1.

CHAPTER I

THE PROBLEM AND ITS SETTING

Every person gets old and when this happens, many

problems in the body occur. Getting old is often associated

with having problems with the joint like rheumatism and

other forms of the said disease that continually hunts not

just aged people but even ordinary people with unfortunate

fate of having the rheumatic problems.

Rheumatoid arthritis (RA) is a

chronic, systemic inflammatory disorder that may affect many

tissues and organs, but principally attacks synovial joints.

The process produces an inflammatory response of the

synovium (synovitis) secondary to hyperplasia of synovial

cells, excess synovial fluid, and the development

of pannus in the synovium. The pathology of the disease

process often leads to the destruction of articular

cartilage and ankylosis of the joints. Rheumatoid arthritis

can also produce diffuse inflammation in

the lungs, pericardium, pleura, and sclera, and also nodular

lesions, most common in subcutaneous tissue. Although the

cause of rheumatoid arthritis is

2.

unknown, autoimmunity plays a pivotal role in chronicity

and progression, and RA is considered a systemic autoimmune

disease.

Home Cures are possible for almost every health

disorder existing in the world. The old age people used to

have higher living rates and they lived a healthy life as

compared to the modern day human being. The sole logic

behind the fact is that they were dependent on the herbal

remedies and home cures and not on the chemically treated

drugs. Herbal medicines can be grown in your backyard and

using them is as simple as growing them. The home cures have

least side effects and they do not obstruct the normal

growth of body. The herbal medicines contain all the

essential ingredients to treat any disease and that's why

they are becoming more and more popular.

Apparently, rheumatism is something that can be taken

care of from home. The best point concerning a home remedy

is that you have many options and, if you think that a

particular ingredient does not suit you, you can try an

alternative. You should give each remedy at least a week

before trying another. This type of natural treatment

3.

avoids the conventional medicine that is used in various

treatments done today.

General Objectives

This study aimed to determine the alternative and most

effective home management practices for rheumatism. As a

member of the health care provider aims to provide health

teaching to manage this chronic illness effectively.

Specific Objectives

At the end of ten days of intensive care affiliation

the student nurse will be able to:

Assess the client and the complication of the disease.

Teach to accept the findings as an awareness to promote

Healthy lifestyle and Safety living condition.

Teach the client how to manage on her own condition

especially at home management.

Gain and widen knowledge about the entire disease

process formulate appropriate plan of care for the major.

4.

Client Profile

Patient: Leticia Rullan

Address: 201 Brgy. Manacnac Palayan City

Age: 60 years old

Gender: Female

Nationality: Filipino

Religion: Roman Catholic

Educational Attainment: High School Graduate

Occupation: Storekeeper

Family History of Illness

The patient’s family has history of hypertension on both

side of the family.

History of Present Illness

The patient was diagnosed with Rheumatoid Arthritis and

Hypertension at Good Samaritan Hospital,4 months ago . Few

day prior to consultation at the said hospital she

experienced headache, pain around nape area and stiffness

and joint pain. The doctor submitted her to several test

like x-ray, pulse oximeter.

Past and Current Medical Condition

Before she was diagnosed with rheumatism she is known to

have Hypertension. She was advised to take rest everytime

she feels stressed and avoid salty and fatty foods and

strenuous activities.

History of Hospitalization and Surgical Operation

The patient was hospitalized because of her hypertension and

knows she preferred to have monthly check-up to a private

doctor and did not undergo from any surgery.

Nutrition and Metabolic Pattern

Usual food intake

The patient usual fluid intake in the breakfast was 1

cup of rice, egg, and 1 glass of milk. Then in lunch time

she preferred pork giniling. In dinner time, she has least

food intake ½ cup of rice and pinakbet.

Usual Fluid Intake:

The usual fluid intake of my patient was 8-10 glasses

of water a day.

Food restriction:

The doctor advised my patient to avoid salty and fatty

foods.

Problems with ability to eat:

My patient told that she has no problem regarding

ability to eat.

Supplementation:

My patient vitamin was vitaplus.

Elimination Pattern

Urination:

She urinate 5 times a day with a yellowish color and

has no complaint.

Bowels:

My patient has bowel movement a day with a formed stool

and no complaint about it.

Activity and Exercise Pattern

Usual daily activities:

The usual daily activities of my patient was walkind

around their house, cooking dish.

Limitation of Physical activities:

The patient doesn’t engage in heavy work

Sleep and Rest Pattern

She usually sleeps at around 9pm to 5am with a total of 8

hours of sleep.

Vital Signs

Wt- 58kg

Ht- 5’2

Date Bp T P R

11-14-11 130/80

mmHg

°C 75 20

11-15-11 130/80

mmHg

36°C 70 20

11-17-11 130/80

mmHg

36.1°C 73 21

11-18-11 130/80 36°C 70 19

mmHg

11-21-11

11-22-11

SUMMARY PRESENTATION OF PATIENT ASESSMENT

Body Parts Assessment Findings

Skull No tenderness

noted upon

palpation,

generally round

with prominent

in the frontal

and occipital

area

Normal

Scalp Lighter in color

than the

complexion; no

scars noted

Normal

Hair Slight dryness,

brittle

Hair can be black or brown.

Nor brittle nor brown

Face No involuntary

movement noted,

shape is oval

and rounded

Normal

Eyes Slight blurred

vision, pupil

clear, Decreased

visual activity

No decrease visual acuity

Pupils react to light

and accommodation

Ear No drainage

No ringing of ears

Skin is same color with complexion

No hearing loss

Normal

Nose and

paranasal

sinuses

No discharges,

no tenderness

noted on

palpation

Nasal septum normally straight and not perforated

Normal

Neck and Throat Soft, no swollen

lymph nodes

Normal

Chest With expansion

and respiration

Normal breath sounds

No cough

Thorax

is symmetric

RR-20

Normal

Abdomen soft, non

tender,

Umbilicus is

midline and

inverted with no

signs of

discoloration

Normal

Upper

extremities

Swelling pain of

the fingers

symmetrically even in color, warmth and moisture without swelling

No edema

lower

Extremities

Swelling pain of

the joints

Both legs are symmetric in size

No swelling or atrophy

CHAPTER II

CASE DISCUSSION/PRESENTATION

PATHOPHYSIOLOGY

Figure 1. medical surgical nursing

In RA, the autoimmune reaction primarily occurs in the

synovial tissue. Phagocytosis produces enzymes within the

Presentation of antigen to T cells

T- and B-cell proliferation. Angiogenesis in synovial lining

Synovitis. Early pannus invasion. Chondrocyte activation. Degradation of cartilage by

proteinase.

Swelling in small joints, associated with pain,

stiffness and fatigue.

Warm, swollen, effusion, pain, and decreased motion with possible rheumatoid nodules.

Increase in severity of physical sign and symptoms.

Neutophil accumulation in synovial fluid. Cell proliferation. No cartilage invasion

joint. The enzymes break down collagen causing edema,

proliferation of the synovial membrane, and ultimately

pannus formation. Pannus destroy cartilage and erodes the

bone. The consequence is loss of articular surface and joint

motion. Muscle fibers undergo degenerative changes. Tendon

and ligament elasticity and contractile power are lost.

Pathophysiology of my client

Sign and symptoms

Stiffness: The joint does not move as well as it once did. Its range of motion (the extent to which the appendage of the joint, such as the arm, leg, or finger, can move in different directions) may be reduced. Typically, stiffness is most noticeable in the morning and improves later in the day.

Inflammation: Redness, tenderness, and warmth are the hallmarks of inflammation.

Swelling: The area around the affected joint is swollen and puffy.

Risk Factors

Age

Although rheumatoid arthritis can occur at any age from childhood to old age, onset usually begins between the ages of 30 - 50.

Gender

Women are more likely to develop RA than men.

Family History

Some people may inherit genes that make them more susceptible to developing RA, but a family history of RA does not appear to increase an individual's risk.

Smoking

Heavy long-term smoking is a very strong risk factor for RA, particularly in patients without a family history of the disease.

Female gender. After the age of 65, women have a much higher risk of developing osteoporosis

Diagnostic Exam

When she was hospitalized last year because of hypertension,

she diagnosed also with rheumatoid arthritis she undergo

with an x-ray. The result was she has a rheumatoid

arthritis.

Prevention

The first step in helping to prevent or reverse arthritis is proper cellular nutrition. You want to fill your body with good antioxidants, so the free radicals roaming around in your system are neutralized and flushed out of your body before they can do more harm.

In the past, good cellular nutrition meant eating the right fruits and veggies every day, but things are more complicated now. Because of the degradation of our food supply, it's harder to get the good antioxidants you need straight from the grocery store. Of course, eating a healthy balanced diet full of fruits and veggies is still a good start, but you need to make sure you're properly supplementing your diet with antioxidants and minerals.

Complication

Rheumatoid arthritis can affect other parts of the body as well as the joints. Some patients with severe disease may then be at higher risk for complications, such as the following:

Peripheral Neuropathy. This condition affects the nerves, most often those in the hands and feet. It can result in tingling, numbness, or burning.

Muscle problems. Many patients have weakness of the muscles.

Anemia. People with RA may develop anemia, which involves a decrease in the number of red blood cells.

Scleritis and Episcleritis. This is an inflammation of the blood vessels in the eye that can result in corneal damage. Symptoms include redness of the eye and a gritty sensation.

Infections. Patients with RA have a higher risk for infections, particularly if they are treated only with immune-suppressing drugs (corticosteroids, anti-tumor necrosis factors, disease modifying drugs).

Skin Problems. Skin problems are common, particularly on the fingers and under the nails. Some patients develop severe skin complications that include rash, ulcers, blisters (which may bleed in some cases), lumps under the skin, and other problems. Severe skin disease can reflects a more serious case of RA in general.

Kidney. Although rheumatoid arthritis only rarely involves the kidney, many of the drugs used to treat it can damage kidneys.

Heart Disease. Patients with RA have increased risk for death from coronary artery disease. Research suggests that he chronic inflammation associated with RA may be a factor.

Nursing Management

Physical therapy helps preserve and improve range of motion, increase muscle strength, and reduce pain.

Hydrotherapy involves exercising or relaxing in warm water. Being in water reduces the weight on your joints. The warmth relaxes your muscles and helps relieve pain.

Relaxation therapy teaches techniques for releasing muscle tension, which helps relieve pain.

Both heat and cold treatments can relieve pain and

reduce inflammation. Some people's pain responds better to

heat and other's to cold. Heat can be applied by ultrasound,

microwaves, warm wax, or moist compresses. Most of these are

done in the medical office, although moist compresses can be

applied at home. Cold can be applied with ice packs at home.

( Medical Surgical Nursing)

Medical Management

In some cases, reconstructive surgery and/or joint replacement operations provide the best outcome

Rheumatoid arthritis was traditionally treated in the past with a stepwise approach starting with nonsteroidal antiinflammatory drugs (NSAIDs) and progressing through more potent drugs such as glucocorticoids, disease-modifying antirheumatic drugs (DMARDs), and biologic response modifiers.

In the past, DMARDs were avoided early in the disease because of their potentially serious side effects and because they did not often bring on remission. DMARDs were

usually reserved for people who showed signs of joint damage.

Over time, however, this strategy was recognized as being faulty, because people treated early with DMARDs have better long-term outcomes, with greater preservation of function, less work disability, and a smaller risk of premature death.

The goal of drug treatment is to induce remission or at

least eliminate evidence of disease activity.

DRUG STUDY

NAME ACTION INDICATI-ON

CONTRAINDICATION

SIDE EFFECT

NSG RESPONSIBILITIES

Leflunomide(Activan) 10-20 mg once daily

AnalGesic/antiPyretics and muscle relaxant

Active RA in adult patients

Severe deficiency of the immune system

Incresase BP; diarrhea, nausea and vomiting, abdo-minal pain

Watch forimpairment of liver function, severe hypoproteinemiaMay be taken with or without food

Methylprednisolone (medrol) 200 mg/day

Hormones and related drugs

Endocrine, rheumatic And hemaTological disorders

Systemic fungal infection

Fluid and elecrtro-

Lyte, muscoskeletal , GIT disturbances

W/draw from long-term therapy gradually.Monitor BP, salt, water & K. Pregnancy & lactation.

DOLO-Neurobion Analge-Sic/ anti-Pyretic andmusclerelaxant

Neuri tis, neural-gia

Acute intermittent porphyria, decompensated cardiac insuffici-ency

Rarely allergy caused by vit. B1.

May be taken with or without food (May be taken w/ meals to reduce GI discomfort.). Watch

for rash & other allergic reaction

NURSING CARE PLAN

Rheumatoid Arthritis

ASSESSMENT DIAGNOSIS NSG. OBJECTIVES

INTERVENTION RATIONALE

SUBJECTIVE:

“Napakasakit ng mga kasukasuhan ko” (I'm having severe joint pain) as verbalized by the patient.

Acute pain r/t distension of tissues by accumulation of fluid.

After 2 weeks of nursing intervention the patient will:

>Report pain is relieved/

controlled

>Appear relaxed, able to sleep/rest

Independent

Investigate reports of pain, noting location and intensity(scale of 0–10). Note precipitating factors and nonverbal pain cues.

Recommend/provide firm

Helpful in determining pain management needs and effectiveness of program

Soft/sagging mattress, large pillows prevent maintenance

OBJECTIVE:

Guarding/protective behavior

Restless

ness

facial grimacing

pain scale of 7 out of 10

V/S taken as follows

T: 37.5˚C

P: 100

R: 20

BP: 120/ 80

and participate in activities appropriately

>Follow prescribed pharmacological regimen.

>Incorporate relaxation skills and diversional activities into pain control program

mattress or bedboard, small pillow. Elevate linens with bed cradle as needed.

Suggest patient assume position of comfort while in bed or sitting in chair. Promote bedrest as indicated.

Collaborative

Apply ice or cold packs when indicated Assist with physical therapies, e.g., paraffin glove,

of proper body alignment, placing stress on affected joints. Elevation of bed linens reduces pressure on inflamed/painful joints.

In severe disease/acute exacerbation, total bedrest may be necessary (until objective and subjective improvements are noted) to limit pain/injury to joint.

Cold may relieve pain and swelling during acute episodes.

Provides sustained heat to reduce pain and improve ROM of affected joints

ASA exerts an anti-inflammatory and mild analgesic effect,

whirlpool baths.

Administer medications as indicated

Salicylates, e.g., aspirin (ASA) (Acuprin, Ecotrin, ZORprin);

decreasing stiffness and increasing mobility. ASA must be taken regularly to sustain a therapeutic blood level. Research indicates that ASA has the lowest toxicity index of commonly prescribed NSAIDs.

Characteristics of anti-inflammatory and immune modifier effects coupled with ability to block metalloproteinases

ASSESSMENT

DIAGNOSIS

PLANNING INTERVENTION RATIONALE

EVALUATION

SUBJECTIVE:

IMPAIRED TO

“SUMASAKIT RAYUMA KO, HIRAP AKONG LUMAKAD”

OBJECTIVE:

>PAIN ON BOTH EXTREMITIES PAIN SCALE OF 3/5

>DISCOMFORT

>RESTLESSNESS

>UNABLE TO WALK

>SWELLING ON BOTH EXTREMITIES

PHYSICAL MOBILITY RELATED TO PAIN ON BOTH EXTREMITIES, AS EVIDENCED BY DISCOMFORT AND RESTLESSNESS

PROMOTE COMFORT AND PREVENT OTHER COMPLICATION.

>SUPPORT AREAS

>ASSIST WITH TREATMENT OF UNDERLYING CONDITION CAUSING PAIN LIKE ADMINISTER MEDICATION PRIOR TO ACTIVITY AS NEEDED FOR PAIN RELIEF

>ENCOURAGE PARTICIPATION IN SELF CARE, DIVERTIONAL ACTIVITY

READING NEWSPAPER

SOCIALIZATION

>ENCOURAGE ADEQUATE INTAKE OF FLUIDS/ NUTRITIOUS FOOD

>TO PERMIT MAXIMAL EFFORT IN ACTIVITY

>ENHANCE SELF CONCEPT IN SENSE OF INDEPENDENT.

AFTER RENDERING OF NURSING CARE PROMOTION OF MOVEMENT AND PREVENTION OF OTHER COMPLICATION ATTAINED

GOAL WAS MET.

COLLABORATIVE:

REFERRAL TO A PHYSICAL THERAPIST.

>PROMOTES WELL BEING IN MAXIMIZES ENERGY PRODUCTION.

ASSESSMENT DIAGNOSIS

PLANNING INTERVENTION

RATIONALE EVALUATION

SUBJECTIVE

NANGHIHINA AKO AS VERBALIZED BY THE PATIENT.

OBJECTIVE:

FATIGUE RELATED TO INCREASED DISEASE ACTIVITY

AFTER 5 DAYS OF NURSING INTERVEN TION THE PATIENT WILL:

VERBA

INDEPENDENT

PROVIDE PERIODS OF UNINTER- RUPTED REST THROUGHOUT

●CLIENT OFTEN HAVE LIMITED ENERGY RESERVE.

AFTER RENDERING OF NURSING CARE PROMOTION OF MOVEMENT AND PREVENTION

DECREASED FUNCTIONAL ACTIVITY RESTLESSNESS

FACIAL EXPRESSION: YAWNING, SADNESS

INTERRUP-TED SLEEP

V/S

BP- 130/80 MMHG

T- 36.3°C

PR -75

RR-19

LIZED/ DEMONSTRATES INCREASED ABILITY TO MOVE PURPOSE FULLY

DAY (30 MIN 3-4 TIMES A DAY)

ALTERNATING ACTIVITY WITH REST

INTERRUP-TED SLEEP:

ENCOURAGE WARM SHOWER OR BOTH IMMEDIA-TELY BEFORE BEDTIME

ENCOURAGE GENTLE ROM EXERCISE AFTER BATH

COLLABORA-TIVE:

●CLIENT OFTEN USES ENERGY THAN OTHER TO COMPLETE SAME TASKS.

●WARM WATER RELAXES MUSCLE , FACILITATING TOTAL BODY RELAXATION

●TO MAXIMIZE EFFECTS OF HEAT

●REDUCES MODERATE

OF OTHER COMPLICATION ATTAINED

GOAL WAS MET.

ADMINIS-TER NIGHTIME ANALGESIC/ LONG-ACTING ANTI-INFLAMA TORY DRUGS AS PRES-CRIBED

INFLAM-MATION

Foreign Literature

In Philippines as well as in many other countries

there is a general overview of the health of the

population based on a national survey. Therefore it is the

time to look at the population risk groups. Rheumatism is

the most frequent illness diagnosed in population. For

example, in the United Kingdom more than 12% of the

population aged 65 years and over are affected with

rheumatoid arthritis. In Finland, the age adjusted incidence

of rheumatoid arthritis in the adult population was

31.7/100,000. Projecting to the year 2020, an estimated

18.2% of Americans will be affected by arthritic disorders,

equivalent to 60 million people. The spread of these

illnesses will increase in the coming years for several

reasons. First, the trends in demographic changes indicate

that the proportion of older people in population is

constantly growing. Secondly, ageing is accompanied by

chronic diseases, including musculoskeletal disorders.

According to Dr. Edward R. Laskowski of the Mayo

Clinic, the application of heat or ice may be useful in the

healing process. In general, you should use ice for swollen,

red and painful joints. Acute inflammation is often damaging

to our own tissues; in cases of rheumatism, the inflammation

is actually doing more damage than the original problem.

Therefore, ice is recommended in order to inhibit

inflammation; this occurs via reduced blood flow and

decreased swelling.

However, if the condition has been present for a

significant period of time, blood flow should be stimulated

in order to promote an active healing process. Chronic

inflammation may lead to the deposition of scar tissue,

which acts to inhibit your body's natural repair processes.

By applying heat, your blood vessels are forced to dilate

and allow more blood to enter the area.

(http://www.livestrong.com/article/330159-exercises-for-rheumatism/,

mayoclinic.com , www.google.com)

Overall, the body's immune response has one primary function: to protect the body from an object that the body does not recognize as a normal object. The immune response can be either normal or abnormal. Inflammation is also one of the body's first responses to infections as the body tries to rush immune cells and cytotoxic chemicals to the infected tissue to defend against the infections or foreign particles. Arthritis tends to develop inflammation in the joints and their surrounding tissues. Rheumatoid arthritis is an autoimmune disease where the body perceives tissue in the joints as being a foreign object and fights the tissue through an immune response. Tests for rheumatoid arthritis are rather simple and readily available. Rheumatoid arthritis has many options available for treatment such as medications and minor surgeries. Future advancements are continually being tested in clinical settings to help in improving treatment for rheumatoid arthritis patients.

(Lethbridge Research Journal. 2007. Volume 2 Number 1.)

There are many alternative methods a person can do to

treat their rheumatism. Especially if they have rheumatism

in their knees. Put on a good liniment like icy hot or Ben

Gay before you go to sleep. When you awake, your knees will

not be stiff. Do not walk or stand when you are in pain. Sit

down and take a rest for a while.

Do not push yourself. Know your limitations. Get the

right kind of exercise. Exercises like bike riding,

swimming, walking and floor exercises are all good for the

joints. Make sure you get your doctor's permission before

starting any exercise program. Three time a week for 30

minutes at a time is plenty of time for a exercise regime.

Do you or someone that you love suffer from rheumatoid

arthritis? If so, the pain and discomfort that is commonly

associated with rheumatoid arthritis may be too much to

handle. When it is, there are many rheumatism sufferers who

turn to over-the-counter medications to seek relief. Yes,

these over-the-counter medications will work in most cases,

but did you also know that there are natural and safe ways

to manage and treat rheumatism? There are and a few of

these natural remedies are highlighted below.

The consumption of raw juices is an effective and

natural remedy for rheumatoid arthritis. Two specific types

that come highly rated and recommended are green juices, as

well as potato juice. In fact, potato juice has been used

to treat the pain and discomfort commonly associated with

rheumatoid arthritis for years on end. For potato juice,

cut a potato into thin slices. When doing so, leave the

skin intact. Place the potato slices in a glass of cold

water and leave sitting for a few hours, overnight is best.

Then drink.

The consumption of Omega 3 Fatty Acids are another

natural way to treat many of the symptoms of arthritis.

Omega 3 Fatty Acids are found in most fish. Those who do

not like eating fish are encouraged to examine Omega 3 Fatty

Acid supplements, which are available for sale at most drug

stores and health stores. This natural remedy can provide

relief from all forms of arthritis; however, those with

rheumatoid arthritis see and feel the best results.

Warm olive oil massaged over the area is another easy

and natural way to relieve the pain and discomfort

associated with arthritis. What is nice about this approach

is that most individuals already have olive oil in their

homes. When using warm olive oil, be sure to let cool a

little, as olive oil that is too hot can result in painful

skin burns. In addition to plain olive oil, sage, rosemary,

or garlic can be diluted with olive oil, with about ten more

parts of olive oil. When applied to the impacted area,

relief should be felt immediately.

Baths are another natural way to treat the pain and

discomfort often associated with arthritis. When using

baths to seek relief, warm baths are advised. In fact, cold

bathes can result in increased pain, which is not the goal.

In addition to a traditional warm bath, many of those

suffering from arthritis recommend adding about three or

four tablespoons of Epson salt to the bathwater. Those

diagnosed with arthritis should remain in a warm bath for at

least thirty minutes.

Small amounts of exercise is another natural way to

relieve the pain and discomfort commonly associated with

arthritis. The only problem is that those suffering from

arthritis must proceed with caution where exercise is

concerned. Moving around, whether it be through walking or

squeezing a stress ball, can help, but it also important not

to over do it. Those who overexert themselves are likely to

experience even more pain and discomfort.

As you can see, there are a number of natural remedies

and home remedies that can be used to seek relief from

arthritis. If you are not suffering from arthritis, but if

you know someone who is, you may want to pass these easy and

natural remedies onto that person. Unfortunately, many

individuals are unaware of natural remedies and their many

benefits.(http://www.knrn.org/natural-remedies-for-arthritis.html,

www.google.com)

Local Literature

Holistic Healing in the Philippines Located on the

tropical island of Cebu, Philippines, AM Wellness is a

center using holistic healing and natural therapy to

overcome disease and achieve total health and well-being. We

also teach our students the keys to life-long health through

the practice of yoga, meditation and vegetarian diet.

Rather than use the word “patient”, we prefer to call

the people who come here “students” because they are here

not only to be cured but also to experience how to remain

healthy and disease-free for the rest of their lives.

Our naturopathy treatments courses run between 12 days

and 4 weeks or more, and include detoxification, herbal

colon cleansing, mud/water/sun therapies, water cleansing,

fasting, alternative medicines, and exercise. These are

complemented by music, art, classes, outings and games. We

do not offer “out-patient” short-term care.

The Wellness Center Situated in a quiet neighborhood of

Pagsabungan, Mandaue, Cebu, the Ananda Marga Wellness Center

is the country’s first affordable stay-in alternative

healing center. It practices a holistic approach to health

through various natural therapies, the practice of yoga,

meditation and vegetarian diet. We do not only assist our

students in their healing, but we also teach them the path

to life-long health.

EMPOWERS PEOPLE

- to overcome problems caused by excess fat, stress and

disease

- to cure themselves through a system of natural therapy

without depending on medicines

- to become physically fit, mentally relaxed and fully

conscious

- to learn new healthy systems of eating, exercise, drinking

water and harmonious thought

We offer a complete systematic, in-patient natural therapy

program. Daily activities are not only therapeutic but also

entertaining and educative.

OUR MAIN THERAPIES

- a nutritious, delicious DIET of alkaline food (fruits,

vegetables and other light vegetarian food), freeing the

digestive system from its normal burdens so the body can

naturally heal itself

- our unique SUPER HERBAL DETOX, which is superior to any

leading colon cleansing herbal products. It not only absorbs

toxins from the digestive system, but also ultimately from

the entire body. It is vital for getting a new start in your

life.

- an exercise program with a wide range: a) gentle YOGA

POSTURES for the glands and nerves b) SLOW EXERCISE of

walking and mild games c) VIGOROUS EXERCISE of brisk walking

& running, treadmill, swimming (at a nearby pool), aerobic

dance and active games

- various individually prescribed treatments include

MUD PACK applying hygienic mud to specific areas of

need, or in some cases to the whole body both absorbing

toxins and attracting healing blood

STEAMBATH to sweat out toxins, while keeping the face

in fresh air (not like sauna, which compels one to breathe

in toxic air)

HOT FOOTBATH also to sweat out toxins, with a

particular effect on lower body and lung problems

COLEMA (in between COLonic machine and EnEMA) internally

cleansing the intestines

SPINAL BATH to cool the spine only, our best physical

treatment for releasing stress

WARM CIDER VINEGAR BATH done only just before sleeping

for those who have difficulty to sleep, enabling nerves to

thoroughly relax

HYDRO BUBBLE BATH with 300 jets of warm or hot water,

directed at specific areas of the needy body, together with

aromatic oils

SYSTEMATIC SUNBATH alternating in and out of the sun,

with water or oil massage according to need, for fixed

number of minutes and during a fixed interval

HIPBATH attracting healing blood to the lower internal

organs including the digestive organs and the female organs

HOT WATER BAGS AND ICE PACKS depending on whether one

needs heat for relaxation or cold for healing

- WATER-DRINKING SYSTEM, 3 to 4 litres or more daily, to

cleanse toxins

- MENTAL EXERCISE & MEDITATION (including deep relaxation

and visualization) to convert stress into calm positivism

- a graduated program of specialized ELIMINATION DIETS &

FASTING on juices, broths, fruits and/or vegetables for

several days.(http://manilasector.org/?p=92, www.google.com)

Autoreactivity plays a major role in the pathogenesis

of RA. The rheumatoid factor has been and still is

for now more than 50 years the only autoreactivity that is

clinically applied in the diagnosis of RA. This

well reflects the current way of thinking that a single

antigen or a single cause drives an individual into

disease. Although by now many other autoantigens and

autoreactivities have been described, their

discovery was always on the search for the one and only

autoreactivity that causes RA. This includes also

immune reactivities directed against xenogenic antigens.

But, none of the known RA-associated

autoreactivities is present in all RA patients and none of

them occurs exclusively in RA. Thus, the

observed sensitivities and specificities are well below

100%. Therefore, RA has often been postulated to

consist of various immunological subentities with similar

clinical symptoms. Nevertheless, none of the

autoreactivities correlates with a distinct clinical feature

or course of disease. It is about time to say goodbye to the

idea that a single antigen or immunoreactvity causes and

maintains rheumatoid arthritis. In this

paper we present RA as the clinical outcome of an immune

system that has shifted from a healthy to an

autoimmune steady state. This is accomplished by many

different reactivities and autoreactivities that

occur either in parallel or one after the other. The

entirety of the known RA-associated reactivities and

(auto)antigens is presented in detail. The major RA-relevant

autoantigens comprise BiP, citrulline, the Saantigen, hnRNP

A2, p205, IgG, calpastatin, calreticulin, collagen and the

shared HLA-DR epitope. The

accumulation of factor--involving autoreactivities,

cytokines, environmental and genetic factors--that

challenge the normal regulatory mechanisms of the immune

system lead to a regulatory catastrophe.

(Z Rheumatol. 2007 Feb;60(1):1-1)

Foreign Studies

Recent studies using tumor necrosis factor-alpha

inhibitors, both alone and in combination with other

medications, have shown that patients demonstrate

significant improvement based on American College of

Rheumatology criteria (Felson et al.,2006)

Respondents to a population pain survey who had

reported having musculoskeletal pain in the survey and who

had consulted about their pain in primary care in the

previous 12 months as well as consenting to further research

and agreeing to an interview. Information was gathered about

their pain and the use of all treatments for pain, including

CAM, in the previous year.

Background

Surveys have suggested that use of complementary and

alternative medicines (CAM) is high and increasing

worldwide. Longitudinal studies in the UK between 1993 and

1999, 1995 and 2001 and between 1998 and 2006 and in the USA

between 1990 and 1997 have confirmed the trend. CAM is most

commonly used for chronic pain and in particular

musculoskeletal pain and is often used in combination with

conventional therapies. GPs are the conventional medical

practitioners most frequently consulted for chronic pain in

the UK.

A number of surveys have been conducted in the UK to explore

CAM use. Some of these were general population surveys,

surveys among patients with definitive rheumatologic

diagnoses attending hospital clinics, or surveys of

healthcare professionals exploring their patients' use of

CAM and access to it.

In primary care in the UK, surveys targeted healthcare

professionals rather than patients. We are not aware of

surveys conducted in the UK that have directly explored CAM

use among primary care patients who suffer from chronic

musculoskeletal pain. Evidence suggests that users do not

necessarily access CAM through primary care and also they

are often reluctant to inform their doctors of their use of

these treatments. Figures on access to CAM through primary

care and on health professionals' provision of CAM,

therefore, might have under-represented actual CAM use among

primary care patients.

We are not aware of previous surveys of primary care

patients that have enquired about the perceived helpfulness

of treatments from the patients' perspectives. This is

important for understanding healthcare seeking behaviour

among chronic pain sufferers, for informing effective pain

management in primary care and because of potential safety

issues related to CAM use.

We wanted to address these issues with particular focus

on musculoskeletal pain sufferers who are using primary care

in the UK. We have therefore investigated the pattern of CAM

use in a sample of chronic musculoskeletal pain patients who

were consulting primary care in the UK. Our hypothesis was

that this group of patients would have a higher prevalence

of CAM use than general population samples or pain sufferers

generally. This was based on the idea that this group will

have selectively more severe problems than the general

population because they have sought health care and because

chronic musculoskeletal pain is often unresponsive to

conventional primary care treatment http://www.google.com

An alternative treatment approach for RA has emerged in

the area of biologic therapies. Biologic response modifiers

are a group of agents that consist of molecules produced by

cells of the immune system or by cells that participate in

the inflammatory reaction. (Koopman,2006)

Local Study

In initiating a community oriented programme for the

control of rheumatic disease (COPCORD), 1685 people of all

ages from a rural area in the Philippines were questioned by

primary health care workers (PHW) for limb and spinal

rheumatic pain and disability. The total complaint rate was

15.3% for men and 18.5% for women. For those 15 years and

older the age adjusted rheumatic pain rates for pain present

at the time of survey were 28.4% for the Philippines and

22.6% for Lawrence's UK population. The most common

rheumatic pain sites in this community were knee, lumbar

spine, neck and the trapezius muscle. The disability rate

was 4.5% for those 15 years and older. One quarter of those

with pain had received medical attention and the remainder,

herbal treatment, massage, various faith and/or self-

treatment methods.

(http://www.springerlink.com/content/gg813l16x4690623/, www.google.com)

The Study of Active Controlled Monotherapy Used for

Rheumatoid Arthritis, An IL-6 Inhibitor (SAMURAI) study

demonstrated that, compared with DMARDs, tocilizumab

monotherapy significantly inhibited progression of

structural damage in Japanese RA patients.[21] In addition,

preliminary results reported from the Tocilizumab Safety and

the Prevention of Structural Joint Damage (LITHE) study

showed that, compared with MTX alone, tocilizumab plus MTX

treatment resulted in significantly less progression of

joint destruction.[22] In the present study, X-ray images at

baseline and at Week 52 of tocilizumab treatment were

available for 149 of 232 patients, allowing us to evaluate

the radiographic effect of tocilizumab. As stated above, the

duration of disease in patients enrolled in this study was

12.4 years, and estimated yearly progression was

significantly high, with 20.8 (1.3) at baseline. Considering

the results of the impact on radiographic and clinical

response to infliximab therapy concomitant with methotrexate

in patients with rheumatoid arthritis by trough serum level

in a dose escalating (RISING) study, in which we reported a

disease duration of ~8 years and mean estimated yearly

progression of 8.1 (9.1)  the present study included

patients with remarkably severe clinical features with long

disease duration and progressive joint destruction.

Irrespective of these severe conditions, the 95% inhibitory

effect of tocilizumab indicates how powerful its inhibition

of joint destruction is. Surprisingly, we found that

tocilizumab inhibits the radiographic damage, not only in

patients treated without TNF inhibitors, but also in those

treated with TNF inhibitors. Although further research is

needed, our findings suggest that the pathological condition

of RA is dependent on TNF. The good results obtained with

tocilizumab are consistent with those of both domestic and

foreign studies.

( http://www.medscape.com/viewarticle/750779_4)

CHAPTER III

METHODS AND PROCEDURE FOR DATA GATHERING

DATA GATHERING TECHNIQUE

The Data Gathering Technique used is Interview, Survey

Home Visits and Questionnaires.

To answer the research problems the student nurse used

a non-experimental design, questionnaires, survey study.

Questionnaire aim to gather information for purposes of

research for market surveys, analysis or even to corroborate

other research findings.  They are one of the cheapest and

most feasible ways of gathering data.  It is important to

remember that for any questionnaire to be really effective

it has to be designed well. Interview is used to collect

facts, structured interviews in their simplest form are

sometimes little more than oral questionnaires. The student

nurse interview the client by asking the questions in the

questionnaire prepared by the Clinical Instructor, it is

done to obtain a higher response rate with respondents,

especially children, who might not be literate or capable of

correctly completing a complex questionnaire. The student

nurse also brought instruments for assessment of the

client’s present condition.

ADMINISTRATION OF INSTRUMENT

The student nurses of Nueva Ecija University of Science and

Technology together with their Clinical Instructors first

asked for the permission of the Barangay Captain before

conducting their case study. We also gathered that Barangay

Manacnac have a total population of 1652 and total house

hold of 457. After gaining the Barangay Captain’s approval

the student nurse first visited one of the respondents house

which became her client. She gather information by means of

an interview, certain questions were asked about the

client’s profile and her past and present medical status.

Basic instruments such as thermometer, BP cuff and

sphygmomanometer was used to assess the client’s vital

signs. Weighing scale was also used to get the client’s

weight, the information acquired serves as the primary

information about the client for the case study.

LOCALE OF THE STUDY

History of Manacnac

Ang kabisera ng lalawigan ng Nueva Ecija ay ang lungsod

ng Palayan. Dito matatagpuan ang Barangay Manacnac. Ayon sa

kasaysayan, ang Manacnac ay dating sitio ng Maligaya na

sakop ng Laur, Nueva Ecija na may kaunting populasyon, taong

1953 si Ginoong Anong Simanero ang naging kapitan sa lugar

na ito. Kung iyong makikita ang Barangay na ito, para kang

nasa isang bundok na malayo sa kabayanan. Ang lugar na ito

ay may gulod na ang makikita ay puro mga damo at talahib

maliban lamang sa piggery na pag-aari ng mga Wycoco.

Tanong 1965 ng mapagpasyahan ng kongreso ng Pilipinas

na ang Palayan City ang magiging bagong kapital ng Nueva

Ecija. December 5, 1965 ang inaguration ng City Government

sa Palayan napagpasyahan ito ni ex-official Mayor Eduardo L.

Joson.Sina Mayor Elpidio O. Cucio at kanyang Vice Mayor na

si Felipe Bautista ay nahalal bilang unang subsequent local

official.

Taong 1966 nang naging Kapitan si G. Romulo V. Sandoval

sa Barangay Manacnac noong ang barangay na ito ay sakop

parin ng Laur. Nang panahong iyon may isang dayuhan na

nanggaling sa Novaliches Q.C. ang nag interas na bumili ng

lupa sa nasabing barangay at dito na rin siya nanirahan.

Siya ay si Ginoong Pedro Valenzuela. Nag-donate ng

kalahating hektaryang lupa para sa eskwelahan ng Cabanatuan

City at Atate, pumapasol ang mga batang nag-aaral noon dito.

Taong 1972 nang dahil sa ordinansang pinasa bg

Sanggunian, Ang barangay Manacnac ay naging isang barangay

sa Palayan City at nang panahong iyon ay kapitan parin si

Ginoong Sandoval.

Taong 1976 tumaas muli ang populasyon ng barangay mula

sa bilang na 662 ay naging 852 at may bilang na 128 ang

bubong ng bahay, may pamilyang 131 nang sumapit ang EDSA

Revolution taong 1986 itinalaga ni Kgg. Presidente Aquino si

Don Pacifico M. Fajardo na OIC ng Palayan City at Vice si

Flor Agustib na kasalukuyang kapitan parin si Romulo V.

Sandoval.

LOCATION MAP

Sampling Design

Purposive sampling starts with a purpose in mind and the sample is thus selected to include people of interest and exclude those who do not suit the purpose.

This method is popular with newspapers and magazines which want to make a particular point. This is also true for marketing researchers who are seeking support for their product. They typically start with people in the street, first approaching only 'likely suspects' and then starting with questions that reject people who do not suit.

Purposive sampling is non-probability and hence can be subject to bias and error. http://changingminds.org/explanations/research/sampling/purposive_sampling.htm)

CHAPTER IV

CONCLUSION AND RECOMMENDATION

CONCLUSIONS

In the light of above findings of the study, the

following conclusions were arrived at:

1. That the most common problems encountered in physical

aspect of the respondents is pain, followed by fatigue,

eating disorder, weight loss, anemia.

2. The most common problem encountered in emotional aspect

is feeling helplessness followed by loneliness, anxiety and

fear.

3. The most common problem encountered in social aspect is

delaying on immediate job or meeting followed by withdrawing

from social activities, and decreased number of friends.

4. The most common problem encountered in economical is

shortage of money followed by delayed pension, change of

employment, early retirement.

5. The most common home management when it comes to physical

aspect is wearing pajamas because that is the simplest way

to prevent too much exposure to cold climate. Followed by

sleeping 8 hours a day, taking steam bathing, massage the

affected area, wearing stocky net/socks, applying hot

compress on the affected area, and applying cold packs on

affected area.

6. All remedies they choose, the most effective remedies is

efficascent oil followed by pau linament oil, white flower

and Betet were used as home remedies.

8. Pain reliever medications were prescribed because of

effectiveness of drug followed by taking over the counter

medicine, and taking extra supplement.

9. Maintaining proper body position is the simplest way to

prevent further deterioration of the cartilages that’s why

it prevents too much pain. Followed by avoiding heavy works,

elevating their legs, attending aerobics exercise at least

twice a week, always engage in brisk walking every morning.

10. Home management for eating disorder the most convenient

is eating fruits and vegetables because they can acquired it

immediately and affordable to their backyards. Followed by

eating green leafy vegetables like malungay, talbos ng

kamote, eating food rich in omega 3 fatty acids and fish oil

such as canned tuna etc., avoiding eating food rich in uric

acid such as mongo, sitaw, gizzards, nuts, and drinking at

least one glass of milk a day.

11. The home management in social aspect is watching

television because they divert their attention to forget the

pain. Followed by playing with their grandson, reading books

and newspaper, and going to mall with their relatives, going

to amusement park, and playing chess with their friends.

RECOMMENDATIONS

The researchers of the study hereby recommend that:

1. Relatives must provide knowledge to the elderly with

regards to home remedies and proper practices because old

aged are easily forget their activities. Practices vary

according to the individual but tasked could be done with

encouragement.

2. Patient should able to manage their activity daily living

to lessen the factor that can cause Rheumatism to occur.

They should also practice to limit eating rich in uric acid

such as monggo, sitaw, gizzards etc., because the crystals

of uric acid are deposited in the joints that causing pain.

3. Patient should have awareness about Rheumatism by

discussing this home management and affective practices as

the primary prevention for further deteriorations of body

functions, the disease process of Rheumatism

BIBLIOGRAPHY

Bautista Joy,THEORETICAL FOUNDATION OF NURSING. A Beginner Journey Into Professional Nursing. first

edition 2008

Brunner & Suddarth’s Textbook of Medical-Surgical Nursing. eleventh edition 2008

Cacanindin,Nursing research : study notes and guide. 2010. by C&E Publishing, inc. 839 EDSA South Triangle, Quezon city

Concise Oxford English Dictionary eleventh edition

Seeley, Stephens, & Tate Essentials Of Anatomy And Physiology sixth edition 2007.

www.google.com;rheumatismworldhealthorganization http://www.disabled-world.com/health/autoimmunediseases /rheumatoid-arthritis/ra-diagnosis.php article5 Galanes feb 2006/

www.google.com; http://www.livestrong.com/article/330159-exercises-for-rheumatism/ mayoclinic.com article 1 Puzas January 2006

www.google.com; http:// www.knrn.org/natural-remedies-for-arthritis.html/2005 article7 Gulanik

www.google.com ; http://manilasector.org/?p=92,/2007 aricle3 klopp

ww. Google.com www.google.com; http://www.springerlink.com/content/gg813l16x4690623/, dec 2009

ACKNOWLEDGEMENT

As a student nurse wish to acknowledge and express

their deep appreciation and gratitude for the kind

assistance given by numerous people who helped them in the

preparation of this case study.

First and foremost, I want to offer sincerest gratitude

to my clinical instructor, Mrs. Girlie Tayao, RN, who was

supported and guided me throughout my case study, for the

humble sharing of her knowledge and experiences, for the

motivation and overwhelming encouragement, and for her

patience and understanding in checking my case.

To my staffing, Mr. Christian Gabuya for her whole-

hearted assistance and suggestions.

To the Dean of College of Nursing, Mrs. Eppie DC.

Bugarin, RM, RN, Ph.D for her valuable contribution to this

study.

To the personnel of Barangay Manacnac Palayan City for

providing necessary information to my research in conducting

this study.

Lastly and most importantly, the God almighty who has

given His great mercy and blessings for the years of study

of the researchers and who has given them a great privilege

to be His children.

Angelica P. Bravo

DEDICATION

After all the challenges, trials, hardships,

sufferings, efforts and sleepless nights, I made this humble

piece of work a successful one.

So, with love and respect, I dedicate this priceless

output to the following persons:

To my clinical instructor Mrs. Girlie Tayao RN who lend

her helping hands to guide me in the success of this study;

To my loving parents who always extend their best love

and care that serve as their inspiration in my studies;

To my staffing who always give their everlasting

support;

Above all, to the Lord Jesus Christ who is the divine

source of their strength, knowledge and abilities for

without Him, this work would have been in vain.

To all of them, I am humbly dedicate this piece of

work.

Angelica P. Bravo

TABLE OF CONTENS

Pages

Title ……………………………………………………………………………………………………………………………………………i

Acknowledgement …………………………………………………………………………………………………………………ii

Dedication …………………………………………………………………………………………………………………………… iii

Table of Contents ……………………………………………………………………………………………………….vi

I. THE PROBLEM AND ITS SETTING

Introduction ………………………………………………………………………………………………………… 1

General Objectives

………………………………………………………………………… 4

Specific Objectives

……………………………………………………………………………… 4

Client’s Profile

Foreign Studies …………………………………………………………………………………………………… 21

Local Studies ……………………………………………………………………………………………………… 24