A patient with rheumatoid arthritis is taking methotrexate. The nurse notes the patient has mild fatigue and recent cold sores. What is the most appropriate action for the nurse to take to address these findings?

A) Advise the patient to increase fluid intake and rest.

B) Suggest discontinuing methotrexate immediately.

C) Encourage the patient to take an extra dose of folic acid.

D) Recommend a high-protein diet to boost immune function.

A patient with rheumatoid arthritis is on methotrexate therapy and presents with mild fatigue and frequent colds. What is the most appropriate nursing intervention to address these symptoms?

B) Discuss infection prevention strategies with the patient

A) Increase physical activity to boost energy levels

B) Discuss infection prevention strategies with the patient

C) Suggest the patient drink more caffeinated beverages to reduce fatigue

D) Advise the patient to stop taking methotrexate immediately

Which dietary recommendation should the nurse make to a patient with mild anemia to help improve their hemoglobin levels?

A) Increase intake of citrus fruits

C) Increase intake of dairy products

D) Increase intake of fiber-rich foods

Which intervention is most appropriate for the nurse to recommend to a patient experiencing mild anemia due to methotrexate therapy?

A) Increasing dietary intake of iron-rich foods

B) Administering subcutaneous vitamin B12 injections

C) Initiating intravenous iron therapy

D) Recommending a high-calcium diet

A patient undergoing treatment with methotrexate reports sensitivity and tenderness in the oral cavity. Which of the following nursing interventions is most appropriate to address the patient's symptoms?

A) Encourage the patient to use a soft-bristled toothbrush

B) Advise the patient to increase intake of acidic foods

C) Suggest the patient rinse their mouth with alcohol-based mouthwash

D) Recommend the patient brush their teeth more frequently

What is the most important action the nurse should take when there is a decrease in the patient's neutrophil count?

A) Educate the patient about the importance of hand hygiene

B) Recommend the patient stop taking oral iron supplements

C) Advise the patient to increase their intake of citrus fruits

D) Suggest the patient use a medium-bristled toothbrush

What is the most appropriate nursing action to prevent infection in a patient with a slightly decreased neutrophil count?

A) Encourage the patient to wear a mask in crowded places.

B) Advise the patient to discontinue her iron supplements.

C) Suggest that the patient increase her intake of dairy products.

D) Recommend that the patient avoid brushing her teeth to prevent gum irritation.

Which of the following interventions should be prioritized for a patient with neutropenia to prevent infection?

A) Encourage frequent handwashing

D) Schedule daily physical exercise

What is the primary reason for implementing heightened infection control measures for this patient?

C) The patient's decreased neutrophil count

A) The patient's slightly elevated temperature

C) The patient's decreased neutrophil count

D) The patient's improved hemoglobin levels

immunosuppression - Nursing Case Study

Pathophysiology

• Primary mechanism: Reduced lymphocyte production - The bone marrow produces fewer white blood cells, especially lymphocytes, which are crucial for fighting infections. This decrease weakens the immune response, making the body more susceptible to infections.

• Secondary mechanism: Impaired cytokine signaling - Cytokines are signaling proteins that help coordinate the immune response. When signaling is impaired, communication between immune cells is disrupted, leading to a reduced ability to respond to pathogens.

• Key complication: Increased infection risk - Due to the weakened immune system, patients are at a higher risk of infections, which can lead to longer recovery times and increased vulnerability to opportunistic pathogens.

Patient Profile

Demographics:

Age: 32, Gender: Female, Occupation: Teacher

History:

• Key past medical history: Diagnosed with mild rheumatoid arthritis two years ago

• Current medications: Low-dose Methotrexate 7.5 mg once weekly, Folic Acid 1 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increased fatigue over the past month

• Key symptoms: Mild joint stiffness in the morning, frequent colds

• Vital signs: Blood Pressure 118/76 mmHg, Heart Rate 72 bpm, Respiratory Rate 16 breaths per minute, Temperature 98.6°F

Section 1

Initial Assessment Findings:

During the initial assessment, the nurse notes that the patient appears slightly pale and exhibits signs of mild fatigue. She reports feeling increasingly tired over the past month, which she attributes to her busy schedule as a teacher and the challenges of managing her rheumatoid arthritis. Despite her fatigue, she remains alert and oriented, able to provide detailed information about her recent health experiences. Her morning joint stiffness lasts about 30 minutes but improves with gentle movement and daily activities.

Upon examination, the nurse finds no significant joint swelling or redness, and the patient's range of motion is within normal limits. Auscultation reveals clear lung sounds, and her heart sounds are regular without any murmurs or extra heart sounds. The nurse notes that the patient's mucous membranes are slightly dry, and she has a few small, healing cold sores around her mouth, suggesting recent viral infections. A review of her medication history confirms adherence to her methotrexate and folic acid regimen, and she denies any recent changes in her diet or lifestyle that could contribute to her symptoms. The nurse also observes that her skin is intact, with no signs of rashes or lesions, except for the cold sores.

These findings suggest that while the patient is experiencing mild immunosuppression-related complications, her overall condition remains stable. The fatigue and frequent colds align with the expected side effects of methotrexate therapy, emphasizing the need for ongoing monitoring and supportive care. The nurse plans to discuss these findings with the healthcare team to determine if any adjustments to her current treatment plan are necessary and to reinforce the importance of infection prevention strategies, such as good hand hygiene and avoiding close contact with individuals who have active infections.

Section 2

A week later, the patient returns for a follow-up appointment, during which new diagnostic results become available. Her laboratory tests indicate a mild anemia, with a hemoglobin level of 10.5 g/dL, slightly below the normal range. Her white blood cell count is at the lower end of normal, but there is a slight decrease in her neutrophil count, consistent with the immunosuppressive effects of methotrexate. Her liver function tests remain within normal limits, reassuring the healthcare team that her methotrexate therapy is not adversely affecting her liver. Additionally, her rheumatoid factor and inflammatory markers, such as C-reactive protein (CRP), show a slight decrease, suggesting that her rheumatoid arthritis is under better control.

The nurse discusses the lab results with the patient, explaining that the mild anemia and lower neutrophil count could contribute to her fatigue and susceptibility to infections. To address the anemia, the healthcare team considers increasing her dietary intake of iron-rich foods and possibly supplementing with oral iron, while continuing to monitor her blood counts closely. The nurse reinforces the importance of maintaining a balanced diet and adequate hydration, especially considering her slightly dry mucous membranes observed during the previous visit.

To help mitigate the risk of infections due to her decreased neutrophil count, the nurse reviews infection prevention strategies with the patient. This includes emphasizing the significance of good hand hygiene, staying up-to-date with vaccinations, and avoiding crowded places during peak cold and flu seasons. The nurse also advises the patient to promptly report any signs of infection, such as fever, persistent cough, or worsening of her cold sores. These proactive measures aim to support the patient's immune function, ensuring she can continue her teaching duties with minimal disruption. The healthcare team plans to monitor her condition closely, scheduling another follow-up in a month to reassess her response to these interventions and make any necessary adjustments.

Section 3

During the next follow-up appointment, the patient reports feeling slightly more energetic, which aligns with the dietary adjustments and oral iron supplementation initiated to address her mild anemia. Her hemoglobin level has increased to 11.2 g/dL, indicating a positive response to the interventions. However, she mentions experiencing occasional dizziness, prompting the nurse to assess her vital signs carefully. Her blood pressure reads 110/70 mmHg, with a heart rate of 82 beats per minute, both of which are within normal limits, suggesting that the dizziness might be related to her slight anemia and not a significant cardiovascular issue.

The nurse conducts a thorough assessment and notices that the patient's mucous membranes are now adequately hydrated, reflecting her improved fluid intake. Additionally, the patient's skin appears to be in good condition, with no new rashes or lesions, and there are no signs of infection. The nurse reviews the patient's self-reported adherence to infection prevention strategies, confirming that she has been diligent about hand hygiene and avoiding crowded places. Importantly, the patient has not experienced any recent fevers or respiratory symptoms, which is reassuring given her slightly reduced neutrophil count.

Despite these improvements, the patient expresses concern about a new complication: increased sensitivity and tenderness in her oral cavity, specifically around her gums and tongue. The nurse considers the possibility of oral mucositis, a common side effect of methotrexate, and advises the patient to use a soft-bristled toothbrush and avoid spicy or acidic foods that may exacerbate the discomfort. The healthcare team decides to monitor this new symptom closely, ensuring that it does not interfere with the patient's ability to eat and maintain her nutritional status. They also schedule another follow-up visit in two weeks to reassess her oral health and overall response to the treatment plan, aiming to address any emerging issues promptly.

Section 4

Two weeks later, at the follow-up appointment, the patient reports some improvement in her oral discomfort, though she occasionally still experiences tenderness around her gums. She has adhered to the nurse’s recommendations, using a soft-bristled toothbrush and avoiding irritating foods, which has helped manage the symptoms. Her appetite remains stable, and she continues to take her oral iron supplements as prescribed. During the physical assessment, the nurse observes that the patient’s oral mucosa appears less inflamed, and there are no visible ulcerations, suggesting that the early-stage mucositis is under control.

In addition to the oral assessment, the nurse reviews the patient’s recent laboratory results. Her complete blood count (CBC) shows a further improvement in hemoglobin, now at 11.5 g/dL, indicating that the anemia is gradually resolving. However, the nurse notes a slight decrease in the patient’s neutrophil count to 1.3 x 10^9/L, slightly lower than the previous value. Given her stable overall condition and absence of infection signs, the team decides to continue the current treatment plan but emphasizes the importance of ongoing infection prevention strategies.

The nurse discusses with the patient the importance of monitoring for any new symptoms such as fever, chills, or unusual fatigue, which could indicate an infection. The healthcare team arranges for another follow-up in one month and advises the patient to contact them if she experiences any concerning changes in her health. With her proactive approach to managing side effects and adhering to the treatment plan, the patient remains optimistic about her progress and continues to focus on maintaining her health and well-being.

Section 5

Two weeks after the last follow-up, the patient returns for her scheduled appointment. During the initial assessment, the nurse notes that the patient appears slightly more fatigued than during previous visits. Although she has not experienced any fever or chills, she mentions feeling more tired than usual, even after a full night's sleep. The nurse conducts a thorough physical examination and observes that while the patient's oral mucosa remains stable, with no new ulcerations or significant inflammation, there is a mild pallor to her skin that was not present before.

Vital signs reveal a stable blood pressure of 120/80 mmHg and a heart rate of 78 beats per minute, but the patient's temperature is slightly elevated at 99.1°F (37.3°C), which could suggest the early stages of an infection, despite the absence of overt symptoms. A review of the most recent laboratory results shows a further slight decrease in the neutrophil count to 1.1 x 10^9/L, raising concerns about potential neutropenia. Hemoglobin levels continue to improve slightly, now at 11.8 g/dL, indicating ongoing recovery from anemia.

In response to these findings, the healthcare team emphasizes the need for heightened infection control measures and reinforces education on recognizing early signs of infection. They advise the patient to increase her rest periods and maintain a balanced diet to support her immune system. The team decides to schedule a closer follow-up visit in two weeks to monitor her condition more closely and consider additional interventions if her neutrophil count does not stabilize or improve. The patient remains cooperative and reassured by the proactive approach, committed to adhering to the updated care plan.