Nursing Assessment Example Of A Client With Rheumatoid Arthritis

Photo courtesy of Alacare (Flickr.com)

In our previous posts, we have discussed the importance of a comprehensive nursing health assessment and how it should be documented. But even though it is ideal for the nurse to make a full assessment of a client, there are factors that make a focused assessment more appropriate. For one thing, a focused assessment is needed if the client needs to be immediately rendered with nursing care and in these situations, the nurse must be more practical with time and effort. For people who would like to have a focused nursing assessment example, let’s have a case of a client with rheumatoid arthritis.

Let’s say a 61 year-old man comes to you, complaining of difficulty moving and intense pain on both his upper and lower extremities, and his relative tells you that the patient has rheumatoid arthritis. Having knowledge of his disease, you will be able to focus on the assessment parameters that are most related to the signs and symptoms of rheumatoid arthritis, and his chief complaint will indicate that the nurse should focus on the client’s mobility and pain. With these two points included in this nursing assessment example, the nurse will be able to quickly identify the client’s relevant nursing diagnoses.

Problem: Pain

Step 1: Ask about the client’s pain.

• When did it start?
• What specific parts of his upper and lower extremities are painful?
• How long has he been experiencing this pain?
• Have the client describe the pain in his own words.
• Is there anything that aggravates the pain?
• Did the client take pain medications? If so, what medications? Aside from pain relievers, is there anything else that the client does to relieve the pain?
• How frequent does he feel this pain? Has he experienced it before? Is it recurring? Are there intervals between episodes of pain?
• How severe is his pain? Ask him to rate it using a numeric pain scale.

Step 2: Do a physical exam of the painful parts.

• Since rheumatoid arthritis is an inflammatory disorder, observe the affected parts for redness and swelling.
• Inspect both extremities for deformities or deviations. Compare the right and left extremity. In rheumatoid arthritis, signs appear bilaterally.
• Palpate the affected parts to confirm swelling. Use the dorsal aspect of the hands to check if the painful parts are warm.
• Put slight pressure on the affected parts to confirm the location of pain.

Step 3: Note any existing diagnostic and lab results that are related to joint inflammation and pain.

If a physician is also examining the client, then he would have these usual tests done to confirm the diagnosis of rheumatoid arthritis. In this nursing assessment example, the nurse would take note of these diagnostic and lab results as supporting data. Here are the major diagnostic and lab results that you should look for:

• X-ray
• Rheumatoid factor
• C-reactive protein
• Erythrocyte sedimentation rate (ESR)
• WBC count

Problem: Mobility

Step 1: Ask about the client’s perceived changes with mobility.

• When did he begin to experience difficulty in moving?
• What specific parts of his upper and lower extremities are difficult to move?
• How long has he been experiencing difficulty in moving?
• Have the client describe his problem with mobility. How does it affect his ability to perform activities?
• Is there anything that makes moving more difficult?
• Is there anything that the client does to cope with his mobility problem?
• Does the client experience difficulty in moving all throughout, or does he just experience this while in pain?

Step 2: Observe the client’s mobility.

• Ask the client to move the affected parts. Observe if the hands, fingers, arms, and feet, toes and legs move within the expected range of motion. If you have a goniometer (an instrument that measures angles of body parts), then you would have a more accurate way of assessing ROM.
• Compare the movements and range of motion of the right upper extremity from the left. Do a comparison of the lower extremities as well.
• Observe if the client finds it easy or difficult to move each body part. You can tell there’s a problem if the client complains of pain or by his facial expression. Note if the client moves more slowly than usual.
• Note for any clicking sounds or crepitus when the client moves a specific body part.

Step 3: Note any existing diagnostic and lab results related to RA.

Mobility is a problem resulting from inflammation and pain, thus the nurse would use the same diagnostic and lab results to support these assessment findings.

This nursing assessment example enumerates the major parameters that you will explore with regard to the client’s chief complaints. Notice that it is essential for the nurse to obtain subjective and objective data, as well as get the diagnostic and lab results that are most relevant to the client’s condition. Remember: always have subjective and objective data to ensure that you’ll accurately formulate a nursing diagnosis because if you don’t, you might implement some actions which are ineffective, at worst detrimental, to the patient’s condition.