Nursing care of a patient with ankylosing spondylitis in the context of Dorothea Orem’s theory: a case report

Introduction

Ankylosing spondylitis, also known as Bechterew’s disease, is the most common form of spondyloarthropathy, affecting the entire spine. This chronic systemic rheumatic disease is difficult to diagnose because it is characterized by alternating periods of remission and exacerbation, and a correct diagnosis may take up to 10 years after the onset of the first symptoms. Moreover, the exact cause of the disease remains unclear. Research indicates that it may have a genetic or infectious basis, although neither hypothesis has been definitively confirmed. Although ankylosing spondylitis is incurable, early diagnosis can help manage symptoms by alleviating pain and slowing the progression of inflammation [1-4].
Ankylosing spondylitis is more common in men than in women. The onset of the disease usually occurs between the ages of 15 and 35. The first symptoms appear before the age of 30 in approximately 80% of patients, and before the age of 16 in 10-20% of patients (juvenile ankylosing spondylitis) [4].
In Europe, ankylosing spondylitis affects approximately 0.3-0.5% of the population, while the global prevalence ranges from 0.3% to 1.5%. In Poland, between 2008 and 2017, the incidence rate was around 0.1% [5].
This disease is characterized by inflammation of the sacroiliac joints, spinal joints, and large peripheral joints, such as the knees, hips, and shoulders. Inflammatory changes in the attachments of entheses and ligaments are also possible [6].
The number and severity of ankylosing spondylitis symptoms depend on the duration of the disease. Patients whose condition has progressed to a state of deterioration and functional impairment require holistic care. Ankylosing spondylitis significantly reduces the quality of life of patients. Patients are often unable to maintain their previous lifestyle and become dependent on others. For this reason, depressive disorders may also occur, which intensify with the loss of independence [1].
Pharmacological treatment depends on the form of ankylosing spondylitis. Nonsteroidal anti-inflammatory drugs (NSAIDs) are often the first-line treatment. If high disease activity persists in the axial form despite NSAID therapy, biological treatment with anti-tumor necrosis factor (TNF) agents should be initiated. Indications for initiating biological therapy include the low effectiveness of first-line drugs, glucocorticoids (GCS), and locally administered sulfasalazine (SSZ). In addition to these criteria, important factors supporting the initiation of anti-TNF therapy include elevated C-reactive protein (CRP) levels, visible sacroiliac joint inflammation on X-ray or MRI, and comorbidities such as uveitis or inflammatory bowel disease. The most commonly used anti-TNF agents in the initial phase are adalimumab, certolizumab, golimumab, and infliximab. If no clinical improvement is observed, interleukin (IL)-17 inhibitors such as secukinumab or ixe- kizumab may be administered. The use of biological agents represents a modern form of therapy aimed at effectively reducing disease symptoms and improving the patient’s quality of life [7, 8].
Rheumatic diseases have a significant impact on a patient’s functioning – not only on a biological level, but also in social, emotional, cognitive, occupational, and spiritual aspects. The disease causes numerous difficulties, including problems in interpersonal relationships and in the ability to express emotions. Furthermore, the patient’s self-esteem significantly declines. The progressive disease also limits occupational activity, potentially leading to job loss. Chronic pain intensifies these problems, most often resulting in depression and a decline in quality of life [9]. It is hoped that this article will raise awareness about this medical condition and emphasize the importance of holistic and professional nursing care for patients affected by it.

Material and methods

A case study method was employed, enabling a thorough description of the patient’s health situation resulting from the disease, its consequences, and the ongoing treatment. It facilitated the identification of the patient’s health problems and the development of an individualized nursing care plan [10, 11]. At the study design stage, standardized tools were selected to enable a holistic assessment of the patient. The applied scales and questionnaire were helpful in analyzing the physical and mental health status of a female patient with ankylosing spondylitis. To collect information about the patient, an author-developed questionnaire was used, containing questions about her needs, along with standardized tools, such as the Numerical Rating Scale (NRS), the Barthel Index of Activities of Daily Living, the World Health Organization Quality of Life-BREF (WHOQOL-BREF), and the Geriatric Depression Scale [12-15]. The care plan was based on the assumptions of Dorothea Orem’s theory, which focuses on identifying the patient’s deficits and needs, as well as determining their ability to engage in self-care [16]. The International Classification of Nursing Practice (ICNP) was used to concisely and clearly present nursing diagnoses using standardized nursing language [17, 18]. The study was conducted in the patient’s home environment (three meetings) after obtaining her informed consent. This work was prepared in accordance with the principles of Good Scientific Practice, the Act of 10 May 2018 on the Protection of Personal Data, and the principles of the Declaration of Helsinki [19, 20].

Case presentation

A 76-year-old female patient was diagnosed with ankylosing spondylitis. The patient had a primary level of education and was a widow living in a rural area. Before the onset of the disease, she had been professionally active, managing a farm – initially with her husband, and later with her son. The advanced stage of the disease resulted in self-care deficits and significant changes to her previous lifestyle. The first symptoms of the disease appeared around the age of 50. Initially, the condition was not properly diagnosed. The cause of the pain, which had gradually limited the patient’s mobility, was being investigated. Nonsteroidal anti-inflammatory drugs (NSAIDs) were introduced as treatment, but after several years, proved insufficient. Extended diagnostic procedures revealed degenerative disease of the right hip joint (coxarthrosis) with necrosis of the femoral head. A total hip arthroplasty was performed on the affected joint. Severe spinal pain required further diagnostic investigation. Magnetic resonance imaging (MRI) revealed advanced degenerative and discopathic changes in the lumbar spine. Pain management and rehabilitation were initiated. The progression of the disease affected the patient’s ability to perform self-care. She became dependent on others, and her quality of life declined. The patient had comorbidities such as arterial hypertension and depression (diagnosed after consultation with a psychiatrist).

Care plan

During the first visit, an interview was conducted with the patient using all standardized tools. Vital signs were measured, and the medical documentation was analyzed. Health needs were identified based on Dorothea Orem’s theory and categorized into universal, developmental, and health deviation self-care requisites (Table 1), using an author-developed questionnaire. The collected data enabled an assessment of the patient’s baseline condition. During subsequent visits, additional interviews were conducted, and vital signs were measured. Pain intensity was monitored using the NRS scale.
Nursing diagnoses developed using the International Classification of Nursing Practice (ICNP) are presented in Table 2.
A supportive-educative system was implemented – intended for patients who require motivation, support, and knowledge to develop various skills – as well as a partially compensatory system, applied to patients who are unable to fully perform self-care due to physical limitations, lack of motivation, or an inability to make independent decisions.

Discussion

Ankylosing spondylitis is a disease that has a significant impact on the lives and daily functioning of affected patients. It is a progressive condition, making it impossible to halt its course; only appropriately selected pharmacotherapy and proper care can slow its progression. Rheumatic diseases seriously affect patient functioning, not only biologically but also socially, emotionally, cognitively, professionally, and spiritually. They may cause difficulties in forming interpersonal relationships and expressing emotions, which can lead to low self-esteem. Persistent pain exacerbates these problems, most often leading to depression and a decreased quality of life [9]. Depression is diagnosed in patients with rheumatic diseases up to twice as often as in patients with other conditions [21, 22].
Pain is one of the main problems in ankylosing spondylitis. During periods of exacerbation, the pain is so intense that it prevents patients from functioning normally and meeting their personal needs. Chronic pain causes sleep disturbances, fatigue, and low mood, making it difficult for patients to fulfill family responsibilities, maintain social relationships, and often leading to work-related difficulties. Patients frequently feel helpless, frightened, sad, and unhappy, and they rate pain very highly on the Numerical Rating Scale (NRS). The application of D. Orem’s self-care model in nursing practice can effectively reduce pain symptoms in patients with rheumatic diseases, as demonstrated in the study by Saeedifar et al. The principles of this theory can be used to promote self-care behaviors and actions among patients [23]. Similar results were obtained in the study by Tuna et al., conducted among patients with rheumatoid arthritis [24]. A lack of early diagnosis often leads to patients with ankylosing spondylitis being perceived as hypochondriacal or unsociable. Such perceptions can even cause feelings of guilt in patients. Therefore, appropriate pharmacotherapy and pain-relieving physiotherapy are crucial to restore patients to a more ‘normal’ life [25]. It is hoped that this paper will highlight the daily problems experienced by patients with ankylosing spondylitis and raise awareness of this medical condition.

Conclusions

This paper presents the needs and deficits that may accompany patients diagnosed with ankylosing spondylitis. Basic daily activities such as washing and dressing posed a significant challenge for the patient. Depression also presented a major issue, causing the patient to experience anxiety and restlessness, reducing her social interactions, and resulting in impaired communication with her immediate environment. Comprehensive observation, a detailed patient interview, and thorough analysis of medical documentation and relevant literature enabled the formulation of nursing diagnoses, based on the International Classification for Nursing Practice (ICNP) [17, 18], and the development of an individualized care plan. The supportive-educative nursing system addressed issues including constipation, obesity, increased risk of falls, fluctuating blood pressure, and communication difficulties that contributed to a sense of loneliness. Education on the risks associated with high blood pressure and excessive body weight motivated the patient to adhere to dietary recommendations and regularly monitor her blood pressure. The partially compensatory nursing system was applied to manage problems related to chronic pain, self-care deficits (in activities such as washing and dressing), and low mood associated with depression. The primary goal of care was to improve the patient’s quality of life, reduce pain, and restore as much independence as possible in daily functioning. The patient’s family was actively involved in the care process. As a result, several bathroom modifications were introduced, including the installation of grab bars, a non-slip bathtub mat, and a shower chair to facilitate safe and comfortable bathing. The implementation of environmental modifications to meet the patient’s needs increased her comfort and sense of safety. The purchase of a walker encouraged the patient to leave the house more willingly, leading to a slight improvement in her overall well-being. The promotion of self-care-based behaviors and activities can significantly contribute to patient activation and the involvement of their family in the care process.

Disclosures

This research received no external funding.
Institutional review board statement: Not applicable.
The authors declare no conflict of interest.

References