A patient with worsening psoriasis and newly suspected psoriatic arthritis presents with significant joint pain and elevated inflammatory markers. The healthcare team is considering introducing a TNF-alpha inhibitor. As a nurse, what is the most important consideration when monitoring this patient after the initiation of etanercept therapy?

A) Monitor for signs of infection, as TNF-alpha inhibitors can increase susceptibility to infections.

B) Check the patient's blood pressure daily to ensure effective control with lisinopril.

C) Schedule regular liver function tests to monitor for potential hepatotoxicity from etanercept.

D) Assess blood glucose levels frequently, as TNF-alpha inhibitors can cause hyperglycemia.

A patient with worsening psoriasis now presents with joint pain and elevated inflammatory markers, suggesting the development of psoriatic arthritis. The nurse is reviewing the patient's medication regimen for potential adjustments. Which intervention should the nurse prioritize to address both the patient's psoriatic arthritis and associated cardiovascular risk?

C) Recommend initiating a TNF-alpha inhibitor like etanercept

A) Increase the dose of lisinopril to better control blood pressure

B) Suggest the addition of methotrexate to manage joint inflammation

C) Recommend initiating a TNF-alpha inhibitor like etanercept

D) Advise starting a statin to lower cardiovascular risk

A patient with a history of psoriasis and psoriatic arthritis is being treated with etanercept and experiences partial improvement in symptoms. However, she reports dizziness, headaches, and has an elevated blood pressure of 148/95 mmHg. Which nursing intervention is most appropriate to address her current health concerns?

B) Instruct the patient to monitor her blood pressure daily and report consistent elevations to her healthcare provider.

A) Encourage the patient to increase her daily fluid intake to manage dizziness.

B) Instruct the patient to monitor her blood pressure daily and report consistent elevations to her healthcare provider.

C) Advise the patient to discontinue etanercept immediately due to side effects.

D) Recommend the patient engage in high-intensity exercise to rapidly decrease her blood pressure.

A patient with psoriatic arthritis is being managed with etanercept and continues to experience elevated blood pressure, dizziness, and headaches. Her liver enzymes are elevated, and blood pressure remains high despite medication adjustments. What should be the nurse's priority action in managing this patient?

B) Consult with the healthcare provider to evaluate potential medication interactions contributing to hypertension.

A) Increase the dose of etanercept to further reduce systemic inflammation.

B) Consult with the healthcare provider to evaluate potential medication interactions contributing to hypertension.

C) Advise the patient to discontinue all medications until further evaluation is completed.

D) Encourage the patient to increase physical activity to assist in reducing blood pressure.

A patient on etanercept therapy presents with new symptoms of fatigue and mild shortness of breath. An echocardiogram reveals mild left ventricular hypertrophy. As a nurse, which of the following interventions should be prioritized to address the patient's cardiovascular health in collaboration with the healthcare team?

A) Educate the patient on the importance of adhering to the prescribed ARB medication to manage blood pressure.

B) Recommend increasing the patient's etanercept dosage to further control joint inflammation and reduce cardiovascular strain.

C) Advise the patient to discontinue all physical activities to prevent exacerbating the cardiovascular condition.

D) Suggest the patient increase sodium intake to help manage blood pressure fluctuations.

A patient on etanercept therapy for rheumatoid arthritis presents with persistent hypertension, fatigue, and mild shortness of breath. The patient's ECG shows premature ventricular contractions and an echocardiogram indicates mild left ventricular hypertrophy. The cardiologist recommends adding an angiotensin receptor blocker (ARB) to her treatment plan. Which nursing intervention is most important in managing this patient's new cardiovascular regimen?

A) Educate the patient on monitoring blood pressure daily and recognizing symptoms of hypotension.

B) Advise the patient to discontinue etanercept immediately to reduce cardiovascular risks.

C) Instruct the patient to increase daily sodium intake to counteract potential ARB side effects.

D) Recommend the patient to limit physical activity until blood pressure is stabilized.

A patient with a history of hypertension and recent initiation of an angiotensin receptor blocker (ARB) presents with mild peripheral edema, jugular venous distention, and an elevated B-type natriuretic peptide (BNP) level. Which nursing intervention is most appropriate to address the current assessment findings?

B) Educate the patient on the importance of low-sodium dietary modifications.

A) Encourage the patient to increase fluid intake to promote kidney function.

B) Educate the patient on the importance of low-sodium dietary modifications.

C) Instruct the patient to discontinue the ARB and report any further symptoms to the healthcare provider.

D) Advise the patient to reduce physical activity to decrease cardiac workload.

A patient with a history of hypertension is on an angiotensin receptor blocker (ARB) and is now experiencing mild peripheral edema and slight jugular venous distention. Lab results show elevated BNP and serum creatinine levels. The healthcare team decides to add low-dose diuretics to her treatment plan. Which nursing intervention is most important to include in the care plan to address the risk of complications associated with this new medication?

B) Monitor daily weight and report any significant increases to the healthcare provider.

A) Encourage the patient to increase fluid intake to prevent dehydration.

B) Monitor daily weight and report any significant increases to the healthcare provider.

C) Advise the patient to take diuretics in the evening to maximize effectiveness.

D) Limit the patient's potassium intake to prevent hyperkalemia.

A patient with heart failure presents with symptoms of persistent peripheral edema, occasional palpitations, and an increase in jugular venous distention. An echocardiogram reveals a mild reduction in ejection fraction. The healthcare team considers adding a beta-blocker to the patient's treatment plan. Which of the following actions should the nurse prioritize to ensure the safe administration of the beta-blocker?

B) Monitor the patient's heart rate and blood pressure before administering the medication.

A) Educate the patient on the importance of maintaining a low-sodium diet.

B) Monitor the patient's heart rate and blood pressure before administering the medication.

C) Advise the patient to avoid potassium-rich foods while on this medication.

D) Instruct the patient to take the medication on an empty stomach to enhance absorption.

A patient with heart failure returns for a follow-up appointment. Her vital signs indicate slightly elevated blood pressure, and she reports feeling fatigued with occasional palpitations. The nurse observes persistent peripheral edema and mild jugular venous distention. An echocardiogram shows a mild reduction in ejection fraction, and BNP levels have increased. After adding a beta-blocker to the treatment regimen, which assessment finding would most likely indicate that the patient is responding positively to the new medication?

A) Decrease in peripheral edema and improved energy levels

B) Increase in heart rate and persistent jugular venous distention

C) Weight gain of 5 pounds over a week and increased BNP levels

D) Development of dizziness and a decrease in blood pressure to 100/60 mmHg

Psoriasis - Nursing Case Study

Pathophysiology

• Primary mechanism: Psoriasis is primarily driven by an overactive immune response where T-cells, a type of white blood cell, mistakenly attack healthy skin cells. This triggers an inflammatory cascade, leading to rapid skin cell proliferation and buildup, forming the characteristic thick, scaly plaques.

• Secondary mechanism: The overproduction of pro-inflammatory cytokines, such as tumor necrosis factor-alpha (TNF-alpha) and interleukins (e.g., IL-17, IL-23), sustains and amplifies the inflammatory response, perpetuating the cycle of rapid skin turnover and plaque formation.

• Key complication: The chronic inflammation in psoriasis can extend beyond the skin, contributing to comorbidities such as psoriatic arthritis and increasing the risk for cardiovascular disease, emphasizing the importance of holistic patient care.

Patient Profile

Demographics:

45-year-old female, construction worker

History:

• Key past medical history: Psoriasis diagnosed 10 years ago, mild hypertension, type 2 diabetes

• Current medications: Methotrexate, topical corticosteroids, metformin, lisinopril

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing severity and coverage of psoriasis plaques

• Key symptoms: Widespread red, scaly patches on skin, joint pain in knees and elbows, fatigue

• Vital signs: Blood pressure 150/95 mmHg, heart rate 88 bpm, respiratory rate 18 breaths per minute, temperature 98.6°F

Section 1

As the patient's psoriasis worsens, she presents to the clinic with new symptoms suggestive of developing psoriatic arthritis, a known complication of her condition. During the initial assessment, the nurse notes the patient's significant joint pain, particularly in the knees and elbows, alongside morning stiffness lasting over 30 minutes, indicating inflammatory rather than mechanical joint pain. The patient's skin plaques have become more extensive and inflamed, now covering over 10% of her body surface area. The nurse also observes mild swelling and tenderness in the affected joints, suggesting synovitis. The patient's blood pressure remains elevated at 152/97 mmHg, despite adherence to her lisinopril regimen, raising concerns about the inflammatory burden contributing to her cardiovascular risk.

Laboratory tests reveal elevated inflammatory markers, with an erythrocyte sedimentation rate (ESR) of 45 mm/hr and a C-reactive protein (CRP) level of 12 mg/L, both indicating significant systemic inflammation. Additionally, a comprehensive metabolic panel shows slightly elevated liver enzymes, which could be a side effect of methotrexate, necessitating careful monitoring. The patient's hemoglobin A1c is 7.8%, reflecting suboptimal control of her type 2 diabetes, likely exacerbated by chronic inflammation and stress.

Given these findings, the healthcare team considers adjusting her treatment plan to better address both her psoriasis and emerging psoriatic arthritis. The introduction of a TNF-alpha inhibitor, such as etanercept, is contemplated to target the underlying inflammatory processes more effectively. The team also discusses the importance of lifestyle modifications, including weight management and stress reduction, to help lower her cardiovascular risk and enhance overall well-being. This comprehensive approach aims to alleviate her symptoms, improve her quality of life, and prevent further complications associated with her chronic conditions.

Section 2

Several weeks into the adjusted treatment plan, the patient returns to the clinic for a follow-up appointment. Upon assessment, the nurse notes that the patient's joint pain has shown partial improvement with the introduction of the TNF-alpha inhibitor, etanercept, but she still experiences some morning stiffness, now lasting about 20 minutes. The extensive skin plaques have begun to recede, covering less than 8% of her body surface area, indicating a positive response to the biologic therapy. However, the patient reports occasional episodes of dizziness and headaches, which prompts the healthcare team to further investigate her elevated blood pressure.

Repeat laboratory tests show a slightly improved inflammatory profile, with an ESR of 38 mm/hr and a CRP level of 8 mg/L, suggesting a reduction in systemic inflammation. However, her liver enzyme levels remain elevated, and a follow-up liver function test reveals an ALT of 65 U/L and an AST of 52 U/L, necessitating continued monitoring. Her hemoglobin A1c has decreased to 7.4%, indicating better glycemic control, but still not at the optimal target. The patient's blood pressure remains elevated at 148/95 mmHg, despite the medication adjustments, raising suspicion of an additional underlying cause contributing to her hypertension, possibly related to the chronic inflammatory state or the medications.

The healthcare team decides to address these ongoing issues by consulting with a cardiologist to optimize her blood pressure management and consider potential medication interactions or side effects. Additionally, the patient is referred to a dietitian to reinforce dietary modifications that can aid in weight management and further control blood sugar levels. This comprehensive and interdisciplinary approach aims to enhance the patient's overall management plan by addressing both the immediate symptoms and the underlying chronic conditions, setting the stage for further evaluation and adjustment as necessary.

Section 3

As the patient continues her treatment plan with etanercept and lifestyle adjustments, she returns to the clinic for a routine follow-up. During her visit, the nurse conducts a thorough assessment and notes that while the patient’s joint pain remains manageable, she reports new symptoms of fatigue and mild shortness of breath during daily activities. Her vital signs reveal a blood pressure of 150/92 mmHg, heart rate of 88 beats per minute, respiratory rate of 20 breaths per minute, and oxygen saturation of 95% on room air. These findings, coupled with her persistent hypertension, prompt further investigation into her cardiovascular status.

The healthcare team decides to perform a comprehensive cardiovascular evaluation, including an electrocardiogram (ECG) and an echocardiogram. The ECG shows normal sinus rhythm but with occasional premature ventricular contractions, while the echocardiogram reveals mild left ventricular hypertrophy, a potential consequence of sustained high blood pressure. These results suggest that the patient’s chronic inflammatory state and possibly the TNF-alpha inhibitor therapy might be contributing to her cardiovascular strain, warranting a careful reassessment of her treatment plan.

In light of these new findings, the cardiologist recommends adjusting her antihypertensive regimen to include an angiotensin receptor blocker (ARB) to better manage her blood pressure and protect her heart function. Additionally, the dietitian emphasizes the importance of reducing sodium intake and increasing cardiovascular exercise, tailored to her current physical capabilities, to support her heart health and overall wellness. This integrative approach aims to stabilize her cardiovascular condition and mitigate further complications, setting a proactive course for her ongoing care.

Section 4

As the patient continues her adjusted treatment plan, she returns for another follow-up appointment after six weeks. The nurse notes that the patient appears more energetic and reports an improvement in her shortness of breath since starting the angiotensin receptor blocker (ARB) and adhering to dietary modifications. However, during the physical assessment, the nurse observes mild peripheral edema in the patient's lower extremities and notices slight jugular venous distention. These findings prompt further evaluation to ensure the cardiovascular interventions are effectively addressing her condition.

Lab work is ordered to assess her kidney function, electrolytes, and inflammatory markers. The results reveal an elevated B-type natriuretic peptide (BNP) level of 150 pg/mL, suggesting some degree of cardiac stress. Her serum creatinine is slightly elevated at 1.4 mg/dL, indicating a potential decline in renal function, likely exacerbated by her antihypertensive therapy. These lab results, coupled with the physical assessment findings, suggest the possibility of early heart failure symptoms, necessitating closer monitoring and a possible re-evaluation of her medication regimen.

The healthcare team decides to initiate low-dose diuretics to alleviate fluid retention and monitor her response closely. The nurse educates the patient on recognizing signs of worsening heart failure, such as increased swelling, rapid weight gain, or severe shortness of breath. By maintaining open communication with her healthcare providers and adhering to her revised treatment plan, the patient is empowered to manage her health proactively, reducing the risk of further complications. The team schedules a follow-up in two weeks to reassess her response to these interventions and ensure her condition is improving.

Section 5

Two weeks later, the patient returns for her scheduled follow-up appointment. The nurse begins the assessment by noting the patient's vital signs: blood pressure is slightly elevated at 142/88 mmHg, heart rate is 88 beats per minute, respiratory rate is 18 breaths per minute, and oxygen saturation is 96% on room air. The patient reports feeling slightly more fatigued than usual and mentions experiencing occasional palpitations. During the physical assessment, the nurse observes that the peripheral edema in the patient's lower extremities has persisted, and there is now a mild increase in jugular venous distention compared to the previous visit.

Given these findings, the healthcare team decides to conduct further diagnostic testing, including an echocardiogram to evaluate cardiac function and a repeat BNP test to assess the level of cardiac stress. The echocardiogram reveals a mild reduction in ejection fraction, suggesting a decrease in the heart's pumping capability. The repeat BNP level has increased to 180 pg/mL, indicating ongoing cardiac strain. These results confirm that the patient's heart failure symptoms are not adequately controlled and suggest that the current treatment plan may need adjustment.

In response to these developments, the healthcare team discusses the possibility of adding a beta-blocker to the patient's medication regimen to help improve heart function and reduce cardiac workload. The nurse provides education on the new medication, emphasizing the importance of adherence and monitoring for potential side effects, such as bradycardia or dizziness. The team also reinforces the need for the patient to continue monitoring her weight daily and report any sudden increases, as well as any new or worsening symptoms. A follow-up appointment is scheduled in another two weeks to reassess the patient's response to the revised treatment plan and to ensure that intervention adjustments are effectively managing her condition.