Case Study: Rheumatoid Arthritis

Introduction

C. K. is how you would define happy. Her aura coupled with an extremely bubbly personality and optimistic outlook will leave you beaming. Married and cradling her first child within a year, was the 42-year-old office administrator's dream come true. Her husband J.M has also just landed a big promotion at work and everything was just impeccable. She wanted to focus all her time on making her family and by God, that was what she would do.

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It was in this perfect moment that C noticed severe pain and swelling on her arm joints. This was just a few months after giving birth. She could not hold her precious baby for long or carry out simple household chores. She had to hire two nannies to help with the baby and the house.

Following a consultation with a rheumatologist, C was informed that she had rheumatoid arthritis. In addition, C was overweight which is also a risk factor for the disease. Her motor functions debilitated which make it increasingly difficult for her to perform even simple tasks. She had to be admitted to a hospital when she could not even walk due to the pain in her knees.

C felt like she was too dependent on others and talked to her doctor about it. Plus, she felt that she could do more, for example, lose some weight as a prelude to getting better. A former passionate dancer, C cannot move to the beat anymore due to the pain she feels. She is confined to the chair all day as she cannot stand up for long. She works at the local community center at the front desk and she is grateful for that. A normal day for C starts at 7:00 am when she wakes up. She leaves for work at 8:30 am till 2:00 pm when she ends her work day. Her biggest wish is to walk again without any pain to be able to work harder for her family and mentor other people.

C lives in a bungalow she moved to because their previous home was not friendly to her condition. Her husband installed a ramp to help her into the raised parts of her home. She lives with her husband, child, and one of her two nannies.

Condition Summary and Occupation Aspects

Swelling of the joints is the biggest sign of rheumatoid arthritis (Prothero, Barley, Galloway, Georgeopoulou and Sturt 2018). This is due to the fluid in the joints that makes them tender and puffy. The irritation also causes redness on the joints. In addition, they become stiff and do not move as should. Joints can take up to hours to feel loose after waking up in the morning.

According to Steultjen et al. (un), the most common symptom of rheumatoid arthritis is the inflammation of joints whether a person is using them or not. Without treatment, the pain increases and can cause damage. The inflammation can also spread to your muscles in the affected area.

Rheumatoid arthritis mainly affects adults between 45 to 60 years of age. Women are more susceptible compared to men and mostly in women who have given birth. People from families with a history of the condition are also at risk of contracting it (Prothero et al. 2018).

Areas of Occupations mostly affected by rheumatoid arthritis include:

• The manufacturing sector that has exposure to smoke or silica dust
• Office work with long hours
• Deficits that affect each area of occupation
• Manufacturing sector

Toxic exposure: without proper protective gear one is left exposed to agents that lead to rheumatic arthritis.

Physically demanding work that might cause strain to the joints causing them to become inflamed. Especially coupled with other risk factors.

Office work

Lack of regular exercise. Putting in long hours at work leaves one too tired to find time to do exercises or go to the gym.

Sitting down for a long time increases the risk of becoming overweight which can lead to rheumatic arthritis.

Role Ota in Safety and Discharge

One standard assessment would be to check and advise on how renovation for a home will be done to improve the daily living skills of the patient.

Suggestions to the caregivers to promote performance and safety would be:

Purchasing appliances and aids that will make tasks easier. For example, raised toilet seats and bath seats for an easier experience in the bathroom. Adaptations can also be installed for example stair lifts and ramps.

Find alternative ways to use the patient's hands to carry out tasks around and also help regain some bit of mobility. For example, using supportive arm splints for light chores.

Roles of COTA in Planning Discharge

COTA can assess on when to discontinue services to a patient. It helps in implementing them and contributes to a discontinuation plan when it is felt that the changes have worked (Pendleton and Shultz 2017).

When being discharged COTA can plan for environmental and personal adaptations. Recommendations are made and assistance given to acquire AT. It helps identify resources needed and a home presentation program as required.

Treatment Plan

One service C is currently receiving is physical therapy. One asset that is key for her in her therapy is commitment. She is keen on working with different specialists to help her rebuild her strength.

The treatment plan is based on the Biomechanical approach. The aspects of the approach include:

• Work simplification and energy conservation.
• Body mechanics methods and principles.

These help C in her rehabilitation process and motor learning through:

• Scheduling and organizing tasks to make it easier to balance between light and heavy work. It also reduces the number of trips. Use of adaptive equipment like electric appliances also makes work easier.
• Advising on how to use joints without causing them strain. Like lowering the body to the level of work, pushing objects rather than lifting, and having feet flat to the floor.

Long term goal (LTG)

Resume light chores around the house

Short term goal (STG)

• Be able to get out of bed independently
• Interventions to assist in achieving short term goals
• Provision of an adjustable wheelchair and for maximum support.
• Assessment of the current abilities and their impact on managing small tasks.
• Education on preventing pressure injuries
• Home assessment for modifications to support C for her return home
• Training of use of splints for more hand control
• Referral to community therapists for external services for home rehabilitation
• Education on managing fatigue

Progress Note

C is now doing very well thanks to her occupational therapy program. She can walk for 10meters with her frame. She can shower but needs someone nearby to help her with dressing. She has a wheelchair to help her when she needs to move over long distances. She needs a carer nearby all through but she is striving towards complete independence. She can cuddle her child longer than she could when her problem began and nothing makes her happier than that.

SOAP Note

Subjective: C.K looks happier coming back for her appointment. She came with her husband. She indicates that she has been doing better after her last therapy session. The inflammation on her hip joints has come down and she can stand for a while. She hopes to maintain it that way.

Objective: vital signs i.e. weight 330 pounds, temperature 35.7 Celsius, and blood pressure 124/71. Inflammation 2/10. The patient fully alert. Musculoskeletal: the patient has increased range of motion for most of her joints. The tenderness is reduced compared to the last appointment.

Assessment: the patient is doing well. Continue the current regimen of methotrexate.

Plan: return for next appointment in 6 months

References

Pendleton, H. M., & Schultz-Krohn, W. (2017). Pedretti's Occupational Therapy-E-Book: Practice Skills for Physical Dysfunction. Elsevier Health Sciences.

Prothero, L., Barley, E., Galloway, J., Georgopoulou, S., & Sturt, J. (2018). The evidence base for psychological interventions for rheumatoid arthritis: A systematic review of reviews. International journal of nursing studies.

Steultjens EM1, Dekker J, Bouter LM, van Schaardenburg D, van Kuyk MA, van den Ende CH. Occupational therapy for rheumatoid arthritis. Accessed at: https://www.ncbi.nlm.nih.gov/pubmed/14974005 on 01 February 2019.