decisions (Strickland, et al., 2018).

The nurse will inform Mary that the benefits of a successful total knee arthroplasty will be reduced joint swelling, inflammation and pain, increased range of motion and functional status and ultimately improved quality of life. Without the procedure Mary should expect experience continuous pain and disease progression. The nurse’s role is to provide psychological support, as well as preoperative teaching in order to ensure Mary is in the best health possible before her surgery (Sau-Man Conny, & Wan-Yim,. 2016). Effective preoperative education will provide Mary with information concerning the surgical process and the surgical procedure, as well as anticipated patient behaviors (eg, anxiety, fear) and expected sensations (Kruzik, 2009). Thus, reducing Mary’s preoperative anxiety surrounding the procedure. For example, informing Mary that she will receive antibiotics prophylactically and for 24 hours post-surgery, to prevent infection (Hinkle & Cheever, 2017). Preoperative education should also include that fact that, as with all medical procedures there are risks involved. Potential risks involving her weight, age, sedation should be disclosed in a factual, easy to understand, but sensitive tone. The enhanced recovery protocol of preoperative education has been demonstrated to significantly reduce perioperative pain and opiate consumption and can improve patient outcomes and satisfaction with the surgical experience (Strickland, et al., 2018, Kruzik, 2009).

Group education is a useful preoperative education strategy as it provides enhanced knowledge, reciprocal help and social networking (Cooke, et al., 2016). The writer suggests that it would be beneficial for Mary could talk to someone who has undergone the same procedure, since it would increase her opportunity for education and socialisation. Although there is little evidence on the most effective educational methods, many studies agree on the benefits of group and individual education versus individual education alone (Cooke, et al., 2016).

The preoperative preparation of Mary will include a visit to the preoperative assessment. Here the nurse will perform an electrocardiogram (ECG) to ensure normal functioning of the heart, take Mary’s vital signs to ensure they are within normal parameters, and measure her weight. She will be advised to fast twelve hours prior to surgery, and only drink water or clear fluids, up to six hours before surgery, to reduce the risk of aspiration. An MRI or CT will be taken of the affected joint. A culture and sensitivity test on Mary’s urine will be sent to the laboratory to rule out any possible infection because, if present, she will not be allowed undergo surgery (Hinkle & Cheever, 2017).