2. I MMUNITY : R HEUMATOID A RTHRITIS A C ASE S TUDY Beth Downing, MSN, RN-BC, ONC

3. O BJECTIVES Demonstrate understanding of the progression and treatment of rheumatoid arthritis (RA). Utilize the nursing process to plan care for a client diagnosed with rheumatoid arthritis.

4. Gail Stevens is a 47 yr old Caucasian female who has been having pain in both hands, with stiffness and tenderness that is worse in the morning. She also reports having a poor appetite and being fatigued easily.

5. What is significant about this report that leads you to RA? What additional nursing assessment data would be significant?

6. H ISTORY M EDICATIONS Mild osteoarthritis (bilateral knees) Laparoscopic cholecystectomy T&A as a child Ibuprofen 2 tabs prn pain MVI daily

7. Mrs. Stevens has mild OA and is now being diagnosed with RA; explain the differences to her.

8. O THER P ERTINENT I NFO Married with 2 children; ages 16 & 20 Currently a loan officer at a bank Active at the local community center Denies ETOH or tobacco use No significant family history NKDA

9. D IAGNOSTICS ?? Complete blood count (CBC) C-reactive protein (CRP) Erythrocyte sedimentation rate (ESR) Rheumatoid factor (RF) Anti-citrullinated protein antibody (ACPA) Synovial fluid analysis Xray

10. How will these laboratory values be affected or how will they assist in the diagnosis of RA?

11. T REATMENT OPTIONS Diagnosed with early RA PT/OT consult Pharmacological treatment NSAID &DMARD

12. According to the American College of Rheumatology what are the 4 sets of data to classify RA? Explain what these 2 classes of medications are (NSAIDS & DMARDS) & how they work? Why is PT/OT involved so early on when there isn’t a current mobility problem? What additional teaching should be completed at this time? What are examples of NSAIDS & DMARDS that could be used at this time?

13. NSAID & DMARD T REATMENT Celebrex 100 mg po bid Methotrexate 7.5 mg po each week for the first 3 months, then increase to 10 mg po each week

14. Prior to starting this treatment plan what should be evaluated? What patient teaching is indicated for these medications? Have student role play patient teaching When would these medications be contraindicated?

15. N URSING D IAGNOSES ???

16. 2 YEARS LATER Mrs. Stevens RA has been well controlled for the past few years. She continues to take the Methotrexate & Celebrex; is in a water aerobics class 4 days a week and walks daily. However, Mrs. Stevens is complaining of increased pain and swelling of both hands and feet. Her fatigue is worsening and she has lost 10 lbs in the past few months.

17. T REATMENT PLAN … Increase: Methotrexate 15 mg po q week Celebrex to 200 mg po bid Add: Humira 40 mg subcut every other week

18. What new patient teaching should be included?

19. T REATMENT PLAN … Mrs. Stevens is not compliant with the Humira because she is having a difficult time giving herself injections. Her physician would like to start her on infliximab (Remicade) now to see if she has better success. She is scheduled to begin her first treatment tomorrow.

20. What information should be taught to Mrs. Stevens about the use/administration of Remicade?

21. R EMICADE INFUSION Mrs. Stevens is preparing to receive her first dose of Remicade in the outpatient infusion care center. She has been talking to a friend who knows someone who had a reaction to Remicade and is concerned that she will have a reaction as well.

22. What should the nurse monitor for during the initial infusion in regards to a reaction? If she were to have a reaction what should the nurse do?

23. D ISEASE PROGRESSION Remicade is effective and she is not having any reactions. Mrs. Stevens has been continuing on the same treatment plan. The disease process is slowly progressing. She is beginning to see additional signs of RA.

24. What are some common signs of disease progression and extra articular signs of RA? (To view photos of these deformities please visit http://images.rheumatology.orghttp://images.rheumatology.org

25. R EFERENCES North Carolina Concept-Based Learning Editorial Board. (2011). Nursing: A Concept- Based Approach to Learning. Volume 1 & 2. Pearson Publishing. Smeltzer, S., Bare, B., Hinkle, J., Cheever, K. (2010). Brunner and Suddarth’s Medical Surgical Nursing. 12 th ed. Lippincott, Williams & Wilkins.