Chronic Problems for Health-Related Quality
Describe about the Chronic Problems for Health-Related Quality.
1: Pathophysiology of the chronic disease condition of rheumatoid arthritis (RA) encompasses a cascade of autoimmune reactions culminating in synovial hypertrophy and chronic joint inflammation along with synovial cell hyperplasia and endothelial cell activation. Uncontrolled inflammation with subsequent cartilage and bone destruction are the ultimate effects of RA. CD4 T cells, autoantibody generating B cells, mononuclear phagocytes, fibroblasts, neutrophils and osteoclasts in conjunction with several cytokines, chemokines and inflammatory mediators such as TNF-α, IL-1, IL-6, IL-8, TGF-β, EFF and PDGF contribute to the pathogenesis of RA (Gibofsky, 2012). Two forms of post translational modification (PTM), citrullination and carbamylation triggered by exposure to certain environmental factors such as smoking or infection by Porphyromonas gingivalis act for local protein modification by citrullination/carbamylation in genetically susceptible individuals. Tissue destruction occurs through functional inactivation of extracellular matrix proteins and chemokinescontribute to autoantibody production by virtue of direct activation of the osteoclasts. Citrullinated epitopes, determination of the enzyme isotypes and environmental factors have been identified as the crucial markers for the regulation of the molecular interactions in RA (Pruijn, 2015).
2: Anatomically RA affects mainly the joints of the human body causing pain, stiffness, swelling and eventually loss of function in extreme situations. The wrist and small joints involving the knuckles and the middle joints of the fingers are the most injury prone locations in case of RA patients. Cervical spine joints including the atlas and axis apart from the thoracic and lumbar spines are also affected in RA. Research reveals that the metatarso phalyngeal (MTP) joints are particularly vulnerable to erosion due to RA indicating an association between the biomechanicl demands and bone conformation alterations in the forelimb (Siddle et al., 2014). Physiological mechanism of RA follows essentially a two step mechanism involving the priming of autimmunity initially and induction of arthritis ultimately. Synovial citrullinated antigens like fibrin, vimentin, α-enolase, collagen type II play pivotal rule in RA pathogenesis through generation of PTM proteins that alter cellular mechanisms significantly (Kinloch et al., 2014).
3: Clinical manifestations of the chronic health problem of RA on the health system of the person affected encompassed a wide range of issues. Persistent symmetric polyarthritis commonly referred to as synovitis in the hands and feet in addition to progressive articular deterioration are seen of RA. Disease onset for RA is normally insidious with fever, malaise, arthralgias at the beginning with progressive symptoms exhibited in joint inflammation and swelling. These were shown in the patient as well. Extra articular structuresa also get affected constituting major hindrance in performing the daily activities. Joint inflammation contributed to the generation of excruciating pain during RA that gets accentuated through central sensitization and structural joint damage. Upper extremities involving the metacarpophalyngeal joints, wrists, elbows, shoulders together with the lower extremities structures like ankles, feet, knees, hips, cervical spine were the most common locations of damage due to RA. Systemic effects were manifested in production of acute phase proteins like CRP, anaemia and cardiovascular disease, osteoporosis, effect on the hypothalamic-pituitary-adrenal axis causing fatigue and depression (Walsh & McWilliams, 2012).
4: The patient reported general weakness, swelling and pain in the joint regions of her body due to the chronic prevalence of RA. The pain was particularly intolerable in the morning typically after waking up from the sleep and subsided gradually. The patient stated that the inflammation in the joints hindered her range of motion severely. Her gait pattern changed significantly due to unequal weight distribution at both feet that got affected as a result of RA. The synovial joint of the knee was most prone to get affected. Patient also revealed that she understood the autoimmune nature of the disease is causing serious harms to her immune functioning compromising her resistance to infection. Heat and cold therapies alleviated her pain apparently, however in conditions of extreme pain, pain killers and analgesics like NSAIDs were necessary to handle the situation. Disease modifying antirheumatic drugs (DMARDs) was also required at certain instances under medical supervision to treat the disease. Research has highlighted that sleep might be the mediating factor between RA and accentuated conditioned pain modulation (CPM) (Lee et al., 2013). Thus pain aggravation in early morning as referred by the patint may be attributed to the sleep problems as the study suggests.
5: The physical impact of RA on the activities of daily living can be witnessed in patient through the joints inflammation. Inflammation particularly in the finger joints lead to stretching of the ligaments and tendons. Bone and cartilage erosion in conjunction with deformity of the joints are the resultant effects of RA. Lack of appetite, overwhelming fatigue and a lack of energy can impact the overall health. Immune system, circulatory system, respiratory system and skeletal system are majorly influenced due to RA (Williams et al., 2013). Psychological impacts due to RA are at the risk of developing anxiety, depression and low self esteem in addition to high levels of related mortality and suicide tendencies. Thus poor mental health status in RA patients are a major concern for the healthcare providers (Geryk et al., 2014).
6: Assessment of the chronic condition of RA in nursing through problem solving approach may be undertaken to mitigate the patient issues and difficulties. Physical examination of the RA patients will include evaluation of the stiffness, tenderness, swelling, deformity and pain during motion. Pathologic examination will include erythrocyte sedimentation rate, C-reactive protein assay, whole blood count, rheumatoid factor assay, antinuclear antibody assay while radiography, MRI and ultrasonography will account for the imaging diagnosis. Gram satin, cell count and culture will contribute to joint aspiration and synovial fluid analysis. Non pharmacologic interventions might be utilized as well for disease management including hot and cold therapies, orthotics and splints, therapeutic exercise and occupational therapy. DMARDs and analgesics may be administered as pharmacologic therapeutics. Thus a holistic mode of approach for RA mitigation may be conducted to offer quality care to the patient and rapid recovery and reducing the risk for further complication (Singh et al., 2012).
7: The interviewee residing in the Dubbo region of Australia has the access to resources and support services for keeping the chronic disease under control. The services and infrastructure offered by the Australian Rheumatology Association may be referred to in this context that provide scope for workforce and trainee development, professional development and practice standards achieved through collaboration and partnerships, extensive research pertaining to rheumatoid arthritis (www.rheumatology.org.au, 2016). Other services for patients suffering from similar conditions as well as other chronic ailments in the region include the Melbourne Hand Rehab (Contact Number: 94585166) (www.melbournehand.com, 2016) and Chronic Disease Clinics (Contact Number: (022) 6333 2800) operating across several important locations in and around Australia (www.marathonhealth.com.au, 2016). For health services the Marathon Health After Hours Services ((02)6884 2100) may also be contacted by the concerned persons living in the Dubbo region (www.dubbo.com.au, 2016).
Geryk, L. L., Carpenter, D. M., Blalock, S. J., DeVellis, R. F., & Jordan, J. M. (2014). The impact of co-morbidity on health-related quality of life in rheumatoid arthritis and osteoarthritis patients. Clinical and experimental rheumatology, 33(3), 366-374.
Gibofsky, A. (2012). Overview of epidemiology, pathophysiology, and diagnosis of rheumatoid arthritis. The American journal of managed care, 18(13 Suppl), S295-302.
Kinloch, A. J., Lundberg, K. E., Moyes, D., & Venables, P. J. (2014). Pathogenic role of antibodies to citrullinated proteins in rheumatoid arthritis. Expert review of clinical immunology.
Lee, Y. C., Lu, B., Edwards, R. R., Wasan, A. D., Nassikas, N. J., Clauw, D. J., ... & Karlson, E. W. (2013). The role of sleep problems in central pain processing in rheumatoid arthritis. Arthritis & Rheumatism, 65(1), 59-68.
Pruijn, G. J. (2015). Citrullination and carbamylation in the pathophysiology of rheumatoid arthritis. Frontiers in immunology, 6, 192.
Siddle, H. J., Hensor, E. M., Hodgson, R. J., Grainger, A. J., Redmond, A. C., Wakefield, R. J., & Helliwell, P. S. (2014). Anatomical location of erosions at the metatarsophalangeal joints in patients with rheumatoid arthritis. Rheumatology, 53(5), 932-936.
Singh, J. A., Furst, D. E., Bharat, A., Curtis, J. R., Kavanaugh, A. F., Kremer, J. M., & Bridges, S. L. (2012). 2012 Update of the 2008 American College of Rheumatology recommendations for the use of disease‐modifying antirheumatic drugs and biologic agents in the treatment of rheumatoid arthritis. Arthritis care & research, 64(5), 625-639.
Walsh, D. A., & McWilliams, D. F. (2012). Pain in rheumatoid arthritis. Current pain and headache reports, 16(6), 509-517.
Williams, A. E., Graham, A. S., Davies, S., & Bowen, C. J. (2013). Guidelines for the management of people with foot health problems related to rheumatoid arthritis: a survey of their use in podiatry practice. Journal of foot and ankle research, 6(1), 1.
www.dubbo.com.au,. (2016). Retrieved on 23 November 2016, from http://dubbo.com.au/LifeInDubbo/DubboDirectory/health
www.marathonhealth.com.au,. (2016). Retrieved on 21 November 2016, from http://www.marathonhealth.com.au/chronic-disease-ruraloutreach
www.melbournehand.com,. (2016). Retrieved on 21 November 2016, from http://www.melbournehand.com.au/index.php?pg=1143
www.rheumatology.org.au,. (2016). Retrieved on 21 November 2016, from http://rheumatology.org.au/otherpages/search_suburbresults.asp?suburb=DUBBO&SubmSu=Search+By+Suburb