Arthritis care rounds

The core of arthritis care rounds is not just to check the patient's pain score and the implementation of doctor's orders, but to achieve the three core goals of "reducing the frequency of acute attacks, delaying the progression of joint deformity, and maintaining the ability to perform daily activities" through accurate bedside assessment, personalized intervention plan adjustment, and long-term self-management guidance. All other ward rounds are centered around these three points.

Last Wednesday, our team examined Uncle Zhou, a 62-year-old patient with a 3-year history of rheumatoid arthritis in bed 32. This time, he was hospitalized because his left wrist joint was red and swollen after being exposed to the rain and his VAS score was 7 points. When the nurse in charge of the bed reported, she said that she had given oral celecoxib and applied cold wet compresses to the local area. The pain was now reduced to 4 points. According to the normal procedure, it seemed that it was time to pass the next patient. However, the attending doctor reached out and touched Uncle Zhou's left wrist. He subconsciously ducked and then opened his clothes. Looking at the sleeves, there is still some inconspicuous fluctuations on the back of the wrist joint, and the skin temperature is almost 1 degree higher than the right side - this is a loophole in just looking at the paper records without bedside palpation. Many times, patients are afraid of troublesome medical care, and the pain will be minimized, and the true and false have to be touched before they can be counted.

Speaking of this, I have to mention a controversial point that our department has argued about several times before: Should we exercise during the acute stage of arthritis? The view of traditional orthopedic care is very clear: in the acute stage, strict immobilization is necessary to reduce synovial friction, avoid exacerbation of inflammation, and even brace the joint. However, the nursing consensus among rheumatology and immunology specialists has been changing over the years: as long as the patient's pain score is less than 5 points, he can carry out passive, non-weight-bearing small-range joint activities. Otherwise, muscle adhesion and joint stiffness may occur if he does not move for 3 days, which will slow down the recovery progress.

We have been through this pitfall before. The year before last, we admitted a 28-year-old rheumatoid patient. During the acute stage, he followed the advice of the orthopedic department and was immobilized for a week. He was able to hold a pen and eat by himself. After the brace was removed, he could not bend his fingers. Later, the rehabilitation department followed him for half a month to recover. Now our department has basically reached a compromise plan: in the first 48 hours of the acute phase, we mainly focus on immobilization, cold compress, and anti-inflammatory and analgesic. After 48 hours, as long as the leakage does not continue to worsen, we can start practicing passive activities for 5 minutes twice a day, such as holding an elastic ball with the fingers and slowly drawing the figure "8" on the wrist. The intensity is as long as the patient does not feel pain. After trying this for almost 2 years, the patient's joint function recovery in the later period was significantly faster.

Ward rounds are not just about looking at the joints, but also about the patients' daily habits. For example, the 70-year-old patient with osteoarthritis who was examined last month had knee pain for almost 10 years. Every time he came for a follow-up examination, he would say, "I'm wearing knee pads, and I've traveled less, but it still hurts." However, during the rounds that day, he rolled up his trouser legs. When I saw that he was wearing cotton knee pads with thick velvet, they were so wrapped that he couldn't bend his knees. Wouldn't this increase the wear and tear? Many elderly people always think that the thicker and warmer the knee pads, the better. In fact, thick knee pads are not supportive and will limit the normal movement angle of the knee joint. When walking, the patella will be deflected due to force, which will wear down the cartilage faster. We all recommend patients to wear thin sports knee pads with support strips on both sides on a daily basis. To keep warm, wearing thick long johns is more useful than thick cotton knee pads. The old man went back to change the knee pads last time. When he came back for a follow-up visit half a month later, he said the pain was much less.

There is another point that must be repeated during every ward round: don’t stop slow-acting antirheumatic drugs on your own. Too many patients think "I'm fine when I don't have any pain" and only take painkillers when they hurt. They stop anti-rheumatic drugs when they are told to stop. Aunt Zhang from the 47th bed last week said that she stopped methotrexate for half a year. She had been well controlled. However, when she came for a review this time, her fingers had a slight swan neck deformity. It is difficult to reverse the deformed joints even after adjusting the medicine. To be honest, every time I meet this kind of patient, I feel sad.

In fact, the nursing rounds for arthritis have never followed a conceptual template. Each patient's living habits, disease progression, and tolerance level are different. Last time, there was an old man rubbing his knees vigorously with safflower oil every day at home. It was originally in the acute stage of synovitis, and the more he rubbed, the more it leaked out, making it swollen like a steamed bun. Later, we taught him to gently massage the quadriceps on the front of his thigh every day without touching the knee, and the swelling disappeared within a week. To put it bluntly, when it comes to nursing, we need to break professional guidelines into pieces and incorporate them into the little things like eating, dressing, and walking, so that we can really help them.