Question

A 72-year-old woman (height 66 inches, weight 82 kg) whose medical history is significant for rheumatoid arthritis (RA), asthma, gastroesophageal reflux disease, and hypothyroidism presents to the clinic with inflammation of the joints of the hands and stiffness lasting 1–2 hours in the morning. She is a smoker. Her current medications include pantoprazole 40 mg daily, salbutamol inhalation 200 micrograms twice daily, levothyroxine 100 mcg daily, methotrexate 12.5 mg weekly, naproxen 500 mg twice daily, calcium 600 mg twice daily, and vitamin D 1000 units twice daily. Her laboratory tests show a negative rheumatoid factor (RF) but positive anti-cyclic citrullinated peptides. Her lab results showed pancytopenia.

1. List: Relevant information, like key lab values/symptoms from the case.

2. Assessment: Identification of 3 problems in drug therapy.

3. Care Plan: Preparing the most appropriate care plan for the patient considering the patient-specific factors.

4. Monitoring: List the safety and efficacy monitoring required, this could be also monitoring a lab value or a prognostic indicator like a change of a symptom.

Answer 1

1. Lab values from the case :-

- RF factor is negative

- Anti -cyclic citrullinated peptides are positive

- Pancytopenia

#. Symptoms from the case are :-

- inflammation of the joints of the hands

- stiffness lasting 1-2 hrs in the morning

3. Nursing care plan :-

a) Reducing pain :-

Provide a variety of comfort measures (eg, application of heat or cold; massage, position changes, rest; foam mattress, supportive pillow, splints; relaxation techniques, diversional activities).

Administer anti-inflammatory, analgesic, and slow-acting antirheumatic medications as prescribed.

Individualize medication schedule to meet patient’s need for pain management.

Encourage verbalization of feelings about pain and chronicity of disease.

Teach pathophysiology of pain and rheumatic disease, and assist patient to recognize that pain often leads to unproven treatment methods.

Assist in identification of pain that leads to use of unproven methods of treatment.

Assess for subjective changes in pain.

b) Reducing Fatigue :-

Provide instruction about fatigue: Describe relationship of disease activity to fatigue; describe comfort measures while providing them; develop and encourage a sleep routine (warm bath and relaxation techniques that promote sleep); explain importance of rest for relieving systematic, articular,

and emotional stress.

Explain how to use energy conservation techniques (pacing, delegating, setting priorities).

Identify physical and emotional factors that can cause fatigue.

Facilitate development of appropriate activity/rest schedule.

Encourage adherence to the treatment program.

Refer to and encourage a conditioning program.

Encourage adequate nutrition, including source of iron from food and supplements.

c) Increasing Mobility :-

Encourage verbalization regarding limitations in mobility.

Assess need for occupational or physical therapy consultation: Emphasize range of motion of affected joints; promote use of assistive ambulatory devices; explain use of safe footwear; use individual appropriate positioning/posture.

Assist to identify environmental barriers.

Encourage independence in mobility and assist as needed: Allow ample time for activity; provide rest period after activity; reinforce principles of joint protection and work simplification.

Initiate referral to community health agency.

d) Facilitating Self Care :-

Assist patient to identify self-care deficits and factors that interfere with ability to perform self-care activities.

Develop a plan based on the patient’s perceptions and priorities on how to establish and achieve goals to meet self-care needs, incorporating joint protection, energy conservation, and work simplification concepts: Provide appropriate assistive devices; reinforce correct and safe use of assistive devices; allow patient to control timing of self-care activities; explore with the patient different ways to perform difficult tasks or ways to enlist the help of someone else.

Consult with community health care agencies when individuals have attained a maximum level ofself-care yet still have some deficits, especially regarding safety.

d) Improving Body Image and Coping Skills :-

Help patient identify elements of control over disease symptoms and treatment.

Encourage patient’s verbalization of feelings, perceptions, and fears.

Identify areas of life affected by disease. Answer questions and dispel possible myths.

Develop plan for managing symptoms and enlisting support of family and friends to promote daily function.

4) Monitoring and Managing Potential Complications

Help patient recognize and deal with side effects from medications.

Monitor for medication side effects, including GI tract bleeding or irritation, bone marrow suppression, kidney or liver toxicity, increased incidence of infection, mouth sores, rashes, and changes in vision. Other signs and symptoms include bruising, breathing problems, dizziness, jaundice, dark urine, black or bloody stools, diarrhea, nausea and vomiting, and headaches.

Monitor closely for systemic and local infections, which often can be masked by high doses of corticosteroids.