Examplar.NUR2101 Assessment 1 PDF

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Part A: Written case analysis: Case Scenario Topic 4 This essay will analyse the case study of Raelene, a 45-year-old female nurse who has presented with lower back pain resulting from a work- related incident. She also has symmetrical pain and swelling (synovitis) in her hands and finger joints and after several months of symptoms has been diagnosed with the chronic condition rheumatoid arthritis (RA). Aletaha et al. (2010) describe synovitis as pain, swelling and tenderness. Her chronic lower back pain (CLBP) affects her sleep and ability to perform activities of daily living (ADL), and she has a history of chronic depression. Arthritis and mental health conditions as umbrella terms for RA and depression respectively, are listed by the Australian Institute of Health and Welfare (AIHW, 2019) as two of eight most frequently occurring chronic diseases in Australia. However, given that depression is also a symptom of RA, RA will be the chronic condition focused on in this essay. In addition to having a chronic condition and other health issues, Raelene is faced with the challenge of living remotely, which limits her access to health services.

Ryan (2020) describes RA as a chronic systemic autoimmune disease with unknown aetiology that causes inflammation of connective tissue, which attacks the joints. This means it is a long-lasting disease where the immune system attacks host tissue, potentially affecting the entire body. Ryan (2020) also explains that its manifestations can range from mild inflammation to severe deformity, with severity and rate of progression presenting differently with every person. With hand joints being most often affected first, RA can be acute or can develop in a gradual and subtle manner and can have periods of inactivity (Ryan, 2020). Raelene appears to have started developing signs of synovitis symmetrically in her hands and finger joints, several months ago. Her condition is chronic as it has been ongoing and will be

permanent, which according to Wilson and Levett-Jones (2020) are one of several groups of characteristics that classify a disease as chronic. The synovitis Raelene is experiencing is explained by the AIHW (2015) who suggest that it is the cause of the immune system attacking the synovial membrane that lines the joints. Raelene’s chronic lower back pain (CLBP) would certainly add to her discomfort and distress as pain and inflammation could potentially impede on her ability to perform her ADLs and exasperate her depression. This is compounded by the fact that people with depression may not care for their ADLs (Moxham, Robson & Patterson, 2020). Raelene’s partner’s concern regarding her depression is well founded because people with RA are likely to suffer from it, along with anxiety and low selfesteem (AIHW,2015). It is important however to note that when RA is active, people may feel fatigued, weak, unwilling to eat and lose weight (Ryan, 2020), which could potentially be confused with the signs and symptoms of depression.

It is well understood that sleep is vital to wellbeing. As Raelene is experiencing disturbed sleep due to CLBP she is at increased risk of developing emotional irritability, poor concentration and difficulty making decisions (Applegarth & Flenady, 2018). While it has not been specified to what extent Raelene suffers from sleep issues, it is important to realise that depression is also a common cause of insomnia, with some types of antidepressant medication being the cause of sleep problems (Nobel, 2014). All of these issues are compounded by the fact that she lives remotely and is unable to easily access services that might otherwise be available to her.

Raelene’s early diagnosis of RA was significant, because according to (Heidari, 2011), early identification and treatment can impact on the course of the disease, prevent the erosion of joints and slow down its progression. In order to study people at the earlier stage

of RA, the 2010 ACR/EULAR classification criteria for RA was developed (Aletaha et al., 2010). An important goal of this criteria is to prevent people from reaching a chronic, erosive state (Aletaha et al., 2010), which is pertinent to Raelene, due to early stage reporting of synovitis. This means there is the potential to slow or retard the disease. Health Direct (2019), a government funded service that provides information and advice explains that diagnostic testing for RA can be difficult especially in the early stages because synovitis can be experienced with a lot of conditions. The 2010ACR/EULAR criteria sets four parameters to determine if a patient has the disease. They are based on joint involvement, which refers to any joint that is swollen or tender; blood tests for rheumatoid factor (RF), anti-cyclic citrullinated peptide (ACPA) and anti- cyclic citrullinated peptide (anti-CCP); levels of acute phase reactants; and the duration of the symptoms, as reported by Raelene (Aletaha et al., 2010). As Raelene has presented early in her disease, joint involvement, especially in regard to synovitis is initially determined by a physical exam, however when there is doubt regarding diagnosis, Kourilovitch, Galarza-Maldonado and Oritz-Prado (2014) explain that conventional radiography, ultrasound or magnetic resonance imaging (MRI) can be utilised, with ultrasound and MRI also being used to predict and track the progression of the disease. X-ray, ultrasound and MRIs are also appropriate to determine the extent of the damage to Raelene’s back and to monitor any deterioration. It is important to note that as Raelene has been diagnosed early in her disease, there may be very little to observe. This is supported by Ryan (2020) who explains that other than joint effusion and soft tissue swelling there may be little evidence of change. Kourilovitch et al. (2014) explain that blood tests will determine levels of rheumatoid factors (RF) and anti-citrullinated/peptide antibodies (ACPA), which will typically be elevated in a person with RA. Levels of acute phase reactants such as sedimentation rate and reactive C protein are used to measure the activity of the disease

(Kourilovitch et al., 2014) and accurate self-reporting of the onset and duration of signs and symptoms of RA are to be done by Raelene in conjunction with her doctor. There are many complications that can develop as a result of RA. Apart from the typical joint related manifestations, those that might be relevant to Raelene’s case could include depression which the World health organisation (WHO, 2019) say is linked with musculoskeletal conditions. As Raelene already has a history of chronic depression, it can be assumed that RA and chronic back pain could potentially exasperate this as she struggles with pain, and the ability to carry out her ADLs. When caring for a patient, it is important to also consider those factors other than their illnesses. For example, relevant cultural aspects, level of health literacy and psychosocial considerations. As Raelene is a nurse, it is safe to assume she would have a reasonable standard of health literacy, however, her geographic isolation and depression could both prevent her from accessing health services regardless of health literacy level. When considering Raelene psychosocially, Erikson’s theory of psychosocial development is a theory that explains that human development is divided in to eight stages, with each stage being driven by some kind of internal conflict or crisis (Svetina, 2014). Raelene’s age suggests she in the generativity versus stagnation phase. She is at an age where most people become aware of the changes in their body that signify the aging process and Harvey (2018) explains that people who do not explore their interests, hobbies and charitable endeavours and accept their state of being middle aged, become stagnant, rather than generative. As Raelene’s RA and CLBP could potentially worsen or even become debilitating, this could impact on her ability to seek out interests and charitable activities, preventing her from achieving the status of generativity, but instead allowing her to become stagnant. This could then exasperate her depression, which is supported by Harvey (2018) who explains that when people fail to accept their aging state, they become withdrawn and isolated. As Raelene is

already geographically isolated, any further forms of isolation will only serve to worsen her health issues. Because there is no cure for RA, currently the goal of treatment is to relieve its manifestations, which include pain relief, reducing inflammation, retarding joint damage and improving the wellbeing of patients and their ability to function (Ryan, 2020). As Raelene suffers from RA and CLBP, both of these conditions need to be explored when considering appropriate nursing interventions. Burston and Corfee (2020) suggest the following pharmacological strategies to address pain relief: simple analgesics, non-steroid antiinflammatory drugs (NSAIDs), opioids and antidepressants. However, Ryan (2020) highlights that simple analgesics and NSAIDS will only manage the manifestations of RA, but not affect its progression, which is an important goal in RA management. Ryan (2020) suggest the use of low-dose oral corticosteroids as to slow the RA progression and disease modifying drugs to potentially reduce joint destruction. Health promotion is another approach that can be utilised as a nursing intervention. For example, Ryan (2020) suggests that people with RA can help prevent deformities and the effects of the disease by strictly following the prescriptions of exercising; resting when necessary; weight management; and mindful posture and positioning. These techniques can also be utilised to assist with the management of Raelene’s CLBP. A third intervention involves embracing the concept of community-based care. This concept is applicable to both RA and to CLBP, where Ryan (2020) explains that education is an important nursing role in caring for people and their families. Topics for home care include but are not limited to the disease process; medications; use of assistive devices; home modifications; and energy conservations (Ryan, 2020).

Raelene’s situation is very complex, with a number of chronic conditions and associated health issues. Each condition is impacted by and impacts on the others, making management of her health very complex. In addition to the complexities of her health is the fact that she lives remotely, making her experience of being a middle-aged woman with multiple chronic illness all that more complicated.

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