Drug Therapy in Rheumatology Nursing

1 Introduction.

1.1 Features of rheumatic conditions.

1.2a) Pain.

1.2b) Stiffness.

1.2c) Swelling.

1.2d) Joint involvement.

1.3 Epidemiology.

1.4 Anatomy and physiology of the musculoskeletal system.

1.4a) Muscle.

1.4b) Bone.

1.4c0 Cartiledge.

1.4d) Synovium.

1.4e) Ligaments and tendons.

1.4f) Tendon sheaths and bursae.

1.4g) Synovival joints.

1.4h) Physiology.

1.4i) Circulation.

1.4j) Lymphatics.

1.4k) Intra-articular pressure.

1.4l) Motion.

1.4m) Innervation.

1.4n) Temperature.

1.5 Anatomy and Physiology of the musculoskeletal system in inflammatory and non inflammatory arthritis.

1.5a) Immunopathogentic mechanism.

1.5b) Susceptibility.

1.5c) Synovitis.

1.6 An overview of rheumatological conditions most commonly encountered in Western Europe.

1.6a) Rheumatoid Arthritis.

1.6b) Juvenille Idiopathic Arthritis.

1.6c) Polmyalgia Rheumatica.

1.6d) Inflammatory arthritis associated with spondylitis.

1.6e) Ankylosing spondylitis.

1.6f) Reiters syndrome.

1.6g) Psoriatic arthritis.

1.6h) Septic arthritis.

1.6I) Reactive Arthritis.

1.6j) Osteoarthritis.

1.6k) Fibromyalgia.

1.6l) Connective tissue dosorders.

1.6m) Systemic Lupus Erythematoisis.

1.6n) Scleroderma.

1.6o) Inflammatory muscle disease.

1.7 The impact of the rheumatological conditions on physical, psychological, social and occupational function.

1.7a) Personal impact of RA.

1.7b) Financial impact of arthritis.

1.7c) Impact on education.

17.d) Impact on employment.

17.e) The role of social support.

17.f) Impact on family relationships.

17.g) depression.

Chapter 2: Drug Therapy (Sarah Ryan, Susan Oliver and Ann Brownfield).

2.1 Pain.

2.1a) Physiology of pain.

2.1b) Pain receptors.

2.1c) Role of the brain.

2.1d) Physiological effects of acute pain.

2.2 Pharmacological interventions in rheumatology.

2.2a) Non opioid.

2.2b) Compound analgesia.

2.2c) Opioids.

2.2d) Anti-depressant drugs.

2.2e) NSAIDs.

2.3 Disease Modifying Anti-rheumatic Drugs (DMARDs).

2.3a) Early treatment of RA.

2.3b) Combination therapy.

2.3c) Mode of action and pharmacokinetics of DMARDs.

2.3d) Anti-malarials.

2.3e) Sulfasalazine.

2.3f) D-penicillamine.

2.3g) Myocrisin.

2.3h) Auranofin.

2.3i) Methotrexate.

2.3j) Leflunomide.

2.3k) Azathioprine.

2.3l) Cyclophosphamide.

2.3m) Ciclosporin.

2.3n) Chlorambucil.

2.3o) Phenylbutazone.

2.3p) Dapsone.

2.3q) Minocycline.

2.3r) Mycophenolate Mofetil.

2.4Biologic Therapies.

2.4a) Classifications.

2.4b) Mode of action-general.

2.4c) Adverse reactions to biologic therapies.

2.4d) Biologic therapies treatment options.

Anakinra.

Anti-Tumor Necrosis Factor alpha.

2.4e) General Issues relating to the mode of action.

2.4f) Side effects for all anti-TNFs.

2.4g) Prescribing and breast feeding.

2.4 h) Immunisation.

2.4 I) Specific information on TNF.

Adalimunab.

Enbrel.

Infliximab.

Rituximab.

2.4j) Biologic therapies-patient issues.

2.5 The use of steroids in the treatment of rheumatic disease.

2.5a) The use of steroids in rheumatoid arthritis.

2.5b) Corticosteroid sparing agents.

2.5c) Adverse effect of corticosteroids.

2.5d) Use of corticosteroids in other rheumatological conditions.

2.5e) Bone mineral metabolism.

2.5f) Peptic ulceration.

2.5g) Atherosclerosis.

2.5h) Reducing the dose of corticosteroid.

2.5I) Pulsed corticosteroid.

2.5j) Intramuscular corticsteroid.

2.5k) Intra-articular injections of corticosteroid.

2.6 Disorders of purine metabolism.

2.7 Nurse prescribing.

2.7a) Independent prescribing.

2.7b) Supplementary prescribing.

2.7c) Educational preparation.

2.7d) Professional responsibilities.

2.7e) Evaluation of prescribing.

2.8 Self Medication.

2.8a) The case for self medication.

2.8b) Advantages of self medication.

2.8c) Stages in the implementation of self medication.

2.9 Complementary Medication.

2.9a) Diet.

2.9b) Massage.

2.9c) Aromatherapy.

2.9d) Reflexology.

2.9e) Acupuncture.

2.9f) Herbal medicine.

2.9g) Naturopathy.

2.9h) holism.

2.10 Glucosamine.

2.11 Capsaicin.

Appendix 1: What happens next.

Appendix 2: Guidelines for nurses on the use and administration on intra-articular injections.

Appendix 3: Patient Group Direction for The Administration of Methylprednisolone Injection 40mg/ml by Intramuscular Injection.

Chapter 3: The Role of the Nurse in Drug Therapy (Sarah Ryan and Margaret Ann Voyce).

3.1 What is rheumatology nursing?

3.1a) The nurse-patient relationship.

3.2 Telephone helplines.

3.3 The philosophy of rheumatology nursing.

3.4 The role of the nurse in drug therapy.

3.4a) Empowerment.

3.5 The commencement of DMARDs.

3.5a) Patient preparation.

3.5b) Monitoring clinic.

3.5c) Documentation.

3.5d) Use of protocols.

3.6 Investigations.

3.6a) Haematological.

3.6b) Biochemical.

3.6c) Assessment of rheumatic disease activity.

3.7 Urine testing.

3.8 Drugs that require surveillance.

3.8a) Gold.

3.8b) Auranofin.

3.8c) D-penicillamine.

3.8d) Sulfasalazine.

3.8e) Methotrexate.

3.8f) Azathioprine.

3.8g) Cyclophosphamide.

3.8h) Ciclosporin.

3.8i) Chlorambucil.

3.8j) Phenylbutazone.

3.8k) Dapsone.

3.8l) Minocycline.

3.8m) Leflunomide.

3.8n) Mycophenolate.

3.9 Vaccinations.

3.10 Pregnancy.

3.11 The role of the community team in drug therapy.

3.12 Community drug monitoring.

3.12a) Documentation.

3.12b) General practitioner concerns relating to practice based monitoring.

3.12c) Patients experience of drug monitoring.

3.13 Community clinics.

3.14 General practice.

3.15 Evaluation of community clinics.

3.15a) Potential problems with consultant based community clinic.

3.16 Nurse led community clinic.

3.17 New ways of utilising outpatient appointments.

3.18 Drug therapy and osteoporosis.

3.18a) Classification of osteoporosis.

3.18b) Risk factors for osteoporosis fracture.

3.18c) Investigations for osteoporosis.

3.19 Hormone replacement therapy.

3.20 Pain management.

3.21 Drugs to reduce fracture risk.

3.22 Other drug treatments.

3.22a) Calcitonin.

3.22b) Calcium.

3.22c) Vitamin D.

3.22d) Calcitrol.

3.22e) Formation stimulating agents.

3.22f) Strontuim Ranelate.

3.23 Prevention/lifestyle strategies.

Appendix 1: Information sheet: The role of the rheumatology nurse specialist.

Appendix 2: Guidelines for nurses on the use and administration of sodium aurothiomalate in rheumatoid arthritis.

Chapter 4: Patient Education (Jackie Hill).

4.1 Definitions of patient education.

4.2 Useful theories and models.

4.2a) Learned helplessness theory.

4.2b) Stress and coping theory.

4.2c) Health belief model.

4.2d) Self efficacy model.

4.3 Purpose of patient education.

4.4 Limitation of patient education.

4.5 Role of the nurse in patient education.

4.5a) Patient education and some fundamental aspect of nursing.

4.5b) Patient education and therapeutic nursing.

4.5c) Reciprocity.

4.5d) Professional closeness.

4.6 Planning a patient education programme.

4.6a) The learning environment.

4.6b) Demographic considerations.

4.6c) Disease duration.

4.6d) Age range.

4.6e) Diagnosis.

4.6f) Mixed educational ability.

4.6g) The type of programme.

4.7 Individual patient education.

4.7a) Preferences of drug therapy.

4.7b) Assess the patient's knowledge of drugs.

4.7c) Establish shared goals.

4.7d) Preferred method of information transfer.

4.7e) Contracting.

4.7 f) The activity to be accomplished.

4.7g) The plan of action.

4.7h) Checking that the contract is realistic.

4.8 Teaching in groups.

4.9 Opportunity education.

4.10 The Arthritis Self Management Programme.

4.11 What to teach.

4.11a) Teaching about drug therapy.

4.11b) What to include.

4.11c) Risk and adverse effects.

4.12 Teaching aids.

4.12a) Written material.

4.12b) The purpose of the material.

4.12c) The intended recipients.

4.12d) Reading levels.

4.12e) Assessing the readability of the information.

4.12f) The cost of the exercise.

4.12g) The quality of the finished product.

4.12h) Videos and CDs.

4.12I) Audiocassettes.

4.12j) Computer programmes.

4.13 The optimum timing of patient education.

4.13a) Readiness for change.

4.14 Patient education and adherence.

Appendix 1: Methotrexate Information Sheet.