Rheumatoid Arthritis Case Study Questions & Answers
Slide 5:

What is significant about this report that leads you to RA?
Pain in hands bilaterally, stiffness, tenderness in the morning, poor appetite and easily fatigued
RA affects women > men and is most common 40-60 yrs old

What additional nursing assessment data would be significant?
Joints spongy feeling, warm/hot, swollen, not easily moved, fever, weight loss, Raynaud’s phenomenon
(cold & stress induced vasospasms that cause white/cyanotic coloring
Slide 7:
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Patient has mild OA and is now being diagnosed with RA, explain the differences to her.
RA is typically symmetrical OA is not
RA targets smaller joints first and OA tends to affect larger joints first
RA is synovitis of the joints (inflammation of the synovial lining), OA is “wear & tear” breakdown of
cartilage
OA is more common
RA is more debilitating & crippling
RA is autoimmune, systemic
RA is remissions & exacerbations
Morning stiffness is < 30 mins in OA and > 1 hour in RA
Slide 10:
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How will these laboratory values be affected or how will they assist in the diagnosis of RA?
RBC & HcT are decreased – chronic inflammation
CRP – elevated indicates active inflammation (Normal is less than 1 mg/dL)
ESR – elevated indicates inflammatory process (Normal is 0-15 Men, 0-25 Women)
RF – Positive in 80% of RA patients , not a specific indicator of RA
ACPA – Positive can indicate RA, not a specific indicator of RA
Synovial Fluid – cloudy with increased leukocytes present
Xray – narrowed joint spaces, not typically seen in the first 3-6 months, also done to determine
progression
Slide 12:
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According to the American College of Rheumatology what are the 4 sets of data to classify RA?
Joint involvement - number & small or large joint
Serology - RF & ACPA
Acute phase reactants - CRP & ESR
Duration of symptoms - less than or greater than 6 weeks

Explain what these 2 classes of medications are & how they work?
NSAID (Nonsteroidal Antiinflammatory Drug) – reduce inflammation to decrease pain, swelling, improve
function. Do not affect the disease process. GI side effects – dyspepsia, ulcers, cardiovascular risks. See
results quicker
DMARD (Disease Modifying Antirheumatic Drug) – have potential to decrease joint damage, slow
progression of disease, preserve joint function, should be started with 3 months of diagnosis. Cause
immunosuppression. Slower onset on action.

Why is PT/OT involved so early on when there isn’t a current mobility problem?
To help preserve joint function; teach the patient ways to decrease stress on joints; ROM; muscle
strengthening; teach appropriate exercises

What additional teaching should be completed at this time??
This is a chronic progressive disease that can affect other organs and it can impact all areas of life; how
to deal with pain, fatigue, and depression that can occur; importance of treatment compliance and
follow-up; this disease cannot be cured – but treatment can be very effective;

What are examples of NSAIDS & DMARDS that could be used at this time?
NSAIDS – naproxen (Naprosyn), ibuprofen (Motrin), celecoxib (Celebrex), meloxicam (Mobic), Diclofenac
(Voltaren)
DMARDS – hydoxychloroquine (Plaquenil), leflunomide (Arava), methotrexate (Rheumatrex),
sulfasalazine (Azulfidine), abatacept (Orencia), rituximab (Rituxan), etanercept (Enbrel), infliximab
(Remicade), adalimumab (Humira)
Slide 14:
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Prior to starting this treatment plan what should be evaluated?
Cardiovascular risk factors, liver enzymes, CBC, creatinine, pregnancy status, history of GI bleeding,
presence of infection

What patient teaching is indicated for these medications? Have student’s role play patient
teaching
Labs – Liver enzymes, Immunizations should be administered prior to DMARD therapy, watch for signs
of GI bleeding, watch for signs of infection, compliance with follow-up labs is essential,
Methotrexate needs to be taken exactly as presecribed (weekly in this case), take on empty stomach
Celebrex – take with food

When would these medications be contraindicated?
Pregnancy, significant cardiac risk factors or hepatic or renal impairment
Slide 15:
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Appropriate nursing diagnoses include:
Acute or chronic pain
Fatigue
Imbalanced nutrition: less than body requirements
Sleep deprivation
Activity intolerance
Impaired physical mobility
Self-care deficit
Disturbed body image
Ineffective coping
Fear
Anxiety
Powerlessness
Risk for infection related to treatment methods
Knowledge deficit: disease process or treatment
Slide 18:
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What new patient teaching should be included?
Humira:
Avoid live vaccines while taking it
Prior to giving it TB screening should be completed
Serious infections can occur
Teach self administration – it is a subcutaneous injection (abdomen, rotate sites, needle care/disposal)
It should be kept refrigerated
Slide 20:
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What information should be taught to Mrs. About the use/administration of Remicade?
It is given via IV infusion over at least a 2 hour period, then repeat in 2 weeks, then at 6 weeks, then
every 8 weeks
If she is going to continue to get Remicade regularly a central line (port-a-cath) could be beneficial for
her
Monitor for infusion related reaction during and for 2 hours after infusion (reactions are more common
after 1st or 2nd infusion)
Monitor for symptoms of systemic infections/fungal infections
TB skin test prior to beginning therapy
Monitor for reactions
Monitor liver function
Monitor CBC (leukopenia, neutropenia, thrombocytopenia, pancytopenia)
Slide 22:

What should the nurse monitor for during the initial infusion in regards to a reaction?
Fever
Chills
Itching
Rash
Dyspnea
Hypotension/Hypertension
Chest pain
Both during and for 2 hours following the infusion

If she were to have a reaction what should the nurse do?
Stop the infusion
Call the MD
Prepare to administer antihistamines, corticosteroids, acetaminophen, and/or epinephrine
Slide 24:

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
Swan neck deformities
Rheumatoid nodules
Boutonniere’s deformity
Ulnar deformity
Hallux toes
Raynaud’s phenomenon – cold or stress induced vasospasm causing white/blue coloring of fingers
Sjogren’s syndrome – dry eyes & mucous membranes
Increased risk for cardiac disease (vasculitis, pericarditis)