A patient with rheumatoid arthritis is being treated with methotrexate. Which of the following is an important aspect of the nursing care plan for this patient?

C) Educate the patient on the importance of regular laboratory tests to monitor methotrexate effects

A) Encourage the patient to increase protein intake to build muscle mass

B) Advise the patient to avoid sunlight exposure due to photosensitivity risks

C) Educate the patient on the importance of regular laboratory tests to monitor methotrexate effects

D) Recommend the patient to perform high-impact exercises to improve joint function

What is the primary reason for advising the patient with rheumatoid arthritis to continue taking methotrexate?

B) To manage symptoms and prevent disease progression

A) To cure rheumatoid arthritis

B) To manage symptoms and prevent disease progression

D) To eliminate the need for follow-up appointments

What is the primary reason for administering folic acid to a patient receiving methotrexate therapy for rheumatoid arthritis?

B) To prevent folic acid deficiency and reduce side effects

A) To enhance the efficacy of methotrexate

B) To prevent folic acid deficiency and reduce side effects

C) To increase the absorption of methotrexate

D) To promote faster joint healing

Which of the following is an important nursing intervention for a patient taking methotrexate for rheumatoid arthritis?

B) Advise the patient to report any signs of infection promptly

A) Encourage the patient to increase their vitamin C intake

B) Advise the patient to report any signs of infection promptly

C) Recommend stopping methotrexate if fatigue increases

D) Suggest reducing physical activity to prevent joint stiffness

Which action is most important for the nurse to take when monitoring a patient on methotrexate therapy for rheumatoid arthritis?

B) Monitor liver enzyme levels regularly

A) Encourage increased intake of vitamin C-rich foods

B) Monitor liver enzyme levels regularly

C) Advise the patient to avoid strenuous exercise

D) Recommend a daily multivitamin supplement

What is the primary reason for monitoring liver enzyme levels in a patient taking methotrexate for rheumatoid arthritis?

A) To assess for potential liver damage

C) To monitor for signs of infection

D) To determine the effectiveness of methotrexate

Which of the following symptoms reported by the patient suggests a positive response to her current treatment plan for early-stage rheumatoid arthritis?

A) Morning stiffness resolving within an hour

B) Occasional fatigue in the afternoons

C) Mild swelling of the metacarpophalangeal joints

Which intervention is most appropriate for the nurse to prioritize for a patient with early-stage rheumatoid arthritis experiencing mild joint swelling and occasional fatigue?

B) Educate the patient on the importance of rest and energy conservation

A) Encourage increased fluid intake to promote hydration

B) Educate the patient on the importance of rest and energy conservation

C) Suggest reducing corticosteroid dosage to alleviate side effects

D) Advise the patient to limit physical activity to reduce joint stress

Which of the following vital signs indicates the patient's condition is stable during her follow-up visit?

B) Heart rate of 74 beats per minute

A) Blood pressure of 140/90 mmHg

B) Heart rate of 74 beats per minute

D) Blood pressure of 160/100 mmHg

During a follow-up appointment, a nurse notes that a patient with early-stage rheumatoid arthritis has mild tenderness in her wrists but no significant progression of joint damage on X-ray. Which action should the nurse prioritize based on this assessment?

B) Encourage the patient to maintain her exercise routine

A) Discontinue the current medication regimen

B) Encourage the patient to maintain her exercise routine

C) Prepare the patient for immediate joint surgery

D) Suggest the patient increase her medication dosage without consulting the healthcare provider

Rheumatoid arthritis - Nursing Case Study

Pathophysiology

• Primary mechanism: Rheumatoid arthritis (RA) is an autoimmune disorder where the immune system mistakenly attacks the synovium, the lining of the joints, leading to inflammation. This chronic inflammation causes the synovial cells to proliferate, resulting in a thickened synovium and joint swelling.

• Secondary mechanism: The inflamed synovium releases enzymes that degrade cartilage and bone within the joint, leading to erosion. This destruction contributes to joint deformity and loss of function over time.

• Key complication: Persistent inflammation and joint damage can result in reduced mobility and chronic pain, significantly impacting quality of life. Early intervention and treatment are crucial to prevent severe joint damage and maintain functionality.

Patient Profile

Demographics:

58-year-old female, office administrator

History:

• Key past medical history: Diagnosed with rheumatoid arthritis 6 months ago, no other significant medical history

• Current medications: Methotrexate 10 mg once weekly, folic acid 1 mg daily

• Allergies: No known drug allergies

Current Presentation:

• Chief complaint: Joint stiffness and mild pain in hands

• Key symptoms: Morning stiffness lasting around 30 minutes, mild swelling in fingers, no significant fatigue

• Vital signs: Blood pressure 120/80 mmHg, heart rate 72 bpm, respiratory rate 16 breaths per minute, temperature 98.6°F

Section 1

Following her initial diagnosis, the patient has been maintaining regular follow-up appointments to monitor her condition and adjust her treatment plan as necessary. During a recent visit, the nurse conducted a thorough initial assessment to evaluate the current state of her rheumatoid arthritis. The patient reports that, while the methotrexate has helped in reducing the severity of her symptoms, she still experiences occasional episodes of joint stiffness and mild pain, particularly in her hands and wrists. On assessment, the nurse notes mild swelling and tenderness in the metacarpophalangeal joints, but no visible deformities or significant loss of joint function at this stage. The patient's grip strength is slightly reduced, but she is able to perform daily activities without major difficulty.

Vital signs remain stable with blood pressure at 118/78 mmHg, heart rate at 70 bpm, respiratory rate at 16 breaths per minute, and temperature at 98.4°F. The nurse educates the patient on the importance of continuing her current medication regimen, emphasizing adherence to methotrexate and folic acid to manage symptoms and prevent progression. Additionally, the nurse advises on lifestyle modifications, such as incorporating gentle exercises and joint protection techniques, to enhance mobility and reduce strain on affected joints. The patient expresses understanding and a positive attitude towards managing her condition, highlighting the importance of ongoing education and support in maintaining her quality of life.

The nurse also discusses the potential need for periodic laboratory tests to monitor methotrexate's effects and any possible side effects, such as liver function tests and complete blood counts. This ongoing monitoring is crucial to ensure the medication's efficacy and safety. As part of the care plan, the nurse schedules a follow-up appointment to reassess the patient's symptoms and evaluate the need for any adjustments to her treatment strategy, fostering a proactive approach towards her rheumatoid arthritis management.

Section 2

Several weeks after the initial follow-up, the patient returns for her scheduled appointment, during which the nurse notes a change in her status. The patient reports experiencing increased fatigue and slightly more frequent episodes of joint stiffness, particularly in the morning, which last about an hour before subsiding. Despite these symptoms, she remains capable of performing her daily activities, albeit with a bit more effort. Her vital signs remain stable, with blood pressure at 116/80 mmHg, heart rate at 72 bpm, respiratory rate at 18 breaths per minute, and temperature at 98.2°F. However, the nurse observes slightly increased swelling and tenderness in the metacarpophalangeal joints compared to the previous assessment.

The nurse reviews the results of the recent laboratory tests, which reveal mildly elevated liver enzymes, indicating the need for careful monitoring of methotrexate's impact on the patient's liver function. The complete blood count shows a mild decrease in white blood cells, suggesting some level of immunosuppression, which is a known side effect of methotrexate. These findings prompt the nurse to discuss with the patient the importance of reporting any signs of infection promptly and to reinforce the need for continued adherence to prescribed folic acid, which can help mitigate some side effects of methotrexate.

Given the current status, the nurse collaborates with the healthcare team to consider a possible adjustment in the patient's medication regimen. Options include evaluating the dose of methotrexate or exploring additional treatments to better manage the symptoms and prevent further complications. The patient is advised to maintain her exercise routine and continue practicing joint protection techniques. A follow-up appointment is scheduled to closely monitor her symptoms and laboratory values, ensuring a comprehensive approach to managing her rheumatoid arthritis and maintaining her quality of life.

Section 3

As the nurse conducts a thorough assessment during the patient's follow-up visit, she notes that the patient is maintaining her weight and appears well-nourished, which is positive for her overall health in managing rheumatoid arthritis. However, the patient reports that her morning stiffness has slightly worsened over the past week, lasting up to an hour and a half before she feels relief. Additionally, she mentions experiencing mild discomfort when engaging in activities that require fine motor skills, such as buttoning clothing or writing. Despite these challenges, she remains committed to her daily tasks and exercise routine, although with increased effort.

The nurse also reviews the patient's latest laboratory results, which show a further slight increase in liver enzymes. While still within a manageable range, this change necessitates closer monitoring to prevent any potential liver damage from methotrexate. The complete blood count indicates a stable but slightly reduced white blood cell count, reinforcing the importance of monitoring for signs of infection. In light of these findings, the healthcare team decides to adjust the patient's methotrexate dosage, reducing it slightly to alleviate potential liver strain while maintaining its therapeutic effects. Additionally, they discuss the potential introduction of a low-dose corticosteroid to help manage the increased joint stiffness and swelling.

The patient expresses her understanding of the medication adjustments and the significance of adhering to her treatment plan, including the continued use of folic acid to mitigate side effects. She appreciates the comprehensive approach taken by the healthcare team and agrees to report any new or worsening symptoms promptly. The nurse schedules her for another follow-up appointment in four weeks, emphasizing the importance of ongoing monitoring and communication. This plan aims to optimize the patient's quality of life while minimizing the risk of further complications, ensuring a balanced approach to managing her early-stage rheumatoid arthritis.

Section 4

At the follow-up appointment four weeks later, the nurse conducts an initial assessment of the patient, noting several key findings that indicate both progress and areas of concern. The patient's vital signs are stable, with a blood pressure of 120/80 mmHg, heart rate of 76 beats per minute, and a temperature of 98.6°F. Despite these stable vital signs, the patient reports that her morning stiffness now resolves within an hour, a slight improvement from the previous visit. She also mentions that her discomfort during fine motor activities has decreased, allowing her to manage daily tasks with less effort. These improvements suggest a positive response to the recent medication adjustments.

However, the nurse observes mild swelling in the patient's metacarpophalangeal joints, and the patient reports occasional fatigue, particularly in the afternoons. These symptoms prompt the nurse to review the recent laboratory results, which reveal that the patient's liver enzymes have returned to normal levels following the methotrexate dosage adjustment, indicating effective management of the medication's side effects. Her complete blood count shows a slightly improved white blood cell count, though still lower than ideal, reinforcing the need for ongoing infection monitoring.

The nurse and healthcare team decide to continue the low-dose corticosteroid treatment, as it appears to be effectively managing joint stiffness and swelling. They also emphasize the importance of the patient's exercise routine and balanced diet in maintaining her overall health and joint function. The patient is encouraged to continue monitoring her symptoms and to maintain open communication with the healthcare team, ensuring any new or worsening symptoms are addressed promptly. This careful coordination of care aims to further enhance the patient's quality of life and prevent any new complications as they manage her early-stage rheumatoid arthritis.

Section 5

In the subsequent weeks, the patient continues to attend regular follow-up appointments, during which the nurse conducts thorough assessments to monitor her condition. At her latest visit, the patient reports that her energy levels have improved, with less frequent afternoon fatigue, indicating a positive response to her current medication regimen. Her vital signs remain stable, with a blood pressure of 118/78 mmHg, a heart rate of 74 beats per minute, and a temperature of 98.4°F, suggesting that her overall health is well maintained.

However, the nurse notes that while the swelling in the metacarpophalangeal joints has slightly decreased, there is now mild tenderness in the patient's wrists, which was not present during previous assessments. This new symptom raises a concern of potential joint involvement progression, which prompts the healthcare team to order additional diagnostic tests, including an updated X-ray of the hands and wrists, as well as inflammatory markers such as C-reactive protein (CRP) and erythrocyte sedimentation rate (ESR).

The results of these diagnostic tests reveal a slight increase in the ESR, suggesting mild inflammation, while the X-ray shows no significant progression of joint damage. This finding reassures the team that while inflammation is present, it is not yet causing significant structural changes. Consequently, the nurse and healthcare team decide to maintain the current treatment plan but emphasize the importance of regular monitoring. They also encourage the patient to continue her exercise regimen and stress management techniques to help control inflammation and support her overall well-being. The patient is advised to promptly report any new symptoms, ensuring they are addressed before complications arise. This proactive approach aims to maintain the patient's quality of life and prevent further complications as she continues to manage her early-stage rheumatoid arthritis.