A patient with rheumatoid arthritis is being evaluated for changes in her treatment plan due to increased joint pain and stiffness, despite current therapy. She reports morning stiffness lasting over two hours and significant fatigue. Laboratory results indicate elevated inflammatory markers and mild anemia. Which nursing intervention is most appropriate to address her current symptoms and support her treatment plan?

A) Encourage the patient to perform gentle range-of-motion exercises each morning

B) Advise the patient to increase her dietary protein intake to combat anemia

C) Suggest scheduling activities during the afternoon to minimize fatigue

D) Recommend the patient take NSAIDs regularly to manage pain and inflammation

A patient with rheumatoid arthritis presents with increasing joint pain and stiffness, significant swelling in the hands and wrists, and morning stiffness lasting over two hours. Laboratory tests reveal elevated ESR and CRP levels, along with mild anemia. The healthcare team is considering the introduction of a biologic agent. Which nursing intervention is most appropriate to implement in conjunction with this change in the treatment plan?

A) Educate the patient about the necessity of regular blood monitoring for potential side effects of the biologic agent.

B) Advise the patient to increase physical activity levels to manage pain and stiffness.

C) Suggest dietary changes to reduce inflammation, emphasizing the reduction of red meat and processed foods.

D) Encourage the patient to use heat therapy daily to alleviate joint stiffness and improve mobility.

A patient with rheumatoid arthritis is being treated with a TNF-alpha inhibitor and reports new-onset fatigue and shortness of breath during exertion. The nurse notes diminished breath sounds at the lung bases. What is the priority action the nurse should take based on this assessment?

B) Notify the healthcare provider about the findings and prepare the patient for a high-resolution CT scan.

A) Administer supplemental oxygen and continue to monitor respiratory status.

B) Notify the healthcare provider about the findings and prepare the patient for a high-resolution CT scan.

C) Educate the patient about performing breathing exercises to improve lung function.

D) Document the findings and schedule the patient for a routine follow-up appointment.

A patient with rheumatoid arthritis on a TNF-alpha inhibitor presents with increased fatigue, occasional shortness of breath, and diminished breath sounds at the lung bases. Which nursing intervention is most appropriate to prioritize at this time?

C) Assess the patient’s oxygen saturation and notify the healthcare provider if it is below normal limits.

A) Encourage the patient to engage in regular aerobic exercise to improve respiratory function.

B) Educate the patient on energy conservation techniques to manage fatigue.

C) Assess the patient’s oxygen saturation and notify the healthcare provider if it is below normal limits.

D) Advise the patient to increase fluid intake to help reduce joint stiffness and improve overall circulation.

A patient with rheumatoid arthritis has been diagnosed with early interstitial lung disease. Her treatment plan includes tapering her TNF-alpha inhibitor and starting low-dose corticosteroids. As a nurse, what is the most important assessment to prioritize in this patient?

C) Evaluating for respiratory distress or changes in lung function

A) Monitoring for signs of infection due to immunosuppression

B) Assessing for joint pain and swelling to evaluate arthritis control

C) Evaluating for respiratory distress or changes in lung function

D) Checking for gastrointestinal side effects from corticosteroid use

A patient with rheumatoid arthritis and recently diagnosed interstitial lung disease is transitioning from a TNF-alpha inhibitor to an alternative DMARD. Which nursing intervention is most appropriate to ensure the patient's safety during this change in medication?

A) Educate the patient on the signs of infection and advise immediate reporting to the healthcare provider.

B) Instruct the patient to increase physical activity to improve lung function and joint mobility.

C) Recommend the patient self-monitor blood pressure daily to detect hypertension early.

D) Advise the patient to decrease fluid intake to prevent potential corticosteroid-induced fluid retention.

A patient with rheumatoid arthritis and interstitial lung disease presents with increased joint pain, tenderness, and slight swelling in her metacarpophalangeal joints and wrists, as well as subtle dyspnea on exertion. Her CRP levels are elevated at 12 mg/L, and her DLCO is at 65% of predicted. Which nursing intervention is most appropriate to address both her joint and pulmonary symptoms?

B) Educate the patient on energy conservation techniques to manage fatigue and reduce dyspnea.

A) Encourage the patient to perform high-intensity exercise to improve lung function and joint mobility.

B) Educate the patient on energy conservation techniques to manage fatigue and reduce dyspnea.

C) Suggest the patient increase her sodium intake to improve blood pressure and circulation.

D) Advise the patient to avoid all physical activity to prevent exacerbating her symptoms.

A patient with rheumatoid arthritis and interstitial lung disease reports increased joint pain, morning stiffness, and mild dyspnea on exertion. Her CRP levels are elevated, and DLCO has declined. Which nursing intervention is most appropriate to address the patient's current symptoms and support her treatment plan?

B) Educate the patient on the importance of medication adherence and recognizing signs of respiratory decline.

A) Encourage the patient to increase physical activity to improve joint mobility and lung function.

B) Educate the patient on the importance of medication adherence and recognizing signs of respiratory decline.

C) Advise the patient to apply heat packs to joints to reduce inflammation and stiffness.

D) Suggest the patient to rest more frequently to conserve energy and reduce fatigue.

A patient with rheumatoid arthritis and progressive interstitial lung disease is started on a biologic agent and an immunosuppressive therapy. During a follow-up visit, what is the most crucial assessment for the nurse to perform to prevent complications associated with these medications?

B) Assess the patient for signs of infection, such as fever or sore throat.

A) Monitor the patient's blood pressure daily.

B) Assess the patient for signs of infection, such as fever or sore throat.

C) Evaluate the patient's joint range of motion and strength regularly.

D) Encourage the patient to perform deep breathing exercises twice daily.

A patient with rheumatoid arthritis and progressive interstitial lung disease has been started on a biologic agent and an immunosuppressive therapy. During the next follow-up visit, which of the following findings should the nurse prioritize and report immediately to the healthcare provider?

B) New onset of fever and productive cough

C) Slight increase in joint stiffness

Rheumatoid arthritis - Nursing Case Study

Pathophysiology

• Primary mechanism: Rheumatoid arthritis (RA) is primarily driven by an autoimmune response, where the immune system mistakenly attacks the synovial tissue, causing inflammation. This is often triggered by genetic and environmental factors, leading to the activation of T-cells and the release of pro-inflammatory cytokines like TNF-alpha and IL-6.

• Secondary mechanism: The chronic inflammation results in the proliferation of synovial fibroblasts, forming a pannus. This aggressive tissue invades and erodes cartilage and bone, contributing to joint destruction and deformity.

• Key complication: Persistent inflammation and joint damage can lead to decreased joint function, pain, and disability. Systemic involvement may also occur, affecting organs such as the lungs and heart, increasing morbidity in RA patients.

Patient Profile

Demographics:

58-year-old female, office manager

History:

• Key past medical history: Rheumatoid arthritis diagnosed 8 years ago, hypertension, osteopenia

• Current medications: Methotrexate, prednisolone, amlodipine, calcium supplements

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing joint pain and stiffness

• Key symptoms: Swelling in hands and wrists, morning stiffness lasting over an hour, mild fatigue, occasional low-grade fever

• Vital signs: Blood pressure 148/92 mmHg, heart rate 88 bpm, respiratory rate 18 breaths per minute, temperature 99.1°F

Section 1

As the patient continues to experience increasing joint pain and stiffness, a detailed initial assessment reveals additional concerns. During the physical examination, the patient's hands and wrists display significant swelling and tenderness, with the metacarpophalangeal and proximal interphalangeal joints particularly affected. Her grip strength is noticeably reduced, impacting her ability to perform daily tasks effectively. The morning stiffness now extends beyond two hours, interfering with her morning routine. An examination of her gait shows a slight limp, indicating the involvement of her knees and ankles, which could signify a progression of her rheumatoid arthritis.

Laboratory tests are conducted to assess the current status of her disease activity. The results reveal elevated inflammatory markers, with an erythrocyte sedimentation rate (ESR) of 48 mm/hr and C-reactive protein (CRP) levels at 24 mg/L, both indicative of active inflammation. Additionally, a complete blood count shows mild anemia, a common extra-articular manifestation of RA, potentially contributing to her fatigue. Given her history of hypertension and osteopenia, further imaging is considered to evaluate her bone density and assess for any erosive changes in the joints, as joint damage risk is heightened with chronic inflammation and corticosteroid use.

The clinical team discusses the potential need for adjusting her current treatment regimen to better control her rheumatoid arthritis and mitigate complications. The possibility of introducing a biologic agent, such as a TNF-alpha inhibitor, is considered to target the underlying inflammatory pathways more effectively. A referral to a rheumatologist is suggested to tailor her therapy, ensuring comprehensive management of her condition while monitoring for any adverse effects. This step aims to improve her quality of life by reducing pain, preventing further joint damage, and addressing her systemic symptoms, setting the stage for ongoing evaluation and intervention.

Section 2

Several weeks after the adjustment to her treatment regimen, the patient returns for a follow-up appointment. Her medication now includes a TNF-alpha inhibitor, alongside her previous disease-modifying antirheumatic drugs (DMARDs). During the consultation, the patient reports some improvement in her joint pain and stiffness, particularly noting that her morning stiffness has reduced to approximately one hour. However, she expresses concern over new symptoms she has experienced, including increased fatigue and occasional shortness of breath. Upon further inquiry, she mentions that these episodes occur mostly during exertion, such as climbing stairs or carrying groceries.

A physical examination reveals that while the swelling in her hands and wrists has diminished slightly, there is persistent tenderness. Her grip strength has not significantly improved, and she continues to experience difficulty with tasks requiring fine motor skills. Vital signs are stable, with a blood pressure of 130/85 mmHg and a heart rate of 82 bpm. However, a closer examination of her respiratory system reveals slightly diminished breath sounds at the lung bases, prompting further investigation.

Given these new respiratory symptoms and her history of rheumatoid arthritis, the clinical team suspects potential interstitial lung disease, a known complication associated with RA and some of its treatments. A high-resolution CT scan of the chest is ordered to assess for any interstitial changes or fibrosis. Additionally, pulmonary function tests are scheduled to evaluate her respiratory capacity and function. The team discusses the importance of monitoring her lung health closely, given the potential impact of rheumatoid arthritis and its treatment on her overall respiratory status. This new development requires careful coordination between her rheumatologist and a pulmonologist to ensure comprehensive management and to prevent further complications, setting the stage for ongoing evaluation and potential modification of her treatment plan.

Section 3

The high-resolution CT scan of the chest reveals early signs of interstitial lung disease, characterized by reticular patterns and mild ground-glass opacities, particularly at the lung bases. Pulmonary function tests indicate a mild restrictive pattern, with a reduced diffusing capacity for carbon monoxide (DLCO), suggesting impaired gas exchange. These findings confirm the suspected diagnosis and necessitate a multidisciplinary approach to her care. In light of these results, the clinical team recognizes the need to balance her rheumatoid arthritis management with the newly identified pulmonary involvement.

The patient is counseled on the significance of these findings and the potential implications for her treatment plan. Her rheumatologist and pulmonologist collaborate to adjust her medication regimen, considering the potential for TNF-alpha inhibitors to exacerbate interstitial lung disease in some cases. They decide to taper the TNF-alpha inhibitor and explore alternative DMARDs that might be less likely to affect her lung function adversely. Additionally, the pulmonologist recommends starting low-dose corticosteroids to address any inflammatory component of her lung condition, with careful monitoring for potential side effects.

As the patient navigates these changes, she is advised to watch for any exacerbation of respiratory symptoms or signs of worsening arthritis. She is scheduled for regular follow-up appointments to monitor her lung function and joint status closely. This coordinated approach aims to stabilize her respiratory condition while maintaining control of her rheumatoid arthritis, highlighting the importance of integrated care in managing complex autoimmune diseases with multisystem involvement.

Section 4

Several weeks into her adjusted treatment plan, the patient presents for a scheduled follow-up with her rheumatologist and pulmonologist. During the initial assessment, she reports a mild increase in joint pain and stiffness, particularly in the mornings, alongside some fatigue. On examination, the patient exhibits tenderness and slight swelling in her metacarpophalangeal joints and wrists. Her vital signs are stable, with a blood pressure of 120/80 mmHg, heart rate of 82 bpm, respiratory rate of 18 breaths per minute, and oxygen saturation of 94% on room air. Despite the stable vitals, the patient notes a subtle increase in dyspnea during physical activity.

Laboratory results reveal a slight elevation in her C-reactive protein (CRP) level at 12 mg/L, suggesting a mild inflammatory process, potentially linked to both her rheumatoid arthritis and interstitial lung disease. The pulmonary function tests indicate a slight decline in DLCO compared to previous measurements, now at 65% of predicted, reinforcing concerns of progressive lung involvement. Given these findings, the clinical team deliberates on the next steps, considering the need for additional intervention, such as further medication adjustments or potential use of immunosuppressive therapy tailored to both her rheumatoid arthritis and pulmonary condition.

The patient is counseled on the importance of adhering to her new medication regimen while being vigilant for signs of further respiratory compromise or worsening joint symptoms. The team emphasizes the necessity of continued multidisciplinary care, including potential referral to a physical therapist to support her mobility and manage fatigue. Plans are made for more frequent monitoring of her pulmonary status and a comprehensive review of her joint health, illustrating the ongoing challenge of achieving a delicate balance in managing her complex autoimmune pathology.

Section 5

Several weeks later, the patient returns for a follow-up appointment, reporting a notable increase in morning joint stiffness and fatigue, which now persists into the afternoon. She also describes experiencing intermittent episodes of shortness of breath, even with minimal exertion, such as walking a short distance or climbing a flight of stairs. Upon examination, her vital signs reveal a slight increase in heart rate to 88 bpm and a mild decrease in oxygen saturation to 92% on room air. There is increased tenderness and swelling in the proximal interphalangeal joints, and the patient expresses difficulty performing daily activities like buttoning clothes or opening jars.

New laboratory tests indicate a further rise in CRP to 18 mg/L, and an erythrocyte sedimentation rate (ESR) of 40 mm/hr, both suggesting an escalation in inflammatory activity. A high-resolution CT scan of the chest reveals a subtle increase in fibrotic changes consistent with progressive interstitial lung disease. The pulmonary function test results show a further reduction in DLCO to 60% of predicted, confirming a decline in her respiratory function and raising concerns about the progression of her pulmonary condition.

Given these developments, the clinical team decides to initiate a more aggressive treatment approach. The rheumatologist recommends the addition of a biologic agent to better control her rheumatoid arthritis and slow the progression of lung involvement. Meanwhile, the pulmonologist considers starting an immunosuppressive therapy to address the worsening interstitial lung disease. The patient is educated on potential side effects and the importance of monitoring for any signs of infection, given the increased risk associated with these medications. The team also arranges for a closer follow-up schedule to closely monitor her response to the new interventions and to adjust the treatment plan as necessary, emphasizing the critical nature of an integrated approach to her complex health needs.