Arthritis Care Plan

Disease Process

  • Surveillance
    • Assess and verify that patient and patient's legal representative (if any) and/or HIPAA authorized representative received written notice/document of patient's rights and responsibilities in a language the patient understands at SOC visit or by the second visit.
    • Assess affected joint area for redness, swelling, warmth and pain location, level/severity, quality, onset, duration, pattern, contributing factors and alleviation measures.
    • Assess (since the last visit or encounter) if patient experienced S/S outside target or goal range (via reported symptoms, symptom logs, telehealth), if changes in plan of care and for overall perception of how condition is being managed.
    • Assess (since the last visit or encounter) if the patient used the ER, Hospital or unplanned physician office visit.
  • Teaching, Guidance and Counseling
    • Provide contact phone numbers and who to contact during evenings and weekends for symptoms/concerns.
    • Provide teaching techniques and strategies that enhance and promote health literacy (improved knowledge and compliance with care requirements).
    • Evaluate knowledge of S/S to report to RN/Therapist or Physician and those that need immediate medical attention. (Refer to Zone/Red Flag Plan). Use Teach Back Method to determine comprehension. Ask patient to repeat IN THEIR OWN WORDS.
    • Instruct on pain management activities/concepts, perform treatment as ordered.
    • Instruct on non-pharmaceutical pain/symptom management strategies, as appropriate (such as relaxation, distraction, guided imagery, etc.).
    • Instruct on definition of disease process, potential causes and basic treatment or rehab goals.
    • Instruct on arthritis complications and effects on other body systems.
    • Evaluate compliance with self-monitoring of pain/symptom management and use of strategies to promote optimal comfort.
    • Evaluate compliance with self-monitoring activities and appropriate follow-up for abnormal findings.
    • Evaluate ability to manage health status independently.


  • Treatment, Procedure
    • Perform procedure to obtain lab specimens as ordered.
    • Administer procedure/test/treatment as ordered.


  • Surveillance
    • Assess (ask to see all medication & supplements) whether correct medications/supplements are in home. Review with patient/caregiver and reconcile medications, identify medication issues, make corrections and emphasize changes in regimen. Leave up-to-date medication profile and schedule in the home.
    • Assess for medication effectiveness/symptom control, side effects, compliance, other issues and for medication changes, review and update medication profile (reconcile medications) as needed.
  • Teaching, Guidance and Counseling
    • Instruct on purpose, action and side effects and how to monitor effectiveness of one or two medication/supplements and how and when to report medication problems.
    • Instruct on strategies to improve medication self-administration (pill box / medi-planner / med pre-fill) and simplification plan to support manageable system and compliance.
    • Instruct on why it is important for current healthcare providers (including pharmacies) to have a complete list of medication/supplements; and why it is recommended to use one pharmacy.
    • Instruct on use of PRN analgesics for pain control.
    • Instruct on use of corticosteroids, if ordered.
    • Instruct on use of steroids and tapering schedule, if appropriate.
    • Instruct on patient's prescribed medications that can cause constipation.
    • Instruct not to take any over-the-counter medications or supplements without consulting physician.
    • Evaluate and ensure current list of medications is left in home before discharge from services.
    • Evaluate and update medication profile with patient / caregiver and evaluate knowledge of actions, doses, side effects and times of medications to continue following discharge.
    • Evaluate knowledge of the importance for a realistic plan for refilling medications before running out and evaluate if the patient/caregiver has a plan in place.


  • Surveillance
    • Assess nutritional/hydration status and dietary/fluid intake.
    • Assess urinary function/status.
    • Assess gastrointestinal (GI) status for nausea, vomiting, diarrhea, constipation, fecal impaction or incontinence.
    • Assess for presence of orders for constipation alleviation or prevention medications or other treatments if patient has s/s or is on opioids formalin.
    • Evaluate effectiveness of bowel management program.
  • Teaching, Guidance and Counseling
    • Instruct on appropriate food choices and provide rationale; provide sample menus; and assist with meal planning.
    • Instruct on use of nutritional supplements and need to obtain approval from physician before taking, if appropriate.
    • Instruct on dietary adjustments and other activities to resolve or prevent constipation.
    • Initiate and instruct on bowel program, if necessary.
    • Evaluate compliance with diet/fluid requirements.
    • Instruct on importance of weight control to reduce strain on joints.


  • Surveillance
    • Assess current activity and tolerance levels, ability to perform ADLs/IADLs, and level of assistance needed.
    • Evaluate need for equipment/assistive devices.
    • Assess for correct/safe equipment use including assistive devices used in transfer activities.
    • Assess ability to grasp or hold objects/ manual dexterity.
    • Assess symmetry, body alignment and ability to assume all positions.
    • Evaluate affected joint ROM and strength, gait, coordination, balance and endurance.
    • Evaluate for effective pain control measures to enable maintenance of mobility or planned increase in activity level.
    • Evaluate return demonstration of safe transfer/ambulation techniques.
    • Evaluate for proper positioning of affected extremity.
    • Evaluate ability to maintain ADLs/IADLs at optimal level.
  • Teaching, Guidance and Counseling
    • Instruct on correct use of equipment/assistive devices and assess return demonstration, as appropriate.
    • Instruct on proper body mechanics for bending, lifting, reaching, transferring.
    • Instruct on and demonstrate pivot transfers and evaluate return demonstration.
    • Instruct on, demonstrate principles of safe ambulation.
    • Instruct on comfort measures/pain management to improve activity tolerance.
    • Instruct on and demonstrate active and passive ROM exercises.
    • Instruct on joint protection during activities.
    • Instruct on importance of alternating rest periods with activity.
    • Instruct on energy conservation techniques, importance of frequent rest periods and avoid overexertion.
    • Instruct on importance of regular activity to resolve or prevent constipation.
    • Instruct on effects of physical activity on disease process.
    • Evaluate compliance with activity schedule.
    • Instruct on activities and exercises to increase energy and endurance.
    • Evaluate compliance with energy conservation techniques.
    • Instruct on importance of maintaining consistent exercise/activity schedule, give examples of exercises that are allowed.
    • Care Management
    • Initiate referral to occupational health for instruction on assistive devices, as needed.


  • Surveillance
    • Assess safety of home environment, for falls or injury and for other safety issues or precautions, and recommend modifications or instruct as appropriate.
  • Teaching, Guidance and Counseling
    • Instruct on procedures to take in the event of a natural disaster (fire, hurricane, tornado, etc.), evacuation plan.
    • Instruct on basic home safety precautions to prevent injuries/falls.
    • Instruct on principles of Standard Precautions (proper handling/disposal of items coming in contact with body fluids).Evaluate compliance with home safety precautions to prevent injuries/falls.
    • Evaluate compliance with Standard Precautions.
    • Evaluate ability to maintain care/safety in home environment.


  • Surveillance
    • Assess patient/caregiver psychosocial, emotional, coping, alertness and sleep status.Assess barriers to care (cultural, financial, cognitive, caregiver, environment, other), and identify plan to address barriers, and implementaction plan and involve patient in action plan.Assess family/social support systems in place and adequacy of support systems.Assess caregiver burden, support, coping skills, stress level and potential risk for caregiver burnout.Assess for stress or feelings of depression related to diagnosis.
  • Teaching, Guidance and Counseling
    • Instruct on use of positive coping strategies (i.e., writing down and/or talking about concerns, relaxation - music, favorite TV show, doingenjoyable activities, etc.).


  • Care Management
    • Instruct on, review plan of care including disciplines, visit frequencies, discharge plan and support involvement of patient/family in plan of care.
    • Provide the patient/caregiver written care planning instructions, based on the signed Plan of Care, to keep in the home within 5 days of Initial Assessment.
    • IF POST-INPATIENT, Instruct on importance of scheduling and attending physician follow-up appointment within 7 days of inpatient discharge.
    • Identify barriers and assist in making and attending appointment(s) or provide phone numbers and time frames.
    • Provide opportunity to practice and role play questions for PCP/ specialist in preparation for follow-up visits or next scheduled visit.
    • Instruct on the importance of a Personal Health Record (PHR), its components, and the need to share with all healthcare providers.
    • Evaluate need for and/or initiate case communication or documentation of communication.
    • Assess for next physician appointment (Date).Evaluate plan of care including visit calendar with patient/caregiver and identify if changes are needed.
    • Instruct on community resources and support groups that can assist in maintaining positive health behavior, meeting long-term care needs and evaluate ability to access resources.
    • Instruct on how and why to reorder or obtain supplies, medications, equipment and lab tests.
    • Instruct on importance of follow-up with physician/other services.
    • Evaluate and update patient's Personal Health Record (PHR) with changes in medications, diet, activity, allergies, s/s to monitor, etc.
    • Evaluate knowledge of and agreement with discharge plans.