This study guide is about juvenile rheumatoid arthritis, diagnosis of juvenile rheumatoid arthritis, treatment of juvenile rheumatoid arthritis, and 4 nursing care plan examples for juvenile rheumatoid arthritis.
Juvenile Rheumatoid Arthritis
What is Juvenile Rheumatoid Arthritis?
Juvenile rheumatoid arthritis (JRA), also known as juvenile idiopathic arthritis (JIA), is a chronic inflammatory disease that primarily affects the synovium of the joints resulting in effusion and eventual erosion and destruction of the joint cartilage.
JRA is categorized into different classification and manifested by remissions and exacerbations with the onset usually occurs between ages 2 to 5 and 9 to 12 years old. Pauciarticular arthritis is the most common form of JRA that involves 4 or fewer joints; polyarticular arthritis involves many joints, usually more than four. Systemic arthritis involves the presence of joints swelling, and associated fever, light-pink rash, and affect internal organs such as the heart, lungs, eyes, liver, spleen, and lymph nodes.
Prognosis is based on the type of arthritis, the severity of the disease, and response to treatment with the most severe complications of permanent deformity, hip disease, and iridocyclitis with visual loss.
What are the types of Juvenile rheumatoid arthritis?
Systemic onset JRA. This type affects one or more joints. There is often a high fever and a skin rash. It may also cause inflammation of internal organs, including the heart, liver, spleen, and lymph nodes. It is the least common type. It affects 1 in 10 to about 1 in 7 children with JIA.
Oligoarticular JRA. This type affects 1 to 4 joints in the first 6 months of disease. If no more joints are affected after 6 months, this type is called persistent. If more joints are affected after 6 months, it is called extended.
Polyarticular JRA. This type affects 5 or more joints in the first 6 months of disease. Blood tests for rheumatoid factor (RF) will show if this type is RF-positive or RF-negative.
Enthesitis-related JRA. With this type, a child has arthritis as well as enthesitis. This is a swelling of the tissue where bone meets a tendon or ligament. It often affects the hips, knees, and feet.
Psoriatic arthritis. With this type, a child may have both arthritis and a red, scaly skin disease called psoriasis. Or a child may have arthritis and 2 or more of the following:
- Inflammation of a finger or toe
- Pits or ridges in fingernails
- A first-degree relative with psoriasis
Undifferentiated arthritis. This is arthritis that has symptoms of 2 or more JIA types above. Or the symptoms might not match any type of JIA.
What causes Juvenile rheumatoid arthritis?
Like adult rheumatoid arthritis, JIA is an autoimmune disease. This means the body’s immune system attacks its own healthy cells and tissues. JIA is caused by several things. These include genes and the environment. This means the disease can run in families, but can also be triggered by exposure to certain things. JIA is linked to part of a gene called HLA antigen DR4. A person with this antigen may be more likely to have the disease.
What are the symptoms of Juvenile rheumatoid arthritis?
Symptoms may appear during episodes (flare-ups). Or they may be ongoing (chronic). Each child’s symptoms can vary. Symptoms may include:
- Swollen, stiff, and painful joints in the knees, hands, feet, ankles, shoulders, elbows, or other joints, often in the morning or after a nap
- Eye inflammation
- Warmth and redness in a joint
- Less ability to use one or more joints
- Decreased appetite, poor weight gain, and slow growth
- High fever and rash (in systemic JIA)
- Swollen lymph nodes (in systemic JIA)
These symptoms can seem like other health conditions. Make sure your child sees his or her healthcare provider for a diagnosis.
Diagnosis of Juvenile Rheumatoid Arthritis
How is juvenile rheumatoid arthritis diagnosed?
Diagnosing JIA may be difficult. There is no single test to confirm the disease. Your child’s healthcare provider will take your child’s health history and do a physical exam. Your child’s provider will ask about your child’s symptoms, and any recent illness. JIA is based on symptoms of inflammation that have occurred for 6 weeks or more.
Tests may also be done. These include blood tests such as:
- Antinuclear antibody (ANA) and other antibody tests. These tests measure blood levels of antibodies that are often seen in people with rheumatic disease.
- Complete blood count (CBC). This test checks for low counts of red blood cells, white blood cells, and platelets.
- Complement test. This test is done to measure the level of complement. This is a group of proteins in the blood that help destroy foreign substances. Low levels of complement in the blood are linked to immune disorders.
- Erythrocyte sedimentation rate (ESR or sed rate). This test looks at how quickly red blood cells fall to the bottom of a test tube. When swelling and inflammation are present, the blood’s proteins clump together and become heavier than normal. They fall and settle faster at the bottom of the test tube. The faster the blood cells fall, the more severe the inflammation.
- C-reactive protein (CRP). This protein shows up when inflammation is found in the body. ESR and CRP show similar amounts of inflammation. But one may be high when the other is not. This test may be repeated to check a child’s response to medicine.
- Creatinine. This is a blood test to check for kidney disease.
- Hematocrit. This measures the number of red blood cells in a blood sample. Low levels of red blood cells (anemia) are common in people with inflammatory arthritis and rheumatic diseases.
- Rheumatoid factor (RF). This test checks to see if RF is in the blood. This is an antibody found in the blood of most people who have rheumatoid arthritis and other rheumatic diseases.
- White blood cell count. This measures the number of white blood cells in the blood. Higher levels of white blood cells may mean an infection. Lower levels may be a sign of some rheumatic diseases or a reaction to medicine.
Your child may also have imaging tests. These can show how much damage the bones have. The tests may include:
- X-rays. This test uses a small amount of radiation to make images of organs, bones, and other tissues.
- CT scan. This uses a series of X-rays and a computer to make detailed images of bones, muscles, fat, and organs. CT scans are more detailed than regular X-rays.
- MRI. This test uses large magnets and a computer to make detailed pictures of organs and structures in the body.
- Bone scan. This uses a small amount of radiation to highlight the bones in a scanner.
Other tests may include:
- Urine tests. These look for blood or protein in the urine. This can mean the kidneys are not working normally.
- Joint aspiration (arthrocentesis). A small sample of the synovial fluid is taken from a joint. It’s tested to see if crystals, bacteria, or viruses are present.
- Full eye exam done by an ophthalmologist
Treatment of Juvenile Rheumatoid Arthritis
How is juvenile rheumatoid arthritis treated?
The goal of treatment is to reduce pain and stiffness, and help your child keep as normal a lifestyle as possible.
Treatment will depend on your child’s symptoms, age, and general health. It will also depend on how severe the condition is.
Treatment may include medicines such as:
- Nonsteroidal anti-inflammatory medicines (NSAIDs), to reduce pain and inflammation
- Disease-modifying antirheumatic medicines (DMARDs), such as methotrexate, to ease inflammation and control JIA
- Corticosteroid medicines, to reduce inflammation and severe symptoms
- Medicines called biologics that interfere with the body’s inflammatory response. They are used if other treatment isn’t working.
Talk with your child’s healthcare provider about the risks, benefits, and possible side effects of all medicines.
Other treatments and lifestyle changes may include:
- Physical therapy, to improve and maintain muscle and joint function
- Occupational therapy, to improve ability to do activities of daily living
- Nutrition counseling
- Regular eye exams to find early eye changes from inflammation
- Regular exercise and weight control
- Getting enough rest
- Learning to use large joints instead of small joints to move or carry things
What are the complications of juvenile rheumatoid arthritis?
Nearly half of all children with JIA recover fully. Others may have symptoms for years. Some will have rashes and fever. Others may have arthritis that gets worse. Problems may include slow growth and thinning bones (osteoporosis). In rare cases, there may be problems with the kidneys, heart, or endocrine system.
4 Nursing Care Plan Examples for Juvenile Rheumatoid Arthritis
What are some of the available nursing care plans for juvenile rheumatoid arthritis?
Nursing care planning goals for a child with juvenile rheumatoid arthritis aims to provide relief of pain, improve coping ability, preserve muscle and joint function, prevent joint deformity, promote positive body image, and increase confidence in the performance of self-care activities.
- Chronic Pain
May be related to
- Long-term physical incapacity
Possibly evidenced by
- Verbalization or noted evidence of pain experienced for more than 6 months
- Single or multiple joints involvement
- Joint stiffness, loss of motion, edema, and warmth in joint and painful to touch
- Guarding behavior
- Difficulty ability to continue activities
- Fear of reinjury
- Social and physical withdrawal
- Child will report that pain has reduced using a pain scale.
|Assess joint pain including its location, duration, severity, remissions and exacerbations, stiffness and aggravating factors such as weight gain, activity, fatigue; effect on mobility and participation in ADL; presence of joint deformity.||Reveals symptomatic of the effect of the disease on the musculoskeletal system: guides for the selection of analgesia/anti-inflammatory medication and better management of activity involvement; inflammatory process causes pain while limited motion resulting from muscle spasms, joint effusion, synovial thickening results in edema; joint destruction causes joint deformity.|
|Administer medications as prescribed and monitor its effectiveness in relieving pain.||Decreases pain and inflammation related with the pain; drugs may be given alone or in combination including the nonsteroidal anti-inflammatory drugs that act as an analgesic, antipyretic and anti-inflammatory; if NSAIDs are not effective slower acting antirheumatic drugs which may be added for optimal effect;
low effective dose corticosteroids are administered for a short period of time particularly during a life-threatening situation.
|Allow the child to assume a position
of comfort; elevate and support painful joints during positional changes.
|Detracts pain through diversionary activities.|
|Apply warm application or moist heating pads to painful areas; paraffin baths and whirlpool as ordered.||Provides the area with circulation through vasodilation to ease pain; moist heat soothes painful, stiff joints.|
|Apply splint as ordered for night use.||Immobilizes inflamed joints to relieve pain during movement.|
|Provide adequate rest periods during the day and quiet environment for sleep.||Lessens stimulation that increases pain, and it promotes rest, especially during acute episodes.|
|Explain to the child about causes of pain and interventions to take in relieving the pain.||Provides understanding on the treatments and medications.|
|Educate child and parents about factors (stress, climate movement) that heighten pain episodes, and to express or report the presence of pain at the onset.||Promotes an opportunity to prevent those situations or activities that contribute to pain exacerbations and to provide for quick relief.|
|Instruct parents and child to avoid
overactivity or movement of affected joints.
|Avoids injury to affected joints during the acute episode when immobilization is important.|
|Teach parents to provide a warm bath daily for 10 minutes or warm wet packs with a towel bath to painful areas.||Supplies heat to affected joints to relieve pain and stiffness.|
|Encourage and teach the child with relaxation techniques such as music, arts, reading, television.||Provides nonpharmacologic measures to relieve pain.|
|Instruct parents and child in the proper administration of medications including side effects and importance of compliance with the regimen.||Promotes compliance with the medical regimen to manage pain and inflammation.|
2. Self-Care Deficit
- Self-Care Deficit
- Self-Care Deficit: Bathing/Hygiene, Dressing/Grooming, Feeding, Toileting
May be related to
- Musculoskeletal impairment
Possibly evidenced by
- Inability to perform ADL and to maintain complete physical care
- Immobility status
- Pain and weakness of joints and intolerance to activity
- Joint deformity and/or contractures
- Child will perform self-care within limits of illness.
|Assess abilities and level of care and assistance.||Provides information about the child’s ability to do self-care and to observe improvement.|
|Allow the child to perform own care and commend any completed actions.||Provides a sense of independence and fulfillment; motivates to continue progress in ADL.|
|Support as much independence in doing activities of daily living as possible but provide assistance when needed.||Promotes self-sufficiency and control over daily personal care needs without damage to joints.|
|Position items and objects used for care within reach; provide physical child aids/devices to assist in the performance of ADL (cane, wheel-chair, easy-to-grip knobs, clothes with button hooks, or Velcro closures, sock aids and zipper pulls etc.).||Promotes self-reliance and allows easy access to aids to improve independence.|
|Assist parents and child to develop plan and goals for daily ADL and to include interventions formed by a physical and occupational therapist.||Promotes independence and compliance in self-care.|
|Instruct parents and child about the application and use of aids and self-confidence.||Promotes independence in ADL and devices to accommodate self-care activities.|
|Discuss possible changes or modifications in the home and school environment to support child’s independence in meeting physical needs (pathways, furniture, doors).||Allows for safe participation in activities that are usually carried out by the child on a daily basis.|
- Disturbed Body Image
May be related to
- Biophysical and psychosocial factors
Possibly evidenced by
- Verbal and nonverbal responses to body appearance changes (joint deformity, side effects of steroid)
- Multiple stressors
- Negative perceptions about own body
- Change in daily living limitations and social relationships
- Child will express feelings about illness.
- Child will identify at least 1 positive thing about his or her body.
|Assess child’s feelings regarding multiple restrictions in lifestyle, chronic illness, difficulty in school and social situations,
inability to keep up with peers and
participate in activities.
|Provides information about the status of self-concept and body image that necessitate special regard.|
|Observe for signs of depression and withdrawal behavior.||Shows responses to body image changes and possible poor adjustment to changes.|
|Observe for presence of joint deformities, need to use splints, weight gain, a shift in fat distribution, edema and effect on the child.||Reveals side effects of steroid therapy and disease manifestations that affect body image.|
|Discourage any negative comments and stress positive activities and accomplishments.||Improves body image and confidence.|
|Encourage expression of feelings and
concerns, and support communications with parents, teachers, and peers.
|Provides an opportunity to express feelings and decrease negative feelings about changes in appearance.|
|Show support and acceptance of changes in the appearance of the child; provide privacy as needed.||Promotes trust and demonstrates respect for the child.|
|Teach parents about maintaining support
for the child.
|Encourages acceptance of the child with special needs (long-term steroid therapy and side effects, lifelong activity restrictions).|
|Discuss with parents and child the impact of the disease on the body systems and risk for deformity and disabilities; correct
misinformation and inform of ways to cope with body changes.
|Gives accurate information in assisting on how to deal with negative feelings about the body.|
|Encourage parents to be adaptable in the care of the child and to integrate care and routines into family activities; to allow the child to participate in peer activity.||Promotes the well-being of the child and a sense of belonging and control of life events by engaging in normal activities for age and improving developmental task
|Discuss with parents and child how to
deal with peer judgments of appearance and how to describe others about change in appearance.
|Prevents child stigmatization by those who are not familiar with the child’s disease; Perception and stand of others will affect the body image of the child.|
|Suggest psychological counseling or child
life worker and educate on the functions offered by these professionals.
|Assists to enhance self-esteem and to acquire coping and problem-solving skills.|
- Compromised Family Coping
May be related to
- Inadequate or incorrect information or understanding
- Chronic disease or disability progression that exhausts the physical and emotional supportive capacity of caretakers
Possibly evidenced by
- Expression and/or confirmation of concern and inadequate knowledge about long-term care needs, problems and complications
- Anxiety and guilt
- Overprotection of child
- Client will express feelings about the child’s chronic illness.
- Client will identify 3 positive coping mechanisms to implement.
|Assess family’s coping methods and its effectiveness, family interactions, and expectations associated to long-term care, developmental level of family, response of siblings, knowledge and use of support systems and resources, presence of guilt and anxiety, overprotection and/or overindulgence behaviors.||Provides information revealing coping methods that work and the need to develop new coping skills and behaviors, family attitudes; child with special long-term needs may strengthen or strain family relationships and an undue degree of overprotection may be detrimental to child’s growth and development (disallow school attendance and peer activities, avoiding discipline of child, and allowing child to assume
responsibilities for ADL).
|Encourage family members to express problem areas and explore solutions responsibly.||Reduces anxiety and enhances understanding; provides the family with an opportunity to identify problems and develop problem-solving strategies.|
|Assist family to establish short- and
long-term goals for child and to integrate the child into family activities include the participation of all family members in care routines.
|Promotes involvement and control over situations and maintains the role of family members and parents.|
|Assist family members to express feelings, how they deal with the chronic needs of the family member and coping patterns that help or hinder adjustment to the problems.||Allows for venting of feelings to determine the need for information and support, and to relieve guilt and anxiety.|
|Assist family to identify positive coping mechanisms they may utilize (e.g., listening and talking about issues, family picnic, hiring a babysitter once a week, etc.).||Promotes ownership of solutions to coping difficulty.|
|Teach family about remissions and
exacerbations of the disease and that an exacerbation may last for long periods of time (over a period of months); that exacerbations may be precipitated by overactivity, stress, presence of other illnesses, climate changes.
|Provides a realistic view of the chronic nature of the disease.|
|Inform family that overprotective behavior may hinder growth and development, and to treat the child as normally as possible.||Promotes understanding of the importance of making child one of the family and the adverse effects of overprotection of the child.|
|Inform parents and child of suggestions
of unorthodox cures for the disease by friends, and the harmful effects caused by some of them.
|Prevents injury as well as a disappointment when cures do not measure up to expectations.|
|Refer to the assistance of social worker,
counselor, clergy, or other as needed.
|Provides support to the family faced with long-term care of the child with a chronic illness.|
|Refer to community agencies and contact other families with a child with the same condition.||Provides information and support to child and family.|