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Rheumatoid Arthritis Case Study Questions & AnswersSlide 5:What is significant about this report that leads you to RA?Pain in hands bilaterally, stiffness, tenderness in the morning, poor appetite and easily fatiguedRA affects women > men and is most common 40-60 yrs oldWhat additional nursing assessment data would be significant?Joints spongy feeling, warm/hot, swollen, not easily moved, fever, weight loss, Raynaud’s phenomenon (cold & stress induced vasospasms that cause white/cyanotic coloringSlide 7:Patient has mild OA and is now being diagnosed with RA, explain the differences to her.RA is typically symmetrical OA is notRA targets smaller joints first and OA tends to affect larger joints firstRA is synovitis of the joints (inflammation of the synovial lining), OA is “wear & tear” breakdown of cartilageOA is more commonRA is more debilitating & cripplingRA is autoimmune, systemicRA is remissions & exacerbationsMorning stiffness is < 30 mins in OA and > 1 hour in RASlide 10:How will these laboratory values be affected or how will they assist in the diagnosis of RA?RBC & HcT are decreased – chronic inflammationCRP – elevated indicates active inflammation (Normal is less than 1 mg/dL)ESR – elevated indicates inflammatory process (Normal is 0-15 Men, 0-25 Women)RF – Positive in 80% of RA patients , not a specific indicator of RAACPA – Positive can indicate RA, not a specific indicator of RASynovial Fluid – cloudy with increased leukocytes presentXray – narrowed joint spaces, not typically seen in the first 3-6 months, also done to determine progressionSlide 12:According to the American College of Rheumatology what are the 4 sets of data to classify RA?Joint involvement - number & small or large jointSerology - RF & ACPAAcute phase reactants - CRP & ESRDuration of symptoms - less than or greater than 6 weeksExplain what these 2 classes of medications are & how they work?NSAID (Nonsteroidal Antiinflammatory Drug) – reduce inflammation to decrease pain, swelling, improve function. Do not affect the disease process. GI side effects – dyspepsia, ulcers, cardiovascular risks. See results quickerDMARD (Disease Modifying Antirheumatic Drug) – have potential to decrease joint damage, slow progression of disease, preserve joint function, should be started with 3 months of diagnosis. Cause immunosuppression. Slower onset on action.Why is PT/OT involved so early on when there isn’t a current mobility problem?To help preserve joint function; teach the patient ways to decrease stress on joints; ROM; muscle strengthening; teach appropriate exercisesWhat additional teaching should be completed at this time??This is a chronic progressive disease that can affect other organs and it can impact all areas of life; how to deal with pain, fatigue, and depression that can occur; importance of treatment compliance and follow-up; this disease cannot be cured – but treatment can be very effective; What are examples of NSAIDS & DMARDS that could be used at this time?NSAIDS – naproxen (Naprosyn), ibuprofen (Motrin), celecoxib (Celebrex), meloxicam (Mobic), Diclofenac (Voltaren)DMARDS – hydoxychloroquine (Plaquenil), leflunomide (Arava), methotrexate (Rheumatrex), sulfasalazine (Azulfidine), abatacept (Orencia), rituximab (Rituxan), etanercept (Enbrel), infliximab (Remicade), adalimumab (Humira)Slide 14:Prior to starting this treatment plan what should be evaluated?Cardiovascular risk factors, liver enzymes, CBC, creatinine, pregnancy status, history of GI bleeding, presence of infectionWhat patient teaching is indicated for these medications? Have student’s role play patient teachingLabs – Liver enzymes, Immunizations should be administered prior to DMARD therapy, watch for signs of GI bleeding, watch for signs of infection, compliance with follow-up labs is essential, Methotrexate needs to be taken exactly as presecribed (weekly in this case), take on empty stomachCelebrex – take with foodWhen would these medications be contraindicated?Pregnancy, significant cardiac risk factors or hepatic or renal impairmentSlide 15:Appropriate nursing diagnoses include:Acute or chronic painFatigueImbalanced nutrition: less than body requirementsSleep deprivationActivity intoleranceImpaired physical mobilitySelf-care deficitDisturbed body imageIneffective copingFearAnxietyPowerlessnessRisk for infection related to treatment methodsKnowledge deficit: disease process or treatment Slide 18:What new patient teaching should be included?Humira: Avoid live vaccines while taking itPrior to giving it TB screening should be completedSerious infections can occurTeach self administration – it is a subcutaneous injection (abdomen, rotate sites, needle care/disposal)It should be kept refrigerated Slide 20:What information should be taught to Mrs. About the use/administration of Remicade?It is given via IV infusion over at least a 2 hour period, then repeat in 2 weeks, then at 6 weeks, then every 8 weeksIf she is going to continue to get Remicade regularly a central line (port-a-cath) could be beneficial for herMonitor for infusion related reaction during and for 2 hours after infusion (reactions are more common after 1st or 2nd infusion)Monitor for symptoms of systemic infections/fungal infectionsTB skin test prior to beginning therapyMonitor for reactionsMonitor liver functionMonitor CBC (leukopenia, neutropenia, thrombocytopenia, pancytopenia)Slide 22:What should the nurse monitor for during the initial infusion in regards to a reaction?FeverChillsItchingRashDyspneaHypotension/HypertensionChest painBoth during and for 2 hours following the infusionIf she were to have a reaction what should the nurse do?Stop the infusionCall the MDPrepare to administer antihistamines, corticosteroids, acetaminophen, and/or epinephrineSlide 24:What are some common signs of disease progression? And extra articular signs of RA?To view photos of these deformities please visit neck deformitiesRheumatoid nodulesBoutonniere’s deformityUlnar deformityHallux toesRaynaud’s phenomenon – cold or stress induced vasospasm causing white/blue coloring of fingersSjogren’s syndrome – dry eyes & mucous membranesIncreased risk for cardiac disease (vasculitis, pericarditis) ................
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