Ankylosing spondylitis (AS) is a chronic inflammatory condition primarily affecting the spine and sacroiliac joints. This progressive disease can lead to the fusion of the vertebrae, resulting in decreased flexibility and potential deformity. As a nurse, understanding the nuances of this condition is crucial for providing comprehensive care to patients with AS.
This article will explore the nursing diagnosis, assessment, interventions, and care plans associated with ankylosing spondylitis.
Causes (Related to)
Ankylosing spondylitis can result from a combination of genetic and environmental factors. The following are common causes and risk factors associated with AS:
- Genetic predisposition, particularly the presence of the HLA-B27 gene
- Family history of AS or other autoimmune disorders
- Male gender
- Age (onset typically occurs between 17 and 45 years)
- Chronic inflammation of the spine and sacroiliac joints
- Repeated mechanical stress on the affected joints
- Possible triggers such as infections or gastrointestinal diseases
Signs and Symptoms (As evidenced by)
Patients with ankylosing spondylitis may present with a variety of signs and symptoms. During a physical assessment, a nurse may observe the following:
Subjective: (Patient reports)
- Chronic lower back pain and stiffness, especially in the morning or after periods of inactivity
- Fatigue
- Decreased range of motion in the spine and affected joints
- Pain that improves with activity and worsens with rest
- Sleep disturbances due to pain
- Chest pain or difficulty breathing deeply
Objective: (Nurse assesses)
- Postural changes, such as forward-stooping posture (kyphosis)
- Reduced spinal flexibility
- Tenderness over sacroiliac joints
- Elevated inflammatory markers in blood tests
- Radiographic evidence of sacroiliitis or spinal fusion
- Decreased chest expansion
- Eye inflammation (uveitis) in some cases
- Skin lesions (psoriasis) in some patients
Expected Outcomes
The following are common nursing care planning goals and expected outcomes for patients with ankylosing spondylitis:
- The patient will report decreased pain and improved mobility within two weeks of implementing the care plan
- The patient will demonstrate improved posture and spinal flexibility within four weeks
- By the end of the education session, the patient will verbalize understanding of AS management strategies, including medication adherence and exercise regimen.
- The patient will maintain or improve their ability to perform activities of daily living (ADLs) within one month.
- The patient will report improved sleep quality within two weeks of implementing sleep hygiene measures
- The patient will demonstrate proper use of assistive devices, if prescribed, by the end of the teaching session.
Nursing Assessment
A thorough nursing assessment is crucial for developing an effective care plan for patients with ankylosing spondylitis. The following steps should be included in the assessment:
- Conduct a comprehensive health history
Gather information about the onset of symptoms, family history of AS or autoimmune disorders, and any previous treatments or medications. - Perform a physical examination.
Assess the patient’s posture, gait, and range of motion in the spine and affected joints. Note any visible deformities or areas of inflammation. - Evaluate pain levels
Use a standardized pain scale to assess the patient’s pain intensity, frequency, and factors that exacerbate or alleviate the pain. - Assess respiratory function
Measure chest expansion and assess for any signs of respiratory compromise, as AS can affect the rib cage and lung function. - Monitor vital signs
Record baseline vital signs, including temperature, to monitor for signs of inflammation or infection. - Review laboratory results
Analyze blood tests for inflammatory markers (ESR, CRP) and genetic markers (HLA-B27) associated with AS.
Nursing Interventions
Effective nursing interventions are essential for managing ankylosing spondylitis and improving the patient’s quality of life. The following interventions should be considered:
Pain management
- Administer prescribed medications (NSAIDs, DMARDs, or biologics) as ordered
- Apply heat or cold therapy to affected areas as tolerated
- Teach relaxation techniques and deep breathing exercises
Promote mobility and exercise
- Encourage regular physical activity, focusing on range-of-motion exercises and stretching.
- Teach proper posture and body mechanics for daily activities
- Assist with physical therapy referrals and exercise programs
Provide education
- Educate the patient about AS, its progression, and management strategies
- Teach medication administration, including proper injection techniques for biologics if prescribed
- Discuss the importance of medication adherence and regular follow-ups
Implement sleep hygiene measures
- Recommend a firm mattress and supportive pillow
- Encourage establishing a regular sleep schedule
- Teach relaxation techniques to promote better sleep
Assist with ADLs
- Provide or recommend assistive devices as needed (e.g., long-handled sponges, raised toilet seats)
- Teach energy conservation techniques for daily activities
Monitor for complications
- Assess for signs of uveitis and refer to ophthalmology if needed
- Monitor respiratory function and encourage deep breathing exercises
- Screen for signs of spinal fractures or neurological deficits
Provide emotional support
- Offer active listening and empathy
- Refer to support groups or counseling services as appropriate
- Encourage stress management techniques
Nursing Care Plans
The following nursing care plans address common issues faced by patients with ankylosing spondylitis. Each plan includes a nursing diagnosis statement, related factors, nursing interventions with rationales, and desired outcomes.
Care Plan 1: Chronic Pain
Nursing Diagnosis: Chronic Pain related to inflammation of the spine and sacroiliac joints secondary to ankylosing spondylitis as evidenced by patient reports of persistent lower back pain, morning stiffness, and a pain score of 7/10.
Related factors:
- Chronic inflammation of spinal joints
- Progressive fusion of vertebrae
- Muscle tension and spasms
Nursing Interventions and Rationales:
- Use a standardized pain scale to assess pain characteristics (location, intensity, quality, and aggravating/relieving factors).
Rationale: Provides baseline data for evaluating the effectiveness of pain management strategies. - Administer prescribed pain medications (NSAIDs, DMARDs, or biologics) as ordered and monitor for effectiveness and side effects.
Rationale: Pharmacological interventions can reduce inflammation and alleviate pain. - Apply heat or cold therapy to affected areas as tolerated.
Rationale: Thermal therapy can help reduce pain and muscle spasms. - Teach and encourage relaxation techniques, such as deep breathing and progressive muscle relaxation.
Rationale: These techniques can help reduce muscle tension and promote pain relief. - Assist the patient in finding comfortable positions and teach proper body mechanics for daily activities.
Rationale: Proper positioning and body mechanics can minimize stress on affected joints and reduce pain.
Desired Outcomes:
- The patient will report decreased pain intensity from 7/10 to 4/10 or less within two weeks.
- By the end of the education session, the patient will demonstrate the use of at least two non-pharmacological pain management techniques.
- By discharge, the patient will verbalize understanding of their pain management plan, including proper medication use and when to seek medical attention.
Care Plan 2: Impaired Physical Mobility
Nursing Diagnosis: Impaired Physical Mobility related to joint stiffness and spinal fusion secondary to ankylosing spondylitis as evidenced by decreased range of motion in the spine, difficulty with ADLs, and forward-stooping posture.
Related factors:
- Progressive spinal fusion
- Joint inflammation and pain
- Muscle weakness and atrophy
Nursing Interventions and Rationales:
- Assess the patient’s current level of mobility, including range of motion, gait, and ability to perform ADLs.
Rationale: Provides baseline data for developing an individualized mobility plan. - Collaborate with physical therapy to develop and implement an exercise program focusing on flexibility, strength, and posture.
Rationale: Regular exercise can help maintain joint mobility and prevent further stiffness. - Teach and assist with range-of-motion exercises for affected joints, emphasizing spinal stretches.
Rationale: Consistent ROM exercises can help maintain flexibility and prevent joint contractures. - Encourage regular position changes and assist as needed.
Rationale: Frequent position changes can prevent stiffness and reduce the risk of pressure injuries. - Recommend and teach the use of appropriate assistive devices (raised toilet seats and long-handled reachers).
Rationale: Assistive devices can promote independence and safety in performing ADLs.
Desired Outcomes:
- The patient will demonstrate an improved range of motion in the spine and affected joints within four weeks.
- The patient will perform ADLs with minimal assistance using proper body mechanics and assistive devices as needed within two weeks.
- The patient will verbalize understanding of their exercise program and commit to regular participation by discharge.
Care Plan 3: Ineffective Breathing Pattern
Nursing Diagnosis: Ineffective Breathing Pattern related to restricted chest wall expansion secondary to ankylosing spondylitis as evidenced by shallow breathing, decreased chest expansion, and reported difficulty taking deep breaths.
Related factors:
- Fusion of costovertebral joints
- Kyphosis (forward curvature of the spine)
- Chest wall rigidity
Nursing Interventions and Rationales:
- Assess respiratory rate, depth, pattern, chest expansion and use of accessory muscles.
Rationale: Provides baseline data for monitoring respiratory function and effectiveness of interventions. - Position the patient in a semi-Fowler’s or high Fowler’s position to facilitate optimal lung expansion.
Rationale: Upright positioning can improve diaphragmatic excursion and lung expansion. - Teach and encourage deep breathing and chest expansion exercises.
Rationale: These exercises can help maintain chest wall flexibility and improve lung capacity. - Implement incentive spirometry as ordered and teach proper technique.
Rationale: Incentive spirometry promotes deep breathing and can help prevent respiratory complications. - Monitor oxygen saturation and administer supplemental oxygen as prescribed.
Rationale: Ensures adequate oxygenation and helps identify any respiratory compromise.
Desired Outcomes:
- The patient will demonstrate improved chest expansion and deeper breathing within 1 week.
- The patient will maintain oxygen saturation ≥95% on room air.
- The patient will verbalize understanding of and demonstrate proper technique for deep breathing exercises and incentive spirometry by discharge.
Care Plan 4: Disturbed Sleep Pattern
Nursing Diagnosis: Disturbed Sleep Pattern related to chronic pain and stiffness secondary to ankylosing spondylitis as evidenced by patient reports of difficulty falling asleep, frequent nighttime awakenings, and daytime fatigue.
Related factors:
- Chronic pain and discomfort
- Difficulty finding comfortable sleeping positions
- Anxiety related to the chronic nature of the disease
Nursing Interventions and Rationales:
- Assess the patient’s sleep patterns, including sleep duration, quality, and factors affecting sleep.
Rationale: Provides baseline data for developing an individualized sleep improvement plan. - A firm mattress and supportive pillow are recommended to maintain proper spinal alignment during sleep.
Rationale: Proper support can reduce pain and improve sleep quality. - Implement relaxation techniques before bedtime, such as progressive muscle relaxation or guided imagery.
Rationale: Relaxation techniques can help reduce pain and anxiety, promoting better sleep. - Educate on sleep hygiene measures, including maintaining a consistent sleep schedule and creating a comfortable sleep environment.
Rationale: Good sleep hygiene practices can improve sleep quality and duration. - Administer pain medication as prescribed, timing it to provide maximum relief during sleep hours.
Rationale: Effective pain management can reduce sleep disturbances caused by pain.
Desired Outcomes:
- The patient will report improved sleep quality and duration within 2 weeks.
- By the end of the education session, the patient will demonstrate the use of at least two relaxation techniques to promote sleep.
- The patient will verbalize understanding of sleep hygiene measures and commit to implementing them by discharge.
Care Plan 5: Risk for Falls
Nursing Diagnosis: Risk for Falls related to impaired balance and mobility secondary to ankylosing spondylitis as evidenced by unsteady gait, kyphosis, and decreased range of motion in the spine and lower extremities.
Related factors:
- Altered center of gravity due to postural changes
- Decreased flexibility and range of motion
- Potential side effects of medications (e.g., dizziness)
Nursing Interventions and Rationales:
- Conduct a fall risk assessment using a standardized tool (e.g., Morse Fall Scale).
Rationale: Identifies specific fall risk factors and guides individualized interventions. - Implement fall prevention strategies, such as keeping the patient’s environment clutter-free and ensuring adequate lighting.
Rationale: A safe environment reduces the risk of falls and promotes patient safety. - Teach and assist with balance and strengthening exercises as recommended by physical therapy.
Rationale: Improving balance and strength can reduce the risk of falls. - Educate on proper use of assistive devices (e.g., cane, walker) if prescribed.
Rationale: Proper use of assistive devices can improve stability and reduce fall risk. - Review medications for potential side effects that may increase fall risk and monitor for these effects.
Rationale: Awareness of medication side effects allows for prompt intervention to prevent falls.
Desired Outcomes:
- The patient will demonstrate proper use of prescribed assistive devices by the end of the teaching session.
- The patient will verbalize understanding of fall prevention strategies and commit to implementing them at home by discharge.
- The patient will maintain a fall-free status during hospitalization and report no falls at home during follow-up visits.
References
- Sieper, J., & Poddubnyy, D. (2017). Axial spondyloarthritis. The Lancet, 390(10089), 73-84.
- Ward, M. M., Deodhar, A., Gensler, L. S., Dubreuil, M., Yu, D., Khan, M. A., … & Maksymowych, W. P. (2019). 2019 Update of the American College of Rheumatology/Spondylitis Association of America/Spondyloarthritis Research and Treatment Network Recommendations for the Treatment of Ankylosing Spondylitis and Nonradiographic Axial Spondyloarthritis. Arthritis & Rheumatology, 71(10), 1599-1613.
