Case Study Rheumatoid Arthritis

Case Study: Rheumatoid Arthritis Mary Ellen Menke Learning Objectives: 1. Discuss the pathophysiology related to rheumatoid arthritis. 2. Describe effects and side effects of the following drugs used in treatment of rheumatoid arthritis: Prednisone, Naprosyn, and Methotrexate. 3. Analyze the data for the patient experiencing hemorrhage and determine the nurse’s immediate interventions 4. Describe the teaching needs of the client with rheumatoid arthritis. 5. Describe the teaching needs of the client with rheumatoid arthritis. 6. Discuss resources that the client could use to care for herself and her mother. 7. Discuss discrimination in hiring practices of nurses with chronic illness. Case Mary Ellen Menke is a 20-year-old single patient with a history of rheumatoid arthritis. She lives with her mother who has metastatic cancer, and Mary Ellen is the primary caregiver. Lately she has been complaining of joint pain and weakness which she attributes to the lifting and care giving of her mother. Her hands and feet are swollen and tender, and currently she has painful knees and hips. She has a marked swan neck deformity of the right index finger and mild ulnar deviation. Her current medications include Prednisone 5mg bid po. Naprosyn 375 mg. bid po, and Methotrexate 75 mg weekly. Focus Questions: 1. Correlate the symptoms that Mary Ellen exhibits and explain in “lay terms” what arthritis is and what lifestyle modifications are indicated. a. Her symptoms that correlate with rheumatoid arthritis are her joint pain and weakness, her painful swollen joints, and her “swan neck” of her right finger. b. For unknown reasons, the body mistakenly attacks itself (autoimmune reaction), causing cells in the fluid in joints to break down (synovial fluid cells to hypertrophy) causing inflammation. c. The pt needs to eat a well balanced diet and maintain a healthy weight. If the pt is overweight or obese they need to lose weight to reduce stress on the joints. Exercising ROM while conserving energy to help maintain mobility. A physical therapy program could be helpful. Rest is important during flare ups to give the joints a chance to recover. 2. What are the actions and side effects associated with her medications? a. Prednisone i. Action – suppresses inflammation and the normal immune response. Suppresses adrenal function at chronic doses of 5mg/day. Replaces endogenous cortisol in deficiency states. Has minimal mineralocorticoid activity. ii. Side effects – depression, euphoria, headache, personality changes, psychoses, restlessness, cataracts, increased intraocular pressure, hypertension, peptic ulceration, anorexia, nausea, vomiting, acne, decreased wound healing, ecchymoses, fragility, hirsutism, petechiae, adrenal suppression, hyperglycemia, fluid retention, hypokalemia, hypokalemic alkalosis, THROMBOEMBOLISM, thrombophlebitis, weight gain/loss, muscle wasting, osteoporosis, avascular necrosis of joints, muscle pain, cushingoid appearance. b. Naprosyn i. Action – inhibits prostaglandin synthesis. Therapeutic – decreased pain, reduction of fever, suppression of inflammation. ii. Side effects – dizziness, drowsiness, headache, tinnitus, visual disturbances, dyspnea, edema, palpitations, tachycardia, DRUG-INDUCED HEPATITIS, GI BLEEDING, constipation, dyspepsia, nausea, anorexia, diarrhea, discomfort, flatulence, vomiting, cystitis, hematuria, renal failure, photosensitivity, rashes, sweating, pseudopophyria, blood dyscrasias, prolonged bleeding time, allergic reactions. c. Methotrexate i. Action – interferes with folic acid metabolism. Result is inhibition of DNA synthesis and cell reproduction. Also has immunosuppressive activity. Therapeutic – death of rapidly replicating cells, particularly malignant ones, and immunosuppression. ii. Side effects – arachnoiditis, dizziness, drowsiness, headache, malaise, seizures, blurred vision, dysarthriatransient blindness, PULMONARY FIBROSIS, interstitial pneumonitis, HEPATOTOXICITY, anorexia, diarrhea, nausea, stomatitis, vomiting, acute renal failure, infertility, ERYTHEMA MULTIFORME, STEVENS-JOHNSON SYNDROME, TOXIC EPIDERMAL NECROLYSIS, alopecia, painful plaque erosiions, photosensitivity, pruritus, rashes, skin ulceration, urticaria, APLASTIC ANEMIA, anemia, leukopenia, thrombocytopenia, hyperuricemia, osteonecrosis, stress fracture, nephropathy, chills, fever, soft tissue necrosis Case Mary Ellen was brought to the emergency room by a neighbor. She has had two episodes of syncope and is complaining of weakness. Vital signs are BP 130/75, P100, R28, T1000 . When asked if she has had any other symptoms, she reports right epigastric pain. While the nurse is away admitting another patient, Mary Ellen goes to the bathroom. When the nurse enters the room, she hears a loud thud followed by a cry to help. The nurse finds Mary Ellen on the floor in the bathroom. She denies being hurt and says, “I just got so dizzy. I think I hit may head.” The nurse notes a black liquid stool in the toilet. After helping Mary Ellen back to bed, Mary Ellen exclaims, “I am going to be sick.” She immediately vomits a large amount of bright red emesis into the bath basin that is sitting on the bedside table. Her vital signs are now: B/P 80/40, P120, R32, T100.40. Her skin is cool clammy, and pale. The nurse notes that Mary Ellen seems confused about where she is. Focus Questions: 1. What does the data indicate is happening? Why do you think this episode occurred? a. The symptoms suggest she is having an active GI bleed, possibly an ulcer. It was likely due to the patient taking methotrexate and Naprosyn. One of the black box warnings for methotrexate is GI problems. 2. What immediate interventions are necessary and what should the nurse anticipate happening next? a. I would anticipate that the pt would have some type of testing to see where the bleeding is originating, such as an endoscopy or colonoscopy. b. Immediate interventions. i. Ensure two IVs in place for blood administration, fluids, antibiotics (if needed), electrolyte replacement, protonix gtt, etc… ii. Make sure pt’s type & screen is current; transfuse as necessary iii. Prep patient for endoscopy (either EGD or colonoscopy) iv. Prep patient for interventional radiology if problem can’t be treated by traditional endoscopy v. Anticipate patient being NPO initially, then clears, then advance as tolerated vi. Administer medications such as protonix, antifungals and antibiotics as needed vii. Replace fluids and electrolytes viii. Anticipate many many trips to the bedside commode (or many many clean-up projects). Blood in the GI tract is very irritating, which leads to increased gastric motility. Case Four days later Mary Ellen is stable on a medical unit. She has improved dramatically from the complication of a bleeding ulcer and is to be discharged in the morning. She shows the nurse a copper bracelet a friend brought to help control her disease. She states, “My friend thinks this bracelet will cure my arthritis, what do you think?” Focus Questions: 1. What teaching needs related to the management of rheumatoid arthritis should be discussed with Mary Ellen prior to discharge? How should the nurse respond to her question? a. The pt should be taught to ask her provider about her medications and side effects to learn more and ensure she knows when to report symptoms. Rest when needed, use ice or heat for pain and swelling, elevate joints, eat a variety of healthy foods, maintain a healthy weight to decrease the strain on joints, go to physical or occupational therapy as directed. Do not smoke, the chemicals in cigarettes can damage your bones and joints. b. The pt needs to be educated that there is no “cure” for arthritis, but there are ways to manage it and the symptoms. It might be possible that the copper bracelet manages some of the symptoms but there is no evidence based practice to support that.(I personally couldn’t find anything about wearing a copper bracelet so this would be my response.) c. 2. What resources could the nurse help Mary Ellen connect with to assist her in managing her disease as well as assisting with her mother? a. She should be given referals for physical and occupational therapy, and resources regarding support groups. For her mother, it should be suggested (and given some type of info or referral) she get some type of home health nurse, hospice (if necessary), or potentially a nursing home. Reflective Writing You are a nurse manager on a medical unit. You are currently hiring a staff nurse. There are two applicants qualified for the position. One of the candidates alludes to the fact that she has rheumatoid arthritis. Your supervisor tells you to hire the other candidate because people with rheumatoid arthritis are always sick and will not be able to pull their own weight on the unit. How do you feel about her suggestion? What are the ethical and legal implications? I don’t think it is right for her to judge someone because they have a disease. I personally don’t believe that the candidate would apply for a job she didn’t believe she could do. However, I also don’t think that it right that she alluded to the fact that she had rheumatoid arthritis. From a legal standpoint, it is considered Employment Discrimination on the Basis of a Medical Condition and is illegal on under both state and federal laws. Ethically, it gets complicated. The candidate should have disclosed she has rheumatoid arthritis. The nurse manager should not deny the candidate due to her medical condition and should not assume the patient can’t pull their own weight. However, since the candidate didn’t initially disclose that she has a medical condition that could potentially affect her work; was the nurse manager really wrong to hire the other candidate?