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As the disease progresses discount vasodilan 20mg, the knees order vasodilan 20 mg with mastercard, shoulders buy vasodilan 20 mg amex, hips, elbows, ankles, and cervical spine joints are affected. Clinical Manifestations • Acute gouty arthritis (recurrent attacks of severe articular and periarticular inflammation), tophi (crystalline deposits accumulating in articular tissue, osseous tissue, soft tissue, and cartilage) • The metatarsophalangeal joint of the big toe is the most commonly affected joint (90%). The nurse is often the first health care team member to come in contact with the patient. Because the rheumatic diseases affect many body systems, the history and physical assessment include a review and examination of all systems, with particular attention given to those areas most commonly affected, including the musculoskeletal system (see Chart 54-1). Diagnosis Nursing Diagnoses Although many nursing diagnoses are appropriate for the patient with a rheumatic disease, the following are a few of the most common ones: Acute and chronic pain related to inflammation and increased disease activity, tissue damage, fatigue, or lowered tolerance level Fatigue related to increased disease activity, pain, inadequate sleep/rest, deconditioning, inadequate nutrition, and emotional stress/depression Disturbed sleep pattern related to pain, depression, and medications Impaired physical mobility related to decreased range of motion, muscle weakness, pain on movement, limited endurance, lack of or improper use of ambulatory devices Self-care deficits related to contractures, fatigue, or loss of motion Disturbed body image related to physical and psychological changes and dependency imposed by chronic illness Ineffective coping related to actual or perceived lifestyle or role changes 265 Collaborative Problems/Potential Complications Based on assessment data, potential complications may include the following: Adverse effects of medications Planning and Goals The major goals for the patient may include relief of pain and discomfort, relief of fatigue, promotion of restorative sleep, increased mobility, maintenance of self-care, improved body image, effective coping, and absence of complications. In addition, knowledge about whether the condition is localized or more widely systemic influences the scope of the nursing activity. Others (eg, gout) have a known cause and specific treatment to control the symptoms. The diseases that usually present the greatest challenge are those with systemic manifestations, such as the diffuse connective tissue diseases. The plan of nursing care in Chart 54-2 details the nursing interventions to be considered for each nursing diagnosis. Relieving Pain and Discomfort Medications are used on a short-term basis to relieve acute pain. Because the pain may be persistent, nonopioid analgesics such as acetaminophen are often used. After administering medications, the nurse needs to reassess pain levels at intervals. With persistent pain, assessment findings should be compared with baseline measurements and evaluations. Additional measures include exploring coping skills and strategies that have worked in the past. These benefits include relief of pain and anti-inflammatory action as the disease is brought under control. Because disease control and pain relief are delayed, the patient may mistakenly believe the medication is ineffective or may think of the medication as merely ―pain pills,‖ taking them only sporadically and failing to achieve control over the disease activity. Alternatively, the patient may not understand the need to continue the medication for its anti-inflammatory actions once pain control has been achieved. A weight reduction program may be recommended to relieve stress on painful joints. Heat applications are also helpful in relieving pain, stiffness, and muscle spasm. Superficial heat may be applied in the form of warm tub baths or showers and warm moist compresses. Paraffin baths (dips), which offer concentrated heat, are helpful to patients with wrist and small-joint involvement. Therapeutic exercises can be carried out more comfortably and effectively after heat has been applied. However, in some patients, heat may actually increase pain, muscle spasm, and synovial fluid volume. If the inflammatory process is acute, cold applications in the form of moist packs or an ice bag may be tried. Both heat and cold are analgesic to nerve pain receptors and can relax muscle spasms. Safe use of heat and cold must be evaluated and taught, particularly to patients with impaired sensation. Canes and crutches can relieve stress from inflamed and painful weight-bearing joints while promoting safe ambulation. Cervical collars may be used to support the weight of the head and limit cervical motion. Other strategies for decreasing pain include muscle relaxation techniques, imagery, self-hypnosis, and distraction. Decreasing Fatigue Fatigue related to rheumatic disease can be both acute (brief and relieved by rest or sleep) and chronic. Chronic fatigue, related to the disease process, is persistent, cumulative, and not eliminated by rest but is influenced by biologic, psychological, social, and personal factors. Plan of Nursing Care: Care of the Patient With a Rheumatic Disease Nursing Diagnosis: Acute and chronic pain related to inflammation and increased disease activity, tissue damage, fatigue, or lowered tolerance level Goal: Improvement in comfort level; incorporation of pain management techniques into daily life. Pain may respond to Identifies factors comfort measures non-pharmacologic that exacerbate or interventions such as joint influence pain Application of heat protection, exercise, response or cold relaxation, and thermal Identifies and uses Massage, position modalities. Pain of rheumatic additional problems inflammatory, analgesic, disease responds to Verbalizes that pain and slow-acting individual or combination is characteristic of antirheumatic medications medication regimens.

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You’ll practice just accepting whatever arises discount vasodilan 20 mg visa, whether it’s the initial event generic vasodilan 20 mg with visa, or the automatic judgments that sneak in before you can refocus your awareness again on the present 20mg vasodilan sale. Non-Attachment and Non-Identifcation: Letting Go of the Velcro Mind When you say to yourself, “I am angry,” or “I am hurt,” or “I am sad,” you’re personalizing your experience. If you can 48 • Mindfulness Medication learn to describe your emotions with the phrases “now anger,” “now pain,” “now sadness,” you’re distancing yourself by just labeling a generic mental state, an emotion, or a physical sensation. In a way, you’re gaining some much-needed perspective, so that you can stand back a bit. Recall that thoughts pop up and vanish just as quickly, but when you latch on to them and stick them into a pattern of storytelling, emotions are triggered. The mind likes to attach new experiences to memories of previous ones and to personally identify with what’s occurring. If you can start to take the “I” out of things, you will be practicing what mindfulness describes as non-identification and non-attachment. Think of an emotion that you experience as not ‘your’ emotion per se but just as ‘an emotion’, a mental state that has developed and can just as easily go away. The experience just becomes a little less sticky and your Velcro Mind, which likes to grab and hold onto things, can let go a bit. You’re just recognizing an experience for its true, impermanent nature and labeling it. In actual fact, by doing so, you’re really experiencing the mental state and its emotional and physical expression in its totality. This may be the most difficult thing mindfulness asks you to do, but the best way to think about it is that you’re really not doing anything. You’re just being present to what presents itself without reacting, judging or criticizing. On the one hand, it’s a passive process in that you’re not trying to alter your experiences in any way. It can also be a very active personal process, as it initially requires a lot of strength, courage Mindfulness: A Technique to Deal with Stress • 49 and endurance to allow very strong thoughts, feelings and physical sensations to just be present without wanting to change them and without getting swept up in their drama. It can also be very interesting to see how dynamic and changing any sensation can be as you simply observe it. When you’re able to observe your mind’s own actions from a distance, by just focusing your awareness, this creates a separation from the activities of the mind. You become the witness, the observer to the experience rather than the “I” who is experiencing the event. Awareness is very valuable, as it allows you to be present from a place that is not your usual thinking, evaluating, judging mind. By observing your thoughts and stepping back, you realize that who you are, is more than just the sum of your thoughts. Mindfulness and Compassion: Be Kind to Yourself Compassion is an integral part of mindfulness. When you’re present to the wild thoughts, emotions and physical sensations that your mind and body are throwing at you every second of every day, it’s important to recognize that all this simply reflects your own unique makeup. What makes you uniquely you, is significantly influenced by your inner child and its need to be loved and accepted. The inner child is a part of your mind that still reacts to events in a child-like manner. Have compassion for the child you once were and the difficulties inherent in the human condition. Have compassion and understanding for yourself, as you go through a process of trying to change long-standing patterns and deeply held beliefs by observing them with your newfound knowledge and awareness. You do not deserve to be rejected and criticized (especially by your own judging mind! When something happens that you feel strongly about, you probably cling to the story and thoughts surrounding the event. This feeds the event and along with its accompanying storyline and emotions, it has more energy to remain front and center in your awareness. It’s important for you to try to experience something only as long as it naturally persists without prolonging it with amplification, attachment and identification. You have the choice of riding on the train and letting it take you wherever it goes, or stepping off the train and just watching it go by without ever climbing on board. Mindfulness and the Origin of Thought We previously examined the origin of thoughts. We discussed the fact that the mind measures every internal and external sensation against a conditioned belief system in order to determine whether the sensation is valuable or not.