Table Of ContentH.A. Bird· Patricia Ie Gallez
Jacqueline Hill
Combined Care
of the Rheumatic
Patient
Foreword by Verna Wright
With 64 Figures
Springer-Verlag
Berlin Heidelberg New York Tokyo
1985
H. A. Bird, MD, MRCP, Senior Lecturer in Rheumatology,
Rheumatism Research Unit, University of Leeds, and Honorary
Consultant Rheumatologist, General Infirmary at Leeds and
Royal Bath Hospital, Harrogate.
Patricia Ie Gallez, SRN, Clinical Metrologist, Rheumatism
Research Unit, University of Leeds, and Honorary Nursing Sister,
Royal Bath Hospital, Harrogate.
Jacqueline Hill, SRN, Clinical Metrologist, Rheumatism Research
Unit, University of Leeds, and Honorary Nursing Sister, Royal
Bath Hospital, Harrogate.
Library of Congress Cataloging in Publication Data
Bird, H.A. (Howard Anthony), 1945-
Combined Care of the rheumatic patient.
Includes bibliographies and index. 1. Rheumatism-Treatment.
2. Rheumatism-Nursing. 3. Arthritics-Rehabilitation. 1. Ie Gallez, Patricia,
1938-. II. Hill, Jacqueline, 1946-. III. Title. [DNLM: 1. Rheumatism.
2. Rheumatism-nursing. WE 544 B6185c] RC927. B54 1985 616.7'23
84-23618
ISBN-l3: 978-3-540-13557-9 e-ISBN-13: 978-1-4471-1365-2
DOl: 10.1007/978-1-4471-1365-2
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We dedicate this book to our respective spouses, Anne,
Geoffrey and Jeff, who showed outstanding tolerance
throughout the writing of this book and to whom we extend
our grateful thanks.
Foreword
Gone are the days when the physician could act as God, the
orthopaedic surgeon as the Lord God and the nurses as minister
ing angels. The concept of a team approach with each discipline
supplying special yet overlapping skills is accepted in principle,
although not always in practice. Physiotherapists and occupational
therapists resist integration of their training among the hierarchy;
however, on the ground, these remedial therapists often do each
other's jobs with remarkable amity. Elsewhere I have discussed
whether we need multipurpose professionals or multiprofessional
persons (Wright 1982).
At Leeds the close collaboration that exists between rheumatol
ogists and non-medically qualified professionals has resulted in a
productive Bioengineering Group for the Study of Human Joints,
a Clinical Pharmacology Unit of international renown and a
Rehabilitation Unit that consistently produces bricks without
straw. One aspect of this combined approach to patient care has
been the development of the discipline of clinical nurse metrology
(Bird et al. 1980). Skilled nursing sisters have worked in this
capacity for a decade in Leeds. Their contribution has not only
enhanced the reliability of the results of clinical trials in which they
have been engaged, but it has been highly s;ost effective and
greatly appreciated by patients. It has also measurably improved
our patient education programme. Moreover, the posts have
provided considerable job satisfaction.
This book arises from the expertise gained during these pioneer
years. It is not a conventional textbook, but nevertheless contains
sound practical advice at many levels. Few books contain a job
description for a new breed of paramedical persons, or a template
for setting up a similar service elsewhere. Rheumatologists, nurses
with experience in caring for rheumatic patients, physiotherapists,
occupational therapists, orthopaedic surgeons with a broad view of
viii Foreword
their specialty, and health planners will gain much from reading
these pages. It is to be hoped the book will be read not only in
Europe but in the United States, the Antipodes and other
countries where combined care by physicians and paramedicals is
being developed.
Leeds 1984 Verna Wright, MD, FRep
Professor of Rheumatology,
University of Leeds
References
Wright V (1982) MUlti-purpose therapist or multi-professional team? Occup Ther
1982, 45: 229-230
Bird HA, Galloway D and Wright V (1980) Clinical metrology-a future career
grade? Lancet 2: 138-140
Preface
This book has been written in an attempt to bridge a gap. On the
one hand there is a variety of advanced textbooks, aimed at
medical practitioners and rheumatologists, on the treatment of
rheumatic diseases. On the other, there are a few texts covering
the same subject but aimed at nurses specialising in rheumatology,
physiotherapists and occupational therapists, such as Rheumatism
for Nurses and Remedial Therapists by Wright and Haslock, an
earlier book from this Unit. We hope that our own book will
occupy an intermediate position and help to draw together all
available expertise in the treatment of rheumatic diseases.
The Rheumatism Research Unit in the University of Leeds has
for some time pioneered the use of paramedical workers in the
integrated management of patients with chronic rheumatic dis
eases. In the light of this experience we believe there is an essential
need for a more practical (and highly cost effective) level of care in
the management of chronic conditions. The concept of 'combined
patient care' is perhaps most advanced in the field of anaesthetics,
where both recovery room nurses and intensive care unit nurses
are trained to a high degree to use complex technological equip
ment, day and night, in collaboration with physicians.
It is ironic that the concept of total patient 'Care has not been
further developed in the treatment of chronic conditions. A
general practitioner frequently relies heavily on his district nurse
as an early warning or screening system for impending deteriora
tion in the medical state of a patient. It has seemed to us that such
combined responsibility in patient care, already applied to the
management of diabetes mellitus, can be equally applied to
chronic chest disease and many chronic rheumatic diseases.
In the rheumatology clinics at the General Infirmary at Leeds
nurses and doctors, each with separate booked lists, consult from
adjacent rooms. Only lack of space currently prevents the
x Preface
allocation of further rooms to occupational therapists and physio
therapists. Patients are booked to see the appropriate specialist
according to their needs. Although this system in part evolved
accidentally in an attempt to extend rheumatology services, in a
financially deprived health service, to those needing them, the
advantages have become obvious. Physicians can devote more
time to using their skills in the art of differential diagnosis and
management of the more complicated patients; 'health pro
fessionals' can devote more time to the monitoring of possible
side-effects from toxic drugs such as gold or penicillamine, the
quantitative assessment of a patient's progress in response to new
drugs, and patient education. This system of combined care is
already established in North America and in certain countries,
such as Australia, where the system has proved itself as a method
of stretching limited resources in sparsely populated areas.
One stimulus that prompted the writing of this book was the
need for a more applied nursing text that might further its aims of
advancing 'total care' of the rheumatic patient. A second stimulus
was that the 1983 combined meeting of the professional medical
societies for rheumatology (The Heberden Society, British Asso
ciation for Rheumatology and Rehabilitation, Royal Society of
Medicine) was the first meeting at which the Rheumatology Forum
of the Royal College of Nurses convened a parallel session with
interchange of delegates-as has long been the practice at meet
ings of the Pan American Rheumatism Association. Appro
priately, this meeting was held in Leeds. Physiotherapists and
occupational therapists also held their own meetings in parallel
with the physicians in Leeds, and it is to be hoped that this
auspicious trend will continue. A third stimulus was provided by
the frequent requests we received from physicians and their
nursing colleagues for help in establishing combined clinics in
hospitals other than the General Infirmary at Leeds.
The book falls into three main sections. The first, comprising
three chapters, commences with a chapter reviewing the common
(and some rarer) rheumatic diseases which are particularly deserv
ing of multidisciplinary care and will be frequently encountered in
hospital units specialising in rheumatology. Chapter 2 covers
recent advances in investigative techniques of the sort that would
be routine in many hospital rheumatology units, together with
accounts of the ward preparation of patients for such investiga
tions. Chapter 3 reviews recent advances in the tfeatment of
rheumatic diseases, a rapidly moving and increasingly scientific
field. The second section of the book (Chapters 4-6) commences
with a description of routine rheumatology nursing, which in
corporates an account of the 'nursing process' recently introduced
in many hospitals in the United Kingdom. There follows a
summary of surgical procedures applicable to rheumatic diseases
and the orthopaedic nursing techniques appropriate to them. This
Preface xi
is followed by a chapter reviewing the role of physiotherapy and
occupational therapy in the multidisciplinary approach.
The third section of this book, comprising the last six chapters,
then applies the concept of 'combined or total patient care' to this
background. We have drawn heavily on our clinical experience
both at the General Infirmary at Leeds, with over 8000 outpatient
clinic attendances each year, and at the Royal Bath Hospital,
Harrogate, which, with 125 beds, is the largest hospital devoted
entirely to the inpatient care of the rheumatic diseases in the
United Kingdom. Chapter 7 deals unashamedly with patient
education. It is placed first in this section in the belief that
prevention is better than cure. Nevertheless, rheumatic diseases
will still advance in some patients; in such cases physicians are
going to be dependent upon their clinical metrologists for an
accurate presentation of the progression of disease activity. Chap
ter 8 describes in detail the wide variety of tests currently
performed by clinical metrologists. Chapter 9 deals briefly with the
psychological aspects of these chronic disabling diseases. Chapter
10 deals with the evolution of a system of combined patient care in
the outpatient clinic and describes how paramedical specialists,
initially recruited as clinical metrologists, might aim to be re
sponsible for the total care of their rheumatic patients in a manner
akin to the role of the nurse practitioner in the United States.
Chapter 11 deals with community care in relation to rheumatic
diseases. The final chapter assumes that nurses and other para
medical specialists will wish to conduct their own research in the
field of rheumatic diseases and introduces the reader to trial
methodology and research techniques.
Although this book has been written by a physician and two
nursing sisters, we have drawn extensively on the experience and
wisdom of our colleagues. Prof. Verna Wright has shared ideas on
administrative and clinical aspects and Dr. Anne Chamberlain on
rehabilitation aspects. Physiotherapists and occupational thera
pists have also been consulted in the hope that at least part of the
contents of this book will be of interest to all workers involved in
the treatment of rheumatic diseases.
When professional advice has been conflicting (which inevitably
occurs in medicine) we have inclined towards description of our
own practice and experience. As a result, any errors or omissions
are entirely the responsibility of the three authors.
If this book is read by trained nurses who, perhaps after a period
of basic nursing on a rheumatology ward, wish to extend their
contribution towards the total care of the rheumatic patient, we
shall be pleased. If the book is also read by rheumatologists, either
established or in training, who, as a result, decide to modify their
rheumatology service to allow these specialised paramedical work
ers to make a greater contribution, we shall be delighted.
Contents
1 The Spectrum of Rheumatic Diseases . . . . . . . . . . . . . . . . . . 1
Introduction; Non-articular Rheumatism; Spinal Disorders;
Osteoarthrosis; Crystal Deposition Diseases; Degenerative vs
Inflammatory Joint Disease; Seronegative Spondarthritides;
Rheumatoid Arthritis; Connective Tissue Disorders; Polymyalgia
Rheumatica and Temporal Arteritis; Septic Arthritis; Rarer
Arthritic Conditions
2 Investigations for Rheumatic Diseases ................. 27
Introduction; Routine Haematological Investigations; Routine
Biochemical Investigations; Immunological Assessment of
Rheumatic Disease Activity; Examination of Synovial Fluid;
Biochemical Assessment of Rheumatic Disease Activity; Detection
ofInfection; Radiology; Bone Biopsy; Investigation of Musc1e
Disorders; Nerve Conduction Studies; Tissue Biopsy; Arthroscopy;
Study of White Cell Blood Groups in Rheumatic Diseases;
Evaluation of Faecal Blood Loss; Use of Radioisotopes in
Rheumatology; Thermography; Research Investigati~m on Urine
3 Treatment of Rheumatic Diseases . . . . . . . . . . . . . . . . . . . . . 57
Introduction; Plan of Patient Care; Analgesics; Non-steroidal
Anti-inflammatory Agents; Disease-Modifying Agents for
Rheumatoid Arthritis; Immunoactive Drugs in Rheumatic
Diseases; Management of Seronegative Spondarthritides;
Management of Connective Tissue Disorders; Management of
Ankylosing Spondylitis; Osteoarthrosis and Crystal Deposition
Disease; Arthritis in Childhood; Patient Compliance
