Michelle Snyder Case Study Report - Diagnostic Testing - Nursing Assignment Help

Assignment Task:

Discussion Post by Michelle Snyder

History:

I would ask the patient when her symptoms began. The patient should be questioned about any recent infection or increased stress. Flare-ups of RA can occur after an infection or increased stress. (Andwele, 2019) Often a flare-up can come without any infection or stress and the cause may not be determined. Obtaining information from the patient may be helpful to determine the cause of the flare and things that can be done to reduce stress and decrease the chances of infection.

ROS:

The patient should be examined for inflammation, swelling, and warmth to joints. ROM should be assessed in the affected areas. RA is characterized by symmetrical swelling of joints, but may not be evident at the beginning of the disease. Palpation of the joints can help the practitioner to distinguish the swelling in joints from inflammation from the bony enlargement of osteoarthritis. Joints frequently affected by RA are the proximal interphalangeal (PIP) and metacarpophalangeal (MCP) joints. (Ruffing & Bingham, 2018) The patient should be assessed for fatigue, malaise, depression, and fever. Fever can occasionally occur with a flare and is usually low grade (99 degrees Fahrenheit). (Ruffing & Bingham, 2018)

Joints and extremities should be examined for rheumatoid nodules. Most nodules develop on the extensor surface of arms and elbows and may develop on pressure points like feet and knees. (Ruffing & Bingham, 2018) The respiratory and cardiovascular systems should also be evaluated, as a cardiopulmonary disease can occur in RA patients. The patient should be evaluated for lung problems such as shortness of breath. Atherosclerosis is the most common cardiovascular problem in RA and is the leading cause of death. (Ruffing & Bingham, 2018) The eyes should also be examined, keratoconjunctivitis of Sjogren’s syndrome is common in patients with RA. Patients may complain of sicca (dry eye). The conjunctiva should be evaluated for redness and pain, a sign of episcleritis. Sjogren’s syndrome is an autoimmune condition that affects exocrine gland function, leading to a reduction in tear production (keratoconjunctivitis sicca), oral dryness (xerostomia) with decreased saliva of poor quality, and reduced vaginal secretions.  The patient should be questioned about any of these symptoms.  

Diagnostic Testing:

Unfortunately, there is no definitive test to confirm a diagnosis of rheumatoid arthritis in patients. Diagnostic testing that can be done for this patient would include; CBC, CMP, RF, antibodies to citrullinated peptides, including anti-CCP, erythrocyte sedimentation rate (ESR), and C - reactive protein (CRP). The CBC will show if anaemia is present, WBCs may be elevated due to the inflammation, or normal. The CMP should be relatively normal in an RA patient, although a decrease in albumin and an increase in total protein may be found reflecting the chronic inflammatory process. (Ruffing & Bingham, 2018) In 70%-80% of patients with RA, the rheumatoid factor is present. A more specific marker for RA is a positive Anti-CCP. An elevated ESR is expected in RA patients and the CRP is usually elevated, as this is a marker for inflammation.

Treatment Options:

One treatment option for this patient would be to temporarily adjust the current medications during the flare. (Andwele, 2019) The adjustment of current medications can help alleviate pain and minimize joint damage that can occur from the inflammation. There are three classes of drugs normally used in treating RA, non-steroidal anti-inflammatory medications (NSAIDs), corticosteroids, and disease-modifying anti-rheumatic drugs (DMARDs). (John’s Hopkins, 2018) For quicker relief of symptoms for the patient NSAIDs and corticosteroids are the best option. NSAIDs and corticosteroids have a short onset of action and can give quicker relief of symptoms. DMARDs can take several weeks to months to reach the desired clinical effect. If the patient is already on a DMARD, adjusting the dose may be appropriate. DMARDs include methotrexate, adalimumab (Humira), etanercept (Enbrel), and abatacept (Orencia). These medications are usually started early in the disease, almost as soon as the diagnosis is made to prevent joint damage. (John’s Hopkins, 2018)

The patient can also do things at home to help alleviate the symptoms of the flare, along with prescribed medications. Balancing activity and rest, combine periods of rest with light activity. Moving all joints to the fullest range of motion possible will help prevent joints from becoming stiff. Adapting a contingency plan for work and family obligations can help alleviate stress. Delegate responsibilities at home to others, and arrange for days off of work during flare-ups or working fewer hours per week. Applying heat or cold packs to inflamed joints can help soothe and reduce inflammation. Heat can increase blood flow to painful areas and relax muscles. Cold can ease inflammation by constricting blood vessels and lessen pain. (Andwele, 2019) Relaxation and mind-diversion techniques can reduce stress and indirectly relieve pain.

Patient Education:

The patient should be educated about how infection and increased stress can trigger flare-ups. Education about medications should also be done. The patient should be advised to continue taking medications as prescribed and how the medication can help prevent further damage to joints that are involved. They take effect over weeks or months and are not designed to provide immediate relief of symptoms. (Cohen & Cannella, 2019)  The patient should be educated about the side effects of these medications. Common side effects include upset stomach and mouth sores. The patient should be educated about limiting alcohol use while taking DMARDs due to the increased risk of liver injury. The patient should also be educated about taking folic acid (1 mg daily) or folinic acid (5 mg weekly) while taking these medications to reduce the risk of side effects (upset stomach and mouth sores) and reduce the risk of developing low blood counts and abnormal liver function. (Cohen & Cannella, 2019)

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