SAS 23

CASE STUDY

Rheumatoid Arthritis

Patient Profile N.M. is a 66-year-old overweight white woman who has RA. When her symptoms began to interfere with her daily activities, she
sought medical help.

Subjective Data

• Has painful, stiff hands and feet

• Feels tired all of the time
• Reports an intermittent low-grade fever
• Takes naproxen (Aleve) 220 mg twice daily
• Wears a copper bracelet on the advice of a neighbor

Objective Data

• Hands show mild ulnar drift and puffiness

• Temp: 100°F (37.8°C)
• Admitted to the hospital for examination and comprehensive treatment plan
• Methotrexate (Rheumatrex) therapy to be initiated

Discussion Questions
You are going to answer the questions below. Each answer will be given five (5) points.

1. How should the nurse explain the pathophysiology of rheumatoid arthritis to N.M.?

N.M. needs to know that it is not known what causes RA but that in a genetically susceptible person autoantibodies, or RF, are formed that react
with substances causing inflammation and damage to a variety of organs. Inflammation and fibrosis of the joint capsule and supporting
structures may lead to complete immobilization of the joint and cause deformities similar to those she is developing in her hands. She should be
told that RA is a disease that affects her whole body, even though her joints are primarily affected at this time. She should be told that the
fatigue and low-grade fever she has are part of the disease and that with disease control these symptoms will improve.

2. What manifestations does N.M. have that suggest the diagnosis of RA?

Manifestations of RA include N.M.’s painful, stiff hands and feet; fatigue; low-grade fever; and ulnar drift deviation.

3. What diagnostic studies will confirm the diagnosis of RA?

Although diagnosis of RA is often based on history and physical findings, positive RF occurs in approximately 80% of adult patients and titers rise
during active disease. Testing for ACPA is a more specific test for RA than RF. Synovial fluid analysis in early disease will show an increase in the
matrix metalloproteinase (MMP)-3 enzyme and WBC count. ESR and CRP are general indicators of active inflammation. An increase in
antinuclear antibody (ANA) titers is also seen in some RA patients. X-rays are not specifically diagnostic of RA, although they may reveal soft
tissue swelling and possible bone demineralization early in the disease. (See Table 65-7; a score of 6 or greater is definitive for RA.)

4. What results may be expected from methotrexate therapy? What are the nursing responsibilities related to methotrexate therapy?

Methotrexate is a chemotherapeutic agent that is used as a disease-modifying antirheumatic drug (DMARD) because it has an antiinflammatory
effect, reducing symptoms in days to weeks. However, it causes bone marrow suppression and hepatotoxicity, so frequent laboratory
monitoring, including CBC and chemistry panel must be done. Its dosage in RA is much smaller than that used for cancer therapy and side effects
are not as common. Teaching N.M. about methotrexate is an important nursing responsibility. Along with periodic laboratory monitoring, N.M
could take a daily supplement of folic acid and should report signs of anemia or any infection. Methotrexate is teratogenic and N.M. should be
informed that contraception must be used during and for 3 months after treatment.

5. What are some suggestions that may be offered to N.M. concerning home management and joint protection?

Protection of N.M.’s joints will be enhanced if she can maintain a normal weight; avoid tasks that cause pain; use assistive devices to prevent
joint stress; avoid forceful, repetitive movements; use good posture and proper body mechanics; seek assistance with tasks that cause pain; and
modify home and work environments to create less stressful ways to perform tasks. To protect small joints N.M. should be taught to maintain
joints in neutral position to minimize deformity, use the strongest joint available for any task, distribute weight over many joints instead of
stressing a few, and change positions frequently (see Table 65-10). She should plan regularly scheduled rest periods alternated with activity
throughout the day and should develop organizing and pacing techniques that spread tasks through the day or the week. Suggesting that she
take a warm shower or bath in the morning to relieve her morning stiffness might be helpful. Exercise regimens will be prescribed and she
should be encouraged to follow the regimens daily

6. How can the nurse help N.M. to recognize ineffective, unproven methods of treatment?

Because of the chronicity and disability associated with arthritis, patients are often vulnerable to claims of unproven remedies. The nurse should
recognize that the copper bracelet will do no harm but may be a waste of money for N.M. It is important to encourage her to recognize that
regular, proven methods of treatment used on a consistent basis are the best way to control her condition. The more she is taught about the
disease and its management, the more compliant she will be with treatment regimens.

7. What other sources of information regarding arthritis might the nurse suggest to N.M.?

Additional sources of information and sharing are available from the Arthritis Foundation (www.arthritis.org) and should be suggested to N.M.

8. Priority Decision: Based on the assessment data presented, what are the priority nursing diagnoses? Are there any collaborative problems?

Nursing diagnoses:
• Acute and chronic pain related to joint inflammation
• Impaired physical mobility related to joint pain, stiffness, and deformity
• Fatigue related to disease activity
• Ineffective self-health management related to use of unproven remedies
• Risk for infection related to altered immune function
• Disturbed body image related to chronic disease activity, long-term treatment, deformities, stiffness, and inability to perform usual activities

Collaborative problem:
Potential complication: bone marrow suppression
ASSESSMENT DIAGNOSIS SCIENTIFIC ANALYSIS PLANNING INTERVENTION RATIONALE