IMMUNITY:
RHEUMATOID
ARTHRITIS
A CASE STUDY
Beth Downing, MSN, RN-BC, ONC
OBJECTIVES
 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.
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.
 What
is significant about this
report that leads you to RA?
 What
additional nursing
assessment data would be
significant?
HISTORY
 Mild
osteoarthritis
(bilateral knees)
 Laparoscopic
cholecystectomy
 T&A as a child
MEDICATIONS
 Ibuprofen
prn pain
 MVI daily
2 tabs
Mrs.
Stevens has mild OA
and is now being
diagnosed with RA;
explain the differences to
her.
OTHER PERTINENT INFO
 Married
with 2 children; ages 16 & 20
 Currently
 Active
 Denies
 No
a loan officer at a bank
at the local community center
ETOH or tobacco use
significant family history
 NKDA
DIAGNOSTICS??
 Complete
blood count (CBC)
 C-reactive protein (CRP)
 Erythrocyte sedimentation rate (ESR)
 Rheumatoid factor (RF)
 Anti-citrullinated protein antibody (ACPA)
 Synovial fluid analysis
 Xray
How
will these laboratory
values be affected or how
will they assist in the
diagnosis of RA?
TREATMENT OPTIONS
 Diagnosed
 PT/OT
with early RA
consult
 Pharmacological
treatment
 NSAID &DMARD





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?
NSAID & DMARD TREATMENT
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
 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?
NURSING DIAGNOSES???
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.
TREATMENT PLAN…
 Increase:
Methotrexate 15 mg po q week
Celebrex to 200 mg po bid
 Add:
Humira 40 mg subcut every other week
What
new patient teaching
should be included?
TREATMENT 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.
 What
information should be taught to
Mrs. Stevens about the
use/administration of Remicade?
REMICADE 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.


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?
DISEASE 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.
 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.org
REFERENCES


North Carolina Concept-Based Learning
Editorial Board. (2011). Nursing: A ConceptBased Approach to Learning. Volume 1 & 2.
Pearson Publishing.
Smeltzer, S., Bare, B., Hinkle, J., Cheever, K.
(2010). Brunner and Suddarth’s Medical
Surgical Nursing. 12th ed. Lippincott,
Williams & Wilkins.