Polymyalgia Rheumatica Case Study and Care Plan

Polymyalgia Rheumatica

Polymyalgia rheumatica (PMR) is the topic of this paper. The disorder is a chronic and inflammatory disease that affects the aged. The condition is not likely to be identified because it does not cause swollen joints in the painful areas. Mostly, the disease occurs along with a number of other illnesses, making it difficult to diagnose. Besides, different people experience diverse symptoms, the cause of which remains unknown. In some instances, patients may experience one or two symptoms, as is reflected by the case study. The disease progress will be explained through a care plan and through a case study. PMR is a condition that causes muscle aches and stiffness, specifically in the shoulders, neck, and hips areas. The symptoms of the disorder are most often experienced at night and without relief, in some cases. The pain usually disappears on its own after a year or two. The topic of research is important because the disorder is a life-threatening problem that affects mostly women. It is apparent that many people do not understand the actual cause of pain; hence, the need to discuss the process of the disease, as well as the appropriate nursing interventions.

Pathophysiology

PMR is a chronic inflammatory condition that mainly affects aged persons. The condition affects individuals who have reached 70 years old, especially Caucasians. It is hard to recognize the condition because it does not cause swollen joints. In most cases, the disorder appears together with other health problems, such as giant cell arteritis (Buttaro, Trybulski, Polgar-Bailey, & Sandberg-Cook, 2012). The cause of PMR is unknown, even though the symptoms, such as weight loss, fatigue, and slight fever, are quite evident. The pain also extends to the neck and the upper arms, as reflected in the case study. The pain does not always appear on two sides, but sometimes appears on one of the areas. During this time period, the disease continues to grow and occurs on other sides. Patients of this disorder claim that the stiffness is usually worse in the morning. During the night, the pain is worse, so people may find it hard to wake up. In some cases, the stiffness and aching may develop suddenly, while, in other cases, the pain appears gradually. The pain is usually intense to the extent that the patient cannot attend to her morning duties. In this, it is apparent that the disorder in the case study is PMR because the pain appears in more than two areas, as required. Besides, the pain disappears and later comes back again. The patient affirms that she experienced the similar pain a few weeks ago.

Signs/Symptoms

The symptoms of PMR appear as reflected in the case. The patient feels weak and exhausted at first; that is when the signs begin. The main symptom is the pain in the hips area and arms, shoulders, thighs, and neck. It is apparent that the pain may begin in one of these areas and then proceed to the other side. Patients may experience stiffness in the morning. The PMR patients find it hard to move without pain. Sometimes, patients might wake up at night due to the striking pain. The gradual and sometimes sudden pain prompts them to seek medical attention. The patient may experience weight loss, fatigue, and slight fever (Buttaro et al., 2012). However, these signs do not occur among all individuals. The 72-year-old woman feels the stiff pain, which decreases by the mid of the afternoon. As a result, the major symptoms include pain in hips, neck, and shoulders, among the aforementioned areas.

Progression Trajectory

According to the research, there is no known cause of PMR. Conflicting observations regard seasonal variation during the incidence of PMR. However, observations suggest the role of the infectious agents, such as respiratory syncytial virus, adenovirus, and parainfluenza virus type 1, among others. Several association studies indicate that there is a possible etiology in the infectious agent, even though no study has been accomplished on the same. The disease is said to have genetic factors, as well as familial cases and ethnic differences. In this, PMR is noted to have an association with the DRB*01 alleles and the HLA-DRB1*04. As a result, the progress of the disorder is influenced by the susceptibility of the disease (Buttaro et al., 2012). Besides, the untreated patients encompass a hormonal role that is achieved by the observation of adrenal gland hypofunction. The levels of dehydroepiandrosterone are also noticed together with the unsuitable levels of standard cortisol. In this, the progression of this disorder remains unknown because the studies which investigate its history do not accomplish the research.

Diagnostic Testing

The common diagnostic tests are conducted on the parts which experience pain. In this, the diagnosis is done in accordance with symptoms. As noted in the case, the practitioner needs to rule out the cause of stiffness and pain. In this, a medical history, as reflected in the case is significant, the performance of a physical exam, as well as an assessment of the current symptoms is also essential. One of the tests is a blood test in which a test tube is inserted into red blood cells. If there is inflammation, the blood cells are likely to fall faster. However, this test alone cannot be used to confirm the presence of PMR. Another diagnosis is the rheumatoid factor (RF) test. In this, a protein or antibody made by the immune system is believed to be present among individuals with rheumatoid arthritis, a differential diagnosis of the disorder (Buttaro et al., 2012). Other tests include platelet and red blood cells counts. It is apparent that platelets help in blood clot. As a result, the people with PMR have unusual numbers of platelets and fewer numbers of red blood cells. The test also confirms the existence of anemia among the patients with fewer red blood cells, as compared to the normal rate. Individuals with PMR are also confirmed for the presence of arteritis. The studies have noted that 15-25% of persons with PMR have the giant cell arteritis. The test is confirmed through a biopsy from the artery, which is examined under a microscope.

Treatment Options

Various treatment options are applied to patients with PMR. As noted in the case, the client has been taking Lipitor, which reduces high cholesterol in blood, and ASA, which reduces inflammation. The case means that the patient suffered from hyperlipidemia and bowel problems earlier. However, the goal of the PMR treatment approach is to establish an inflammation that is free from any symptoms. Corticosteroids are usually used in low-dose levels and often respond within 24-72 hours. The dose of corticosteroids is increased until the normalization and symptom resolution of CRP and ESR is achieved (Ennis, LeClair, Wadas, & Patterson, 2011). The diagnosis is considered a resistant treatment, if there is failure of response, which should lead to diagnosis re-evaluation. The dose extends to the duration of one month, where osteoporosis prophylaxis is recommended, along with an induced corticosteroid of both Vitamin D and calcium. The withdrawal symptoms of malaise, arthralgias, and fatigue might be confused with the intermittent PMR symptoms and signs.

A second form of treatment is the non-steroidal anti-inflammatory drugs, commonly known as NSAIDs. As noted in the above context, some pain is associated with the withdrawal of corticosteroids. As a result, NSAIDs are recommended to ease the withdrawal pain and not for the treatment of PMR (Ennis et al., 2011). The treatment also reduces risks, such as proton-pump inhibitor and GI bleeding, which also prevent the development of ulcers.

Studies have indicated that corticosteroids are the most commonly used mode of treatment for PMR. Other medications, such as methotrexate are used to ease the pain or risks, associated with the illness. The type of medication should be considered at the beginning of the treatment. Individuals who have a risk of prolonged therapy or relapse indicate that they had an inadequate dose of corticosteroids, which is linked to significant adverse effects, such as cataracts, glaucoma, osteoporosis, and diabetes. However, methotrexate is not initiated if the patient is confirmed with an interstitial lung disease.

Disorder and Normal Development

Individuals who develop PMR have different symptoms, as compared to those who develop normally. For instance, it is unusual for a healthy person to experience pain, as witnessed by the patient. It is apparent that the patient had pain for a period of one month. In this, it is clear that there must have been a problem, leading to the discomfort or illness. Besides, the woman was unable to sleep, while a healthy person would sleep without any difficulties. The patient is unable to perform her normal duties. A normally developed person would conduct her activities without any complications. The patient has been feeling weak and tired for a couple of weeks, since the period when the first symptoms just appeared. In this, a normal person would be strong due to the lack of health problems related to the disease. The woman is uninterested by her present condition and finds it hard to go shopping with her colleagues. In this, a normal individual would be active and participate in different activities with her friends. These issues present underlying complications, which make the disorder different from normal development. Besides, a person cannot be absolutely healthy when he/she experiences pains, as reflected by the case of the patient.

Physical and Psychological Demands

The consequences of PMR, as mentioned in the case, place physical and psychological demands on the patient and the family. The patient affirms that she was feeling weak and tired, since the period when the symptoms just started. The physical demand suggests that the patient was unable to do anything for herself. She also had a decreased range of motion, in that she could not go out to shop with her friends. The condition indicates that she could not participate in any activities that involved moving the shoulders. The situation also means that the patient lacks exercise, which is required for optimal disorder management. As a result, the disorder has worsened the physical condition of the patient through the feeling of pain after a physical activity. Alternatively, PMR places the patient in a psychological demand, where she admits being low. The condition means that the patient is not active and feels discouraged by her present illness. The loneliness, brought by the health problem, is likely to yield to psychological concerns, such as the distressful general appearance of the client.

Key Concepts with Patient and Family

The patient and the family need to be informed on the key concepts that lead to optimal disorder management and outcomes. The client is afraid of exercising, as she feels pain after engaging in physical activities. The nurse practitioner should stress the significance of regular exercise in disorder management. The exercise is likely to create a sense of well-being and reduce the feeling of pain. Besides, moderate stretching keeps the joints and the muscles flexible. Since the patient is not used to exercising, she should start slowly and gradually. Again, the nurse practitioner should teach the significance of a healthy diet, reflecting on the present health condition. The previous high blood pressure needs to be regulated to prevent additional health problems. Good nutrition also boosts the immune system. The aged patient must have a weak immune system; hence, the practitioner should emphasize on the consumption of fresh vegetables and fruits, fish, lean meat, and whole grains (Ennis et al., 2011). During this time period, the client should limit consumption of sugar and salt. Additionally, the client needs bone-building nutrients, such as vitamin D and calcium. The practitioner should explain other available sources of calcium, such as dietary supplements, if calcium cannot be found in the products one is allowed to consume. A third key concept is to pace oneself. The client needs to try repetitive or strenuous tasks by reaching for shower grab and reaching aids to make work simpler.

Interdisciplinary Team Personnel

The disorder, as reflected in the case, has affected the patient’s brain because she looks distressed. In this, she requires a nurse psychologist to intervene in her attitudes, actions, and cognitions (Ennis et al., 2011). Besides, the psychologist will improve the patient’s outcomes by providing an appropriate way of disorder management, considering that the patient is widowed and has no children. A dietician is a person, who needs to provide the aged patient with knowledge about the right foods. Practicing a healthy lifestyle also provides the patient with energy, as she feels very weak. The patient should learn to include fruits and vegetables in her diet. The patient should also be taught on the effects of drinking wine, which improves her physical dysfunction.

Facilitators and Barriers

The case of the 72-year old woman presents some facilitators and barriers to the optimal disorder management and outcomes. Among the facilitators is that the patient provided information on the present and past illnesses, likely to be used in the healing process. The medical history provides some positive outcomes because the practitioner can use the information to provide some quality care. A barrier to the provision of optimal disorder management is the fact that the patient does not conform to the review of systems. In this, it is notable that the history of the patient was reviewed, even though it does not relate to the recovery process. For example, the HEENT examination was conducted. Another barrier results from the brain problems of the patient. The general appearance indicates that the patient looks very distressed due to the painful condition, which she undergoes. The age of the patient is a barrier to disorder management because such individuals experience depression, as well as difficulties in treatment because she cannot provide adequate information that is needed to improve her health. According to the patient’s case, it is difficult to achieve optimal disorder management because she hates her care provider. The ruined relationship between the patient and the practitioner is a barrier to positive health outcomes. As a result, a comprehensive physical review is required to guide throughout the assessment process.

Strategies to Overcome Barriers

The practitioner should participate in the management of the disorder by providing strategies to overcome the barriers. In this, the systems review should be assessed to provide the required responses, which are vital to the optimal care. For instance, the client consumes wine, hence, an assessment of the lungs and chest is essential in this case. The patient should be asked to quit wine consumption, and that will improve her health. The distressful condition needs to be considered to enable the patient to be cooperative during the physical examination. The age factor is another barrier, which can be overcome through monitoring by the nurse practitioner to identify the present medical information. In this, the nurse should record information through a detailed history that reflects the assessment and the response between the patient and the caregiver (Buttaro et al., 2012).

Care Plan Synthesis

Patient: The patient is a 72-year old white woman.

Subjective Data

Client Complaints: The woman complains of pain in her hips, neck, and arms.

HPI: The client had a four-week history of pain in her hips, neck, and arms. The pain worsens during the night, making the patient unable to sleep. The patient has not received treatment of the present condition. She takes hypertension medications and denies smoking. She takes one to five ounce glasses of wine every month. The patient has not received any radiation or chemotherapy in the past. She also hates her HMO doctor, who does not display the qualities of a nurse leader.

PMH: The patient had hyperlipidemia, meaning high cholesterol in the blood. She also had post-mastectomy breast reconstruction in 2007, where she received no radiation or chemotherapy. She also had a mild osteoarthritis.

Review of systems: the patient does not conform to the HEENT examination.

Medications: the patient takes one tablet of the 20mg Lipitor and 1 ASA 81mg. She denies smoking, but drinks wine.

Allergies/Reactions: the client has no identified drug allergies.

Family History: the patient’s family history was assessed and it does not add to his present or past condition.

Social/Personal History:

Occupation: The patient’s occupation is not indicated, even though she has a fixed income

Lifestyle: The client is widowed. However, she does not disclose much about her way of life.

Diet: The patient’s diet is not identified. She does exercise five days per week by walking one mile.

Substance Abuse: the client denies smoking but drinks 1-5 glasses of wine once in a month. She does not partake in any illegal drug use.

Client Awareness of Abilities, Disease Process and Health Care Needs: The client partly understands her health condition. The case indicates that she consumes wine, which could be threatening to her present and past illnesses. She has a normal blood pressure even after exhibiting a distressful appearance. The situation means that the client understands the disease process and has had the potential to deal with striking or painful situations. The patient has health insurance, despite encompassing a fixed income. She also visited the clinic after experiencing the pain in her neck, lips, and arms. The aspect of visiting the clinic indicates that she understands and values her health.

Objective Data

Vital Signs: The patient’s blood pressure is 124/8, meaning that she has a normal blood flow. The blood pressure level also designates that the previous illness, which was, hyperlipidemia, was successfully treated. The present condition of a patient indicates that the previous health problem has disappeared. Besides, her pulse rate is 84, meaning that the client has a normal heart beat (Buttaro et al., 2012).

Physical Assessment Findings: The patient has palpation or tenderness on the trapezius and paracervical muscles. The decreased level of physical activity means that the patient is unable to move due to the painful joints. The temperature of the patient, though not marked, indicates that she does not have fever. The X-rays of the cervical spine indicated that the patient had mild degenerative spine, apart from the numerous past degenerative changes, which did not encompass any abnormalities.

Client’s Locus of Control and Readiness to Learn: the client is willing to learn because she has been keen on her previous ailment, which disappeared upon the administration of the right medication. Even though she experienced the pain some weeks ago, it is noteworthy that she takes previous medications to ease the pain.

ICD-10 Diagnoses/Client Problems: The ICD-10 code for PMR is M5.3. The case study notes that the patient had high cholesterol levels, which disappeared upon regular exercise. Even though the patient is aged, it is clear that she has a strong immune system because she has not developed other uncontrollable illnesses, apart from the present illness. Even though the most striking symptoms symbolize those of PMR, it is evident that patients with this condition experience complications during the process of the disease (Buttaro et al., 2012). The disorder could also be confused with aortic aneurysm or a stroke because she claims to have pain in the neck, hips, and arms.

Advanced Practice Nursing Intervention Plan

Patient’s Socio-Cultural Background: The patient is a white female, as reflected by the case study. A general understanding of the client’s socio-cultural background may influence optimal disorder management. In this, the nurse practitioner should have some knowledge about cultural diversity, which is a dispute to caregivers. The nurse should be familiar with the ways of delivering quality care in diverse settings in order to provide social, cultural, and linguistic needs of the client. The fact that the patient is white requires the care providers to be familiar with western health outcomes. In this, it is possible to eliminate the administrative and linguistic barriers to eradicate ethnic and racial health disparities (Buttaro et al., 2012).

Key Issues Identified: the key issues of the case study reflect the past and present medical condition. Even though the client suffered from high cholesterol in the blood, the regular exercises have improved the health condition, leading to recovery.

Disorder Management: PMR is a health problem that was found difficult to manage and sought for immediate intervention from the hospital. The condition can be managed through follow-ups, which are made by the care providers (Buttaro et al., 2012). The hospital should also arrange with the patient to review her progress, a condition that will eradicate the possibility of the differential diagnoses.

Conclusion

The signs and symptoms of the woman are similar to PMR. Earlier, the patient had been diagnosed with high cholesterol in blood. The present condition indicates that the patient no longer has high cholesterol after receiving the appropriate medication. The main symptom is the pain in hips and arms, shoulders, thighs, and neck. It is apparent that the pain may begin in one of these areas and proceed to the other side. Patient experiences stiffness in the morning. The goal of the PMR treatment approach is to establish an inflammation that is free from symptoms. Corticosteroids are usually used in low-dose levels and often respond within 24-72 hours. PMR is a chronic inflammatory condition that affects the aged persons. The condition affects individuals who have reached 70 years old, especially Caucasians. The patient’s blood pressure is 124/8, meaning that she has a normal blood flow. Other vital signs predict the management of the disorder, as well as the monitoring the outcomes. There is no known cause of PMR, according to the research. Conflicting observations regard seasonal variation during the incidence of PMR. However, observations suggest the role of the infectious agents, such as respiratory syncytial virus, adenovirus, and parainfluenza virus type 1, among others. An understanding of the client’s socio-cultural background can impact the optimal disorder management. The nurse practitioner should understand what cultural diversity is, which some of the caregivers are not aware of.