Nursing care of patients with ankylosing spondylitis
Ankylosing spondylitis is a chronic inflammatory arthritis of unknown etiology, occurring mainly in young men
Ankylosing spondylitis is a chronic inflammatory joint disease of unknown etiology, occurring mainly in young men, affecting the joints at the base of the extremities and spine, rapidly leading to ankylosing spondylitis, deformity and disability waste.
Seen in all parts of the world, but the incidence is different because it is related to the factor HLA - B27.
Males account for about 90-95%, under 30 years old account for 80%, 3-10% are family members.
Age of disease: Nearly 70% before the age of 30.
70% start slowly, 30% start suddenly, 75% start at the hip, 25% start from the spine.
Initial signs: hip pain, sciatica, Achilles tendonitis..., in our country often start with arthritis in the lower extremities (ankle, knee, groin) and lumbar spine pain. These symptoms last for months or years.
Swelling, pain, limited range of motion in many joints, muscle atrophy, rapid deformity. Arthritis is usually symmetrical in nature, pain increases at night.
Joints in the limbs:
Hip: 90% usually starts on one side, then both sides.
Knee joint: 80% may have water.
Other joints are possible but rare.
Usually occurs later than the joints of the extremities.
Lumbar spine: 100% continuous pain, limited range of motion, muscle atrophy next to the spine.
Back spine: usually later than the lumbar region, dull pain, limited range of motion, deformity (humpback) or stiffness, muscle atrophy.
Cervical spine: maybe later or earlier than other segments, deformity limits movement.
It is an early, specific sign (mainly on radiographs).
Pain in the pelvis, radiating to the thigh.
Pelvic wing dilation test (+).
Some other symptoms may be seen in patients with ankylosing spondylitis. overseas: 20-30% of cases, in Vietnam: about 3%. Some possible symptoms are:
Eyes: iritis, iridocyclitis.
Heart: 5% have conduction disturbances, aortic regurgitation.
Other rare manifestations:
Compression of spinal nerve roots.
Inguinal, umbilical hernia.
The general trend of the disease is 50% progressive, progressive, 10% progressive, leading to ankylosing spondylitis and deformity. If not treated early and correctly, patients have many bad postures, disabilities.
Complications: respiratory failure, congestive heart failure, pulmonary tuberculosis, paralysis.
Poor prognosis: young age, peripheral polyarthritis, fever, weight loss.
Better prognosis: disease after age 30, spondylolisthesis.
Tests and X-rays
General tests: of little diagnostic value:
Erythrocyte sedimentation (90%).
Increased fibrin (80%).
Protein electrophoresis: albumin decreased, globulin increased.
Immunoassays: Waaler Rose, antigen antibodies, Hargraves cells are mostly negative and have no diagnostic value.
Other tests were little changed.
Test Mucine (+).
HLA - B27:
Ankylosing spondylitis: 75-95% (+), in Vietnam 87% positive.
Normal people can be 4-8% (+), in Vietnam 4% positive.
Early signs: bilateral sacroiliitis stage 3 & 4.
Hip joint: narrow joint space, blurred joint surface, bone defect, adhesion.
Spine: bone bridge (bamboo stem), the fibrous band (rail).
Protozoa: accounts for about 40%, poor prognosis.
Spinal type: slow progression, starting after age 30.
Painless form: the spine gradually adheres, painless.
May be associated with rheumatoid arthritis: there is additional inflammation of the small joints of the hand.
Women: light, discreet.
Children under 15 years old: rapid progress, poor prognosis
Disease according to X-ray picture:
There may be no signs of sacroiliitis.
There may be a bony bridge in front of the spine.
Body with destructive form, bone defect.
Causes, mechanisms of pathogenesis, and damage
Cause and pathogenesis:
The etiology is unknown, there is no immunological evidence, but there is evidence of a role for infection.
Synovial membrane & articular cartilage:
First stage: synovial membrane proliferates, infiltrates cells (lymph, plasmocytes).
Later stage: articular cartilage is inflamed.
Late-stage: joint capsule, fibrous synovial membrane atrophy, calcification, ossification.
The buffer organization between the anterior long ligament and the vertebral body is inflamed, calcified, ossified, and forms a bone bridge.
The spinal ligaments are fibrous and calcified below the ligaments, causing adhesions to the spine.
New York Rheumatology Society Standards, 1968:
History or current of low back or low back pain.
Limit movement of the lumbar region in all 3 positions.
Decreased thoracic expansion.
Bilateral sacroiliitis stage 3, 4.
Diagnosis is confirmed when there is 1 symptom, which is the symptom of X-ray.
Practical application in Vietnam:
Pain and limited range of motion in both hip joints.
Elevated erythrocyte sedimentation rate.
X-ray: Bilateral sacroiliitis stage 2 or higher.
With proximal arthritis:
Tuberculosis of the hip.
Bleeding joints in hemophilia.
The vertebral body is mainly:
Bacterial spondylitis (tuberculosis, staphylococcus...).
Spinal injury in Scheuermann's disease: pain, kyphosis, no inflammatory manifestations.
Deformity, sequelae of trauma.
Paravertebral muscle diseases: inflammation, trauma, bleeding.
The relationship between ankylosing spondylitis and joint diseases with HLA-B27 (+):
Reiter's syndrome, HLA-B27 (+) 80%.
Psoriatic arthritis: HLA-B27 (+) is high with spondylolisthesis.
Chronic juvenile arthritis of the spine: HLA-B27 (+) is high.
Assess the situation
Patients with ankylosing spondylitis are often a chronic disease, progressing progressively worse and leading to disability if not treated promptly and properly. Therefore, nurses when interacting with patients need to properly assess the situation as well as the necessary needs of the patient in order to have a good treatment and care.
Assess by asking the patient:
Pain level, duration of pain, and limitation of movement.
Which joint usually hurts first and how does it start?
Have you had any other illnesses before?
Living conditions, economic, work, and patient's perception.
Worried or traumatized?
How long is the illness?
What drugs have been used and how effective are they?
How the disease progresses: worsening or moderate...
Judging by observation:
Patient's mental status.
Can walk on their own or need help.
Is the condition of the limbs and joints deformed?
Other accompanying signs.
Evaluation of the patient examination:
Check vital signs.
Assess the condition of the damaged joints, pay attention to the spine joints.
Evaluate complications or comorbidities, especially paying attention to digestive conditions, such as abdominal pain, signs of gastrointestinal bleeding...
Obtain information through medical and family records.
Prior treatment and care.
The drugs used and the effectiveness of the treatment.
By identifying patients with ankylosing spondylitis, some nursing diagnoses may include the following:
Swollen and painful joints due to inflammation.
Deformity and limited range of motion due to inflammation and partial adhesions of the joint.
Muscle atrophy due to immobility.
Limited breathing capacity due to kyphosis scoliosis.
Risk of treatment failure due to disease progression.
By exploiting the above symptoms, nurses need to make nursing diagnoses in accordance with the needs of the patient. The nurse analyzes, synthesizes and summarizes the data to determine the patient's needs, thereby creating a specific care plan. When planning care must consider the economic condition of the patient.
Rest the patient in the most comfortable position and avoid poor posture.
Explain to patient and family about a medical condition.
Educate patients and families on how to exercise joints to avoid muscle atrophy, especially during the acute phase.
Eat full of energy and lots of fresh fruit.
Instruct patients on how to self-monitor for drug side effects.
Execute the commands:
Administer medication to the patient and administer medication as directed.
Do basic tests.
Pulse, temperature, blood pressure, breathing rate.
Monitor joint damage, especially spinal joints.
Monitor some tests such as: complete blood count, erythrocyte sedimentation rate, joint X-ray, Waaler Rose, antigen antibodies, Hargraves cells.
Monitor drug side effects and drug response to treatment.
Monitor clinical progression of the disease.
Patients and families need to know about the causes, favorable conditions, lesions and progression of the disease in order to have a supportive treatment and caring attitude, in order to limit complications for the patient.
Implement a care plan
Patients with ankylosing spondylitis are a long-term progression and get worse if not treated and cared for. The disease leaves very serious sequelae leading to disability. Patients may die from complications of the disease or from treatment complications.
Perform basic care:
Place the patient at rest in a functional position if in the acute phase.
Instruct the patient on how to self-serve if a joint deformity has occurred, by daily having the patient's belongings arranged in an appropriate position and accessible when needed.
Encourage and reassure patients to feel secure in treatment.
Eat full of energy, lots of vitamins.
Cleanliness: daily cleaning of teeth and skin to avoid infections, early detection of infections to guide treatment for patients. Clothes, pants, linens and other items must always be kept clean.
Execute the commands:
Medicines used: fully comply with medical orders when taking drugs, such as: injections, oral drugs.
It should be noted that anti-inflammatory drugs must be taken after eating. In the process of taking the drug, if there is any abnormality, you must notify the doctor.
Blood tests such as erythrocyte sedimentation rate, blood count...
Other tests such as X-ray, joint ultrasound, electrocardiogram...
Vital signs: pulse, temperature, blood pressure, breathing rate.
Clinical status of joint damage.
Drug use status and drug-induced complications.
Monitor the progress of the disease and the patient's cooperative attitude.
It is necessary to educate patients and families about the causes, lesions and progression of the disease in order to have a caring attitude to treatment and care.
Patients need to know how to exercise, especially in the acute phase.
Patients need to be aware of the possible side effects of the drug.
The patient's condition after performing the medical order and implementing the care plan compared to the initial time. Some of the issues to be assessed are as follows:
Assess whether the condition of the joints is in remission: the nature of swelling and pain, as well as the degree of limitation of movement of the patient.
Assess disease progression.
Side effects of drugs.
Assess the patient's and family's ability to treat.
Is the primary nursing care assessment performed and responsive to the patient's needs?
Evaluate errors or omissions to add to the plan of care.