Major Relationship Between Arthritis, Arthritis Patients, And Nurses
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Abstract
Arthritis is a disease in which the body tend to malfunction as one grows older. The body of a human being works through a series of veins. Veins are thin walled blood vessels that carry blood from the body tissues back to the heart. Together, veins form a network of ‘straw’ vessels throughout the body. In the limbs i.e. hands and legs, the distance from the heart lowers the pressure with which the heart pumps the blood (Francesca, et al. 12). Therefore, to facilitate the movement of blood from the legs and arms towards the heart and vice versa, the muscles squeeze the deep veins forcing the blood upwards. There are several disorders attached to the deep veins. The focus of this paper is on the deep disability of the veins which can be termed as arthritis. Arthritis affects different parts of the body, this include the knees, elbow and various joints. Research shows that the number of people is very high compared to the majority number of services. In different terms the mode in which various medical facility have been distributed all over the world is minimal and can not cater for the whole population. This facility includes joint replacement machines and medicines in case of an early detection. As arthritis tends to grow into different stages there is need for of the patients affected by the disease, the care requires learned personnel’s who can be able to cater for different services.
IntroductionTo nursing
Nursing has one of the most interesting histories in comparison to other professions. In the %the century BC, a famous philosopher Hippocrates is known to have advocated for care for the sick and wounded as they recover back you normal health and the fit in maintenance of their health. The religious books of our times, The Bible to be precise, records that Jesus a Key figure in the foundation of Christianity is known to have advocated for care of the sick as well. History apart, it was not until the 17th century that nursing began to live as a service. In England for instance, care giving; the early form of nursing then was delegated to men and women in punishment. These were often prostitutes and criminals serving in prison. Florence Nightingale is remembered today for being the first person to consider nursing as a profession, getting into it well learned, she began a formal training procedure for nurses. In 1901, New Zealand became the first nation to enact a provision for nursing as a profession. Today, nursing is a profession like any other, governed by both national and international law. It is trained as a course at various levels of study the largest being the PHD. The process of entering into a nursing profession is a choice by interest basis. However, unlike other professions, nursing is associated with a calling into the profession. Interest into other courses is commonly driven by job availability or professional marketability, salary and reward associated patterns, previous experiences among other many preferences. However, nursing is an interest by devotion and dedication based profession. Although not formally stated, nursing has been talked of as a service oriented profession and therefore, its personnel are expected operate not to meet the requirements set within their ethics, but to devotedly eradicate human suffering through care services. Majority of personnel in the nursing profession in the past are had personalityies tending towards the ethical expectation of nursing. However, today, recent records proof otherwise. At the expression of interest to enter the profession, not many formalities are followed. Prospective entrants only need to go to college, study a minimum of a diploma certificate and register as a nurse.
arthritis
This paper is a focus on the cares and the risk factors of arthritis in South African population. Dr.Virchrows in early 2005 ( HYPERLINK “http://www.pathguy.com/virchow.htm” www.pathguy.com/virchow.htm, www.oralchelation.net/../page8a.htm) spent time in South Africa and observed that prevalence of arthritis in patients grew at a rate of 18%. Most of these patients were also HIV positive (Liu, et al p.32) (edrv.endojournals.org/../313). He conducted a systematic study and in the end of his study, he outlined several principal factors risking arthritis in South Africa. Deep vein thrombosis also known as deep venous thrombosis [medicine] is caused by formation of blood clot in the deep veins of the body. It mostly occurs in the deep veins of the legs. In most cases, the blood clots usually dissolve on their own without any medical intervention. However, this clotting tends to make the body malfunction as one age (Bjorklund p.14). This is however tends to affect joints, the elbow and knees. People tend to ignore this factor because they think that it is a result of aging. This condition has no cure but, better medical care is needed for people suffering from this disease.
Background / Literature Review
Dr.Virchrows in early 2005 spent time in South Africa and observed that prevalence of arthritis in patients grew at a rate of 18%.Most of these patients were also HIV positive (Canadian Arthritis Network 11). He conducted a systematic study and in the end of his study, he outlined several principal factors risking deep vein thrombosis in South Africa (McNeil and Sack-2005-health and fitness).
Prolonged Inactivity: Lack of leg movement up to four hours or more due to driving for long hours or long flights causes calf muscles in the legs be unable to contract. Contraction of muscles is necessary for facilitating smooth blood circulation in the veins of the legs hence lack of blood circulation enhances the risk of blood clotting in the veins. This can also occur to patients in bed rest or patients with paralysis. (p.22)
Genetic disorder: exactly how much does genetic affect the case of arthritis? Generic are transferred from one generation to the other. Clough insinuates that genetic has a slight chance of affecting the body of the generation to get the same disease (p.34) According to medicine heredity traits are acquired from the parent through genes. This genetic material does not necessary change during fertilisation. Thus a genetic disorder in the family can be said to be one of the ways of having arthritis. Deep vein thrombosis could be as a result of a genetic disorder causing blood clots in the veins. Meaning that joints will start having disorders as one age, this can be counted with specified time. ( p.36-38)
Surgery: During surgery general anaesthesia used tends to dilate veins raising the risk of blood clotting. Injury to veins could also slow down blood circulation hence blockage of veins. According to Shen (p.981), surgeries that could risk arthritis include: Orthopaedic operations involving the hip and knees, neurological procedures, major pelvic or abdominal surgery caused by malignant like cancer(Anderson ML, rheumatoid arthritis(2006))
Some high-level sports: Over the years sports has been determined to be one of the best ways to keep fit. Thus it is very difficult to determine how sports would cause arthritis. Sports as a general lead to side effects which are generally not positively oriented. Various exercises and sports can lead to bone joint injury and subsequent arthritis. During sports some people tend to have hearts issues. Poor heart conditions slacken blood flow and this may lead to blood clots causing veins blockage, as seen earlier this may lead to arthritis. The benefits of sports generally out numbers the chances in which one risk at getting arthritis(McNeil and Sack-2005-health and fitness).
Obesity: Joints are responsible for supporting the body. Joint damaged thus is highly dependant on the total weight exerted on specific areas. Excess weight puts pressure on the legs and pelvic thus reducing blood circulation in the lower limbs. This could cause blood clots. Excessive weight may also increase the chances of getting arthritis through damages caused by the excessive weights (The British Pain Society-2005-p 2).
Occupational hazards: Some workers stand a great chance of being affected by arthritis. This include people who work in assembly areas, assembly areas generally involves working with heavy machines. This weight exerted in different body parts affect joints; this may end up injuring different joints in the body. Workers working in smoke oriented industries stand a high chance of getting arthritis. Smoke slows down blood circulation in the body and could also cause blood clot.(Armstrong L-2007)
Illness or infection: People with infections which affect the joints, high levels of gout, or any other medical conditions. These conditions tend to leave people very vulnerable to diseases. An example of this is arthritis. Previous injuries also tend to cause abnormality of the normal smooth join surfaces. The tibia plateau fracture is an example of an injury which may cause arthritis. The space which had the fracture may enter the knee joint. This is an example of arthritis on the knee joint (Belcher c- (2004-2007)-gycosaminoglycans)
Well over 200,000 South Africans suffer from arthritis each year, (p.4) but, because most arthritis is occult, the true incidence is unknown (Burnside, et al. Page 493). Approximately 50,000 patients per year require hospitalization for 5-10 days of intravenous heparin therapy. In addition to those with acute thrombosis, thousands more suffer from Sequelae such as stasis dermatitis and venous ulcers. While the degree of morbidity is significant, mortality rates are equally problematic. Thromboembolic disease is annually responsible for 20,000 deaths in South Africa. The elderly are in greatest jeopardy; arthritis is associated with around 20% annual mortality in this age group (Coates p.56). Many in this subgroup die from associated pulmonary embolism (PE), while others succumb from co morbid disease, especially cancer. Even children are at risk for acute arthritis. Paediatric patients at risk include those with spinal mechanism that propels blood into the central circulation. Stasis plays a role in joint encountered in the morbidly obese and in individuals with cardiac disease. Limb paralysis from stroke or spinal cord injury is associated with a difficult to evaluate syndrome of painless or occult arthritis (Burnside, et al. P.493). Surgery and trauma are responsible for up to 40% of all joint related diseases, which results from both a hypercoagulable state and immobility. These insults activate the clotting cascade, and indices of arthritis and fibrinolysis rise rapidly (Aurich M, Squires GR- differential matrix degradation- 2005)
Arthritis Condition
Questions heparin for arthritis, interestingly, this practice is not justified by the literature. For patients not on warfarin, assessment of the partial thromboplastin time (PTT) will almost never affect management. Obviously, a PTT should be obtained six hours after standard heparin in begun (Goodacre, et al. P. 129). If a patient with acute arthritis is currently on warfarin, an International Normalized Ratio (INR) is essential for management. It is now well documented that the prothrombin time (PT) is both antiquated and inaccurate, primarily because the sensitivity of joints tissue reagents differs from batch to batch. Fortunately, the International Normalized Ratio (INR) adjusts for this lack of standardization by comparing each batch with an International Sensitivity Index. (McNeil and Sack-2005-health and fitness).
Measurement of the prothrombin time could be eliminated from clinical practice if replaced by the (INR). Adequate anticoagulation for arthritis is reflected by an International Normalized Ratio(INR) between two and three. If a patient with a sub-therapeutic INR develops arthritis, they will require more aggressive anticoagulation— first with heparin, and then an increased dose of warfarin. However, a patient who is on warfarin, but sustains an acute clot and has a therapeutic INR, requires a Greenfield filter. Emergency Medicine Reports (p.17) chest pains or shortness of breath should have a volumetric quantitative computed tomography (VQCT) scan to expedite the diagnosis (Heit, et al. P.697). Two joints tests are valuable in the management of arthritis disease: the D-dimer and the INR. Current D-dimer assays have predictive value for arthritis, and the INR is useful for guiding the management of patients with early detected arthritis who are on warfarin. While no blood test can conclusively rule in or rule out venous arthritis, a normal D-dimer in a patient with no risk factors for thrombosis makes proximal arthritis extremely unlikely. Despite the fact that it is frequently ordered, a complete blood count (CBC) rarely provides useful information in patients with joint signs or symptoms. The leukocyte count cannot distinguish between arthritis and cellulitis and is neither sensitive nor specific for either condition (Torjuul, Elstad and Sorlie p.9) Coagulation studies rarely are required as part of the initial evaluation of venous arthritis (Gottlieb, et al. P.853). Occasionally, these studies may be valuable after Doppler demonstrates an acute arthritis, and in patients who develop the disease while on warfarin.
Physical Examination
A caveat that is nearly 20 years old remains valid today. “A combination of clinical signs and symptoms that included tenderness, swelling, redness, and the assessment of Humans’ sign [can] not adequately differentiate patients with or without arthritis (Righini p.55).”This is not to imply that physical examination is useless, but that a number of physical findings in combination with risk factors assist in the diagnosis of a patient with joint complaints. Occasionally, a rectal temperature can help distinguish cellulitis from arthritis. While patients with arthritis may have a low grade fever due to a systemic inflammatory response, this fever rarely exceeds 102°F (McNeil and Sack-2005-health and fitness).
To help make this differentiation, it is essential to completely undress the patient with leg symptoms and inspect for lymphangitis, erythema, and ulcerations. Joints may become infected, especially in patients with intravenous drug abuse. Remember to examine the entire joint for abnormalities, as lymphangitis may have large “skip” areas. Be alert for psychiatric patients or prisoners who may tie a tourniquet around their thigh to produce factitious arthritis. Lack of discrepancy in calf size does not rule out arthritis. Some researchers have standardized calf measurements at 10 cm below the tibial tuberosity. While asymmetry of the calves of 1 cm or more is abnormal, such asymmetry does not definitively distinguish between patients with Thromboembolic disease and that without (MacKay, et al. P.29).
However, asymmetric calf swelling of greater than 3 cm is almost always a significant finding. Examine the joints for pitting edema; extremities affected by acute thrombosis are frequently warmer than the opposite limb. Palpation includes a search for “cords,” which are very specific, although insensitive for thrombosis. Cords are most often detected in the popliteal fossa. Palpate distal pulses and evaluate capillary refill to assess limb perfusion. Pulses may also be diminished in long-standing arterial disease. The presence of pain with passive range of motion of the toes or ankle is an important clue to compartment syndrome. Move and palpate all joints to detect acute arthritis or other joint pathology (McNeil and Sack-2005-health and fitness).
Neurologic evaluation may detect nerve root irritation; sensory, motor, and reflex deficits should be noted. Search for a thrill or bruit which is associated with arteriovenous (AV) fistulas. Patients with large fistulas have abnormally high cardiac output, and manual compression of the fistula reflexively slows the heart by reducing the shunt (Branham’s sign). Patients with a remote history of a gunshot wound to the extremity are most likely to present with a fistula (p.89) Bony tenderness does not rule out DVT. Indeed, up to 65% of patients with DVT will have pain with percussion of the medial tibia (Smolen 8). Bancroft or Moses’ sign is pain with compression of the calf against the tibia. Some patients with arthritis will have more pain with this manoeuvre than with transverse compression of the gastrocnemius. A review of venous thrombosis would not be complete without mention of Homans sign: pain in the posterior calf or knee with forced dorsiflexion of the foot. It is often present in patients with sciatica (McNeil and Sack-2005-health and fitness).
Despite numerous references to Humans sign in the medical literature, this finding is inaccurate and unreliable. Examination of the patient with arthritis does not end with evaluation of the extremity. Search for stigmata of PE such as tachycardia (common), tachypnea or neck findings (rare), and exam for signs suggestive of underlying malignancy. Diffuse swelling can indicate the presence of an up coming numbness. Effort-induced arthritis occurs in young, active males, while catheter-related arthritis is limited to patients with prior instrumentation or intravenous old people (aging). Dilated collateral veins are frequent in the joints, but these are more easily seen in Caucasians (Wells p.295). Look for arm discoloration and palpable axillary veins. Diagnostic Studies Clinical examination alone is able to confirm only 20-30% of cases of arthritis. Because of the limitations associated with the physical examination and history, the diagnosis of arthritis must be pursued in any patient who presents with unexplained extremity pain or swelling. A patient, who presents with symptoms in both arms and both legs, usually will not be suffering from bilateral arthritis.
Patients with risk factors for bilateral arthritis, however, who present with bilateral findings, need careful examination. Patients with unilateral complaints and no clear explanation, such as a direct blow to the extremity, twisted ankle, etc., require further evaluation. The presence of risk factors for arthritis must decrease the threshold for obtaining imaging studies. Accordingly, nearly all patients with complaints compatible with venous arthritis, and who have no typical alternative diagnosis, require an imaging study. (McNeil and Sack-2005-health and fitness).
Therapy
This Clinical Pathway is a suggested approach for suspected arthritis patients, and is intended to supplement rather than substitute for professional judgment (The British Pain Society –p.4). The physician may change this plan at any time depending upon the patient’s individual needs. Failure to comply with this pathway does not represent a breach of the standard of care. Emergency Medicine Reports dimer measured by the whole-joints disability assay almost rules out the diagnosis (i.e., there will be less than a 1% chance of proximal arthritis). While some physicians (nurses) may opt to forgo imaging studies in patients with a negative D-dimer, others may be reluctant to rely entirely upon a joint test. It seems reasonable that a negative D-dimer may obviate the need for off-hour Doppler studies in low-risk patients (Stupack, et al. p.571). If a patient presents at night with an immobile leg or any other part of the body, it can not be postponed till the next day.
Imaging Studies
Imaging studies include both invasive (venography, radiolabeled fibrinogen) and noninvasive (ultrasound, plethysmography, MRI) techniques. Current options are discussed in the next sections. While venography aspires to be the “gold standard” modality for the care and diagnosis of arthritis, it is a “gold-plated” standard at best (Eby p.1137. First, radiologists disagree on interpretation in at least 10% of cases, and 5-15% of all studies are technically inadequate (Celeste C and Jonescu, M- matrix metabolism,-2005).
Moreover, side effects are significant and 2-5% of patients develop phlebitis from this painful procedure. The rare case of anaphylaxis remains a significant clinical concern. For the most part, ultrasound has supplanted venography for the initial evaluation of the patient with suspected arthritis. If the ultrasound is equivocal or unavailable, venography may be useful. Venography is also useful if the patient has a high clinical probability of arthritis and a negative ultrasound, and it is also valuable in symptomatic patients with a history of prior thrombosis in whom the ultrasound is non-diagnostic (Wells p.295). In these patients, it usually can distinguish between acute events and chronic changes seen on ultrasound. A contrast study can delineate occlusion, recanalization, and collateral channels. Since neither ultrasound nor
impedance plethysmography (IPG) is accurate for clot in Up to 10% of patients with DVT have an underlying coagulation disorder such as antiphospholipid syndrome or protein ‘S,’ protein ‘C,’ or antithrombin III deficiency. However, measurements of these levels usually are not necessary for emergency management. On occasion, the admitting internist may screen young adults with unexplained arthritis for more common coagulation disorders, D-dimer. If an emergency physician wishes to use a single tissue test in order to exclude the diagnosis of DVT, the D-dimer assay would be that test. Only 2% of patients with a negative
D-dimer (measured by the whole by agglutination assay) will have arthritis. In patients with a low pretest probability, the negative predictive value is 99.4%. D-dimer is a specific degradation product of cross-linked fibrin (D’Adamo and Whitney p.58). Because concurrent production and breakdown of clot characterize arthritis, patients with Thromboembolic disease have elevated levels of D-dimer. There are three major approaches for measuring D-dimer. The two older tests include the sensitive, but time consuming, enzyme-linked immune absorbent assay (ELISA) and rapid, but less sensitive, muscle inactivity. These tests suffered from specificity of as low as 15-38% in arthritis and PE.
Currently, the most useful assay is the whole blood arthritis test (SimpliRED). This five minute, bedside test is both rapid and sensitive. In one study, this technique had a sensitivity of 93% for proximal arthritis, 70% for calf arthritis, and an overall specificity of 77%. 69 All D-dimer tests, regardless of the process, are more sensitive for proximal than distal clot, and may miss as many as 30% of calf arthritis (Cheriel, et al. p.1494). False-positive D-dimers occur in patients with recent (within 10 days) surgery, trauma, injuries, fractures, recent myocardial infarction or stroke, and acute infection: 69 in a patient with no risk factors for arthritis, a negative DTEST.
Motivation
The motivation of this paper is found in the fact that the risk factors of arthritis in South Africa have already been identified. Virchow first elucidated the causes of deep venous arthritis with a description of a classical triad: stasis, hypercoagulability, and endothelial injury. While at least 50% of patients with arthritis have risk factors the strongest risk factor for venous arthritis is prior Thromboembolic disease. Moreover, risk factors are additive in nature (Goodacre, et al. p.143). The idea that a nurse knows major steps in taking care of patients has also inspired this research.
Research Question: Is conducting research on arthritis necessary for nurses?
The necessity to do the research based on the current health implications of DVT to South Africans. Scientists have shown through practical and theoretical arguments the clear effects of arthritis to humans (arthritis advisory committee) When a condition affects too many people and hits them with severe effects, then necessity arises for research to contain the issue. Further, the research is aimed at making reliable recommendations for future arthritis prevention and treatment procedures on basis of its findings.
Research Hypothesis: Tomorrow’s implications of arthritis in South Africa are depended on research conducted today
The findings of this research shall enable the laying of preventive measures/ procedures of arthritis in South Africa. Further, the research findings are aimed at making reliable recommendations for future treatment procedures on basis of its findings (Wicki, et al. p.173).
Aim: The main aim of conducting this research is to identify the risk factors for arthritis (DVT) in South African population. Nurses can also use this when taking care of arthritis patient. This is attained through:
Conducting a literature review on arthritis in South Africa
Proposing research
Conducting research and
Reporting Research findings
Methodology
This is the systematic study of methods that have, can be, and have been applied in this research. They are systematic and orderly procedures which will help the main researcher achieve their objectives. The method used for this methodology may be expanded to include philosophically coherent collection of ideas. This method does not employ any philosophical assumption rather it creates space for real facts and theories which have been proven by scientist.
Research is a frequent used word in academic writing. It means different things. Microbiology concept of research would mean different to that of a statistician. This becomes different to that of a philosopher. Research is a process of searching that ideally, never ends. Research enabled gather information on and about patients with arthritis. It was an attempt to seek knowledge of what is on ground matters affecting health of individuals. Research will employ scientific and systematic search for the portent information, on specific arthritis cases.
Research helped formulating with the phenomenon to achieve new insights to active and applicable solutions. This included testing a hypothesis of a casual relationship between independent variables.
It is further defined as comprising, defining and redefining problems. Later, Formulating hypothesis or suggested solutions, organizing and formulating data. Deductions are made and reaching to conclusions and at least, carefully testing the conclusion to determine whether they fit the formulating hypothesis.
Research methodology characterized by the fact that it is deterministic. Clinical medicine issues should be thoroughly research to keep up to date with arising. It was generally seeking to accommodate all patients. The elimination and exclusion of some individuals will be geared at being biased.
The main methodology for use in this research is based on Rajit research structure ( HYPERLINK “http://www.csl.Cornell.edu/../” www.csl.Cornell.edu/../ recletters.html). According to Rajit, reliable research is based on an eight step structure. Each step is a process in itself as described below.
Formulating a research problem. This step involves literature review, formulation of a research problem, identification of variables and formulation of possible hypothesis.
Conceptualizing of a research design: In this step, only two activities are involved. First is identifying a research design and second is selecting a study design for the research.
Construction of an instrument for data collection: In this step, selection of a data collection method is done, then data is collected using attitudinal scales and last, a test to establish the validity of the data collection instrument is done.
Sample selection: this is a brief step as it only involves the selection of a sample.
Writing a research proposal: this is literary the most important step in the research process. Its success determines whether or not the research is to take place and how reliable its outcome is going to be. With reference to this research, it wouldn’t be an overstatement to note that the research proposal was successful and that the outcome of the completed research is undoubtedly going to be a success.
Data collection: This step marks the initial stage of the research process in the field. It simply involves collecting data as depicted by the name.
Data analysis: During this second last step, data collected is processed and prepared for display and presentation.
Report writing: This marks the end of the research. It compiles the research process in detail and provides conclusions of findings and recommendations.
This structure as designed by Kumar in 2005 is the research methodology applied in this research.
Ethical and Legal Considerations
For a just and fair research in this research, ethical and legal issues ought to be considered. The legal issues expected are in form of, collaborative partnerships with all stakeholders, social or clinical relevance, and scientific merit, fair selection of subjects, ffavourable risk-benefit assessment, informed consent, independent ethical review and respect for participants.
On the other hand, ethical issues to be considered can be considered as outlined in the Principles for ethical research (Wicki and Miller p.533). These are: respect for persons through, autonomy (informed consent), privacy and cconfidentiality; beneficence to do well and protect from harm and lastly justice as in through fair distribution of benefits and burdens.
Research Design
The designs shown below are a plan of how the data in the population is going to be accessed or received. There are various means of data gathering that can be used in the following proposals, but due to saving resources, time and money. The proposals outline the most important aspects only that can be used for data collection
The researcher used various methods in her course work to investigate the relationship between environments and health implications. This includes the questionnaire method, interviews, library research and observation which are the four major methods used. A combination of this helped the researcher to come up with concrete and diverse information.
3.1.1 Questionnaires
‘A questionnaire is a group or sequence of questions designed to elicit information upon a subject or sequence of subjects from an informant. Kapera defines a questionnaire as an instrument that consists of a set of questions to which the subject responds in writing (De Andres p.12).
The questionnaire was administered to patients in an open manner. This ensured that it attracts the most basic and true information on the patients. This was similarly, administered though the media in programs aired in them.
The researcher administered questionnaires on students because it was easier and faster to reach the teenagers and youth who are the most vulnerable persons of the disease-arthritis.3.1.2 Interview Schedule
National Collaborating Centre for Chronic Conditions (2) defines an interview schedule as a conversation in which the researcher tries to get information from the interviewer. The method assumes that the respondents to be interviewed have the information required they can understand the question put to them and would be willing to give honest answers while they are face to face with the researcher.
Interviews were quite useful for the interviewer because through creating a good rapport with the respondents, much more vital information was obtained. It was up to the interviewer to control the order in which the questions flowed basing on the prior given answers by the interviewer. The tools used were unstructured interviews to get views on people’s opinion on religion, like whether it should be done away with in the media, how it has influenced people’s lives and what shou
