Rheumatoid arthritis is a chronic autoimmune inflammatory disease of connective tissue, the cause of which is not fully understood. It progresses with episodes of remission and exacerbations and affects about 1% of the world population.  The progression of the disease is variable over time, leading to joint destruction and deformity, resulting in severe disability, the need to give up work or premature death. Disability of a person with RA raises the need for surgical treatment or rehabilitation [1]. A 2012 study by the National Institute of Public Health found that in Poland, 10% of men and 25% of women between the ages of 30 and 60 suffer from rheumatic diseases, including RA. In Europe and North America, the prevalence ranges from 0.5 to 1% [2,3]. The consequences of this disease include physical ailments, i.e.: pain, reduced range of motion in the joints or generalized weakness, but the condition also has a major impact on the patient's mental health. It causes disorders of a depressive nature, failure to participate in social life or abandonment of daily life activities [4]. The diagnostic procedure is based on a thoroughly collected history, including many detailed questions. This will make it possible to reduce the number of laboratory and imaging tests performed and narrow the number of diseases with which RA is differentiated [5]. The condition is characterized by the presence of symmetric arthritis and the presence of extra-articular lesions and systemic complications. Pain of varying degrees of severity, multiple joint deformities, disability or premature death occur. As a result of alternating periods of remission and exacerbation, long and strenuous therapy, morning stiffness and chronic pain, there is impaired functioning in social and occupational competencies [6].The disease also leads to systemic symptoms, i.e. frequent fatigue, weight loss, sub-febrile episodes, decreased appetite. The disease is systemic and causes changes in the circulatory system, nervous system, lungs, and kidneys [6]. The goal of treatment is to achieve complete remission of pain associated with active inflammation, although this is rarely successful, so efforts include slowing the progression of destructive changes in the joints and maintaining the best possible function and ability to work. The pharmacological treatment of the mild course of this disease involves non-steroidal anti-inflammatory drugs (NSAIDs) and disease-modifying drugs, or so-called "basic drugs" (LMPCH). Occasionally, patients require delivery or periarticular corticosteroids, which have side effects, i.e. cataracts, gastric ulceration, premature atherosclerosis or osteoporosis [7]. Non-pharmacological treatment of rheumatoid arthritis includes balneotherapy, which uses natural mineral waters, gases and peloids for treatment. Supplemented with kinesitherapy, it has analgesic, myorelaxant and immunoregulatory effects. This therapy includes balneohydrotherapy, balneogas therapy and peloid therapy. Sulfide-hydrogen and randomized baths have beneficial effects in the treatment of RA. Random waters have a beneficial effect on connective tissue due to sulfide, hydrosulfide and hydrogen sulfide ions [8].

The patient, 68 years old woman, was admitted to the Rheumatology Department of a specialized hospital in Krakow (Poland) in January 2020 for septic inflammation of the left knee in the course of rheumatoid arthritis. During the three days preceding her hospitalization, she experienced knee pain that prevented her from walking. On the second day of hospitalization, the patient developed a fever (37.9-38.5?), which lasted for another two days. Because of the pain and dizziness caused by the improperly controlled blood pressure, the risk of falling was high. The patient also experienced morning stiffness that lasted for more than one hour, and the wrist and interphalangeal joints were particularly involved in lesions. The patient also reported sensory disturbances and sudden weakness and fatigue. She also had difficulty bending and lifting objects. Weight and height measurements on the day of admission were 88 kg and 165 cm tall, respectively. The patient's BMI was 32.32, indicating a first degree of obesity. The patient also suffers from diabetes, osteopenia, hypercholesterolemia and depression. The patient has difficulty sleeping and repeatedly awakens during sleep. The patient has never received any form of rehabilitation. On the second day of hospitalization, joint fluid was collected from the left knee for culture and general examination. The study had abnormal values for leukocytes, lymphocytes, monocytes, eosinophils, MCH, RDW and MPV. Detailed results can be found in Table 2.

Table: Abnormalities in joint fluid findings.

*Own elaboration based on the patient's medical records.

An X-ray of the knee joint was also taken, which showed that there were no significant lesions of disease significance. After the results of the joint fluid examination were obtained, antibiotic therapy (Vancomycin 1g; 2xdaily; i.v) was included in the treatment, which was administered for 12 days, the entire period of the patient's stay in the ward. After a week of antibiotic use, the knee joint pain resolved. Blood was also drawn for general tests. The blood tests showed elevated levels of urea, leukocytes, CRP, creatinine, glucose, fibrinogen and uric acid. Iron, Vit.D 25-OH and HDL cholesterol had lowered levels. Detailed information can be found in Table 2.

Table 2: Abnormalities in blood laboratory tested results.

*Own elaboration based on the patient's medical records.

Other laboratory results were normal.The patient is continuously taking the following medications: Atorvastatin 40mg 1x1, p.o.; Amlodipine 10 mg 1x1, p.o.; Paracetamol 500 mg 2x1, p.o.; Medrol 4mg 1x1, p.o.; Bicardiol 5mg, p.o.; Telimisartan 80mg 1x1, p.o.; Liprolog and Humulin N insulins - dosage determined by blood glucose levels. During her stay in the ward, the patient received supportive psychological therapy due to her depression and the process of adaptation to the disease and hospitalization. She participated in group classes in relaxation and psychoeducation focused on health-seeking behavior. The patient was discharged home after thirteen days in the ward, in good general condition. She was informed about her medical condition and further management. Consultation with the cardiology, diabetology and rheumatology clinics was recommended. On the basis of the above case report, the most important nursing problems experienced by the patient were highlighted:

1. Severe, nagging pain and swelling of the knee due to septic arthritis of the knee in the course of rheumatoid arthritis.
   Goal of care: Pain relief.
   Interventions used:
   - administered pain medications according to medical orders
   - compassing nursing interventions while the analgesics were in effect
       - application of warm and dry compresses
       - ordering the use of orthopedic equipment
   Results: Pain complaints decreased slightly
2. Lack of acceptance of the disease due to progressive disability in the course of rheumatoid arthritis manifested by depression.

Goal of care: To improve the emotional state and strengthen the sense of control of the disease.
Interventions used:
 - Imparting knowledge to the patient about the disease and how to cope with it
 - Identifying the patient's needs according to the stage and period of the disease
 - Encouraging the patient to actively participate in the care process
 - Encouraging participation in self-help and occupational therapy groups

Results: The patient felt in control of the disease and was more willing to talk.

3. Partial self-care deficit due to progressive disability manifested by difficulties in performing daily self-care activities and mobility.
   Goal of care: To reduce the self-care deficit and halt the progression of disability.

Interventions used:
    - Providing the patient with orthopedic equipment to facilitate mobility
    - Making the patient aware of the benefits and encouraging the use of physical therapy treatments
    - Motivating the patient to participate in occupational therapy
    - Providing the patient with the appropriate amount of time for him or her to take full advantage of his or her mobility
    - Adjusting the patient's environment to facilitate self-care activities
Results: The self-care deficit has decreased. The patient needs assistance with dressing and undressing and getting into the shower. The patient does not participate in occupational therapy.

4. Complications due to chronic use of glucocorticosteroids (diabetes, hypertension, osteopenia) and the risk of gastrointestinal bleeding.
   Goal of care: To reduce side effects from glucocorticosteroid use.
   Interventions used:
   - Control and documentation of blood pressure, heart rate, temperature values
   - On doctor's orders, administration of medications that reduce gastric juice secretion and medications that reduce blood glucose levels, as well as vitamin D preparations
    - Adherence to the principles of safe use of glucocorticosteroids:
    - Take medications while eating meals
    - Follow a diet rich in vitamins and calcium
    - Reduce drug doses gradually
   Results:  Temperature, heart rate and CTK values within normal limits. Patient takes GCS medications with meals, supplementing with vitamins and calcium.

In highly developed countries, i.e. the United States or Western European countries, rheumatoid arthritis affects as much as 2% of the population. Of the severe cases, up to 20% of them lead to disability. Despite medical advances, the pathogenesis of rheumatoid arthritis is not fully understood. There are theories, based on various factors such as environmental, genetic or hormonal factors leading to the development of this disease [5]. In our study, we confirmed the prevalence of cardiovascular disease in a patient with RA, despite a normal lipidogram. Increased risk of cardiovascular disease despite normal values of total cholesterol and LDL fraction are common. This phenomenon is called the lipid paradox [9]. The described case confirms the coexistence of diabetes and obesity with rheumatoid arthritis. The prevalence of diabetes among RA patients is as high as 14-18% of patients.  Regardless of the amount of body fat, it has been proven that chronic inflammation has a role in glucose metabolism, thereby reducing tissue sensitivity to insulin. In addition, obesity aggravates joint pain and accelerates joint destruction and deformation. Therefore, it is necessary to reduce body weight in order to reduce the level of inflammatory mediators and inhibit accelerated joint destruction [10]. Our own results indicate a significant problem which is the continued experience of generalized pain and joint deformity. Since pain is a factor that determines the quality of life, it causes a significant reduction in it. The discomfort is most often felt at night or after waking up, as well as when walking or changing body positions. During exacerbations of the disease, there is a noticeable reduction in mood and self-esteem due to the increased pain and the altered appearance of the patient through joint deformity. Such effects often require the intervention of a psychologist [6]. The patient's study showed that she is not currently receiving any form of rehabilitation. A study conducted by the Department of Rehabilitation at the Medical University of Bialystok showed that comprehensive medical rehabilitation is a proven effective method used in the non-pharmacological treatment of rheumatoid arthritis. It is necessary to take appropriate steps to encourage rheumatology patients to opt for this form of therapy [8].

Based on the above case report, it can be concluded that the problems of RA patients are multifaceted. Therefore, it is essential to pay attention to the patient's mental state, especially during the period of disease exacerbation. A patient with high self-esteem and a normal mood is more likely to cooperate with the therapeutic team and more likely to take up non-pharmacological treatment and rehabilitation. It is important to systematically take the prescribed medications and adhere to therapeutic recommendations, so that the occurrence of periods of disease exacerbation may be less frequent.

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