Rheumatoid Arthritis Presentation 3

Presented by Julie Gray, Kate Balagety, Nazia Arif, Christine, Gemma,

Oral Prednisolone Is One of the drugs used in management of Rheumatoid Arthritis. Mainly because;

•It can be used in low doses to decrease the symptom of inflammation. •Reduces swelling in the joints •Prednisolone reduces symptoms of pain, •Reduces stiffness, and maintains mobility •Prevent deformity as the process of disease makes the individual rigid.

3 SIDE EFFECTS • Peptic ulceration; A GI effect, caused by long term use of predisolone. • Osteoporosis; Muscloskeletal effect. • Papiloedema; Opthalmic effect.

Nursing Care Issues Regarding Patients on Predisolone Wean Patient off from dosage, as it may lead to sudden collapse. Monitor blood glucose levels, Pre and post meals because prolonged use of steroids could lead to possible diabetes. Predisolone is a glucocorticoid, which increases blood glucose levels due to the breakdown of proteins and fats by the process of gluconeogenesis. Glucocorticoids suppress WBC e.g. lymphocytes; part immune/inflammatory response, therefore risk of infection. Use aseptic techniques, whilst caring for wounds and invasive procedure, to reduce risk of infection as patients become more suseptable whilst on predisolone. This can be achieved by; maintaining a clean environment, using PPE and hand washing. [infection control techniques]

A nursing colleague says to you that her patient has asked for more painkillers but she is not going to rush to get them because she does not believe that the patient is in that much pain.

In this situation, the first priority would be the patient in pain. There are many ways around ensuring the patient receives analgesia.

Legal & Ethical Issues around Pain Seers 1987, found that nurses recorded pain to be less severe then the patients own assessment very often. Patients maybe stereotyped as being a nuisance or dramatic over expressing their pain. Equally patients in pain may not express as well (introvert personalities) and receive less analgesia. This situation can be brought on by the nurses own culture and beliefs on the concept of care and pain. Such has strong personalities can endure pain, and weaker people are demanding analgesia in fear of pain. The NMC code of conduct and ethics of nursing; Nurses must: Attend to every report of pain by clients or their families Regard the personal privacy of clients as they deal with pain. Respect the lifestyle and belief systems of clients. Strive to sustain human life and dignity while relieving pain and suffering.

Advocacy • Although not specifically your patient, as a nurse you must take on the role of advocate for all patients and make it your responsibility to look after their interests and health. You would therefore be in breach of the NMC Code of Conduct which states: • “You must act as an advocate for those in your care, helping them to access relevant health and social care....” Also: • “You must listen to the people in your care and respond to their concerns and preferences”.

Ethics: • McCaffrey (1968) proposed a definition of pain that reminds nurses of the subjectivity of pain: • “Pain is what the patient says it is and exists when he/she says it does”.

Effects of unrelieved pain: • Unrelieved pain increases a patient’s susceptibility to develop detrimental physical, psychological, spiritual and social effects. Good management of pain enables mobility and deep breathing, and reduces the risk of physiological events such as deep vein thrombosis, hypertension and tachycardia. • Preventing these complications avoids prolonged hospital stays which has cost implications for the NHS.

1 You could ask your colleague what the patient is prescribed, and offer to provide the medication as a staff member, or under supervision as a student. Making it very difficult for nurses to say no, because legally and ethically they know they have a duty of care.

2 You could question the effectiveness of the drug the patient is receiving, as they need more analgesia. Highlighting the fact that the patient must be in pain, and its better to give them the analgesia now, and evaluate the results. It might be the medical team need to prescribe an alternative.

3 Communicating with your colleague is important, you may take them aside for a moment, and remind them that if the patient says they are in pain, they are in pain. Ethically as nurses we are obliged to manage that pain as much as possible. It will help to build a good nurse patient relationship and maintain ‘trust’ by providing the patient with prescribed pain relief.

4 As a last resort, if your colleague doesn’t recognise and acknowledge the non maleficence; to report the pain to another member of staff, and later discuss with a senior member of staff how a patients pain should be managed and how nursing attitudes effect this on the ward.

Legal: There are additional legal and financial considerations for health care providers who do not treat serious pain appropriately. In the USA, a health care provider was held liable for failure to treat serious pain in terminal illness appropriately and the family were awarded substantial damages, (Estate of H. James vs Hillhaven Corp. 1991). Although this case involved terminal illness, there are implications for all health care staff and managers.