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A 48-year old female presents stiffness in both hands in the morning for last 7 months. Stiffness now lasted more than 1 hour every morning and includes hands, wrists and ankles. She also had increasing difficulty standing for long periods at work or at home due to foot and ankle pain. She began taking ibuprofen 800mg 3 times daily and found it helped her get through her day with less pain and stiffness. Three months ago, Joy noticed pain in her right and left shoulders when she would cut or blow dry her client’s hair. She also began feeling extremely tired and short tempered. She had no energy to do her usual activities. Ibuprofen was no longer very effective for her pain or stiffness. One morning, Joy could not lift her arms at all without extreme shoulder pain. She knew it was time to get help. 

Pt is married with 3 teenagers, and works part time as a hairdresser.

Dx: Rheumatoid Arthritis (RA) 

Rx: methotrexate, Physical Therapy

You are providing the patient with education on her new diagnosis. Create a patient teaching plan that covers the following questions. 

1. What is rheumatoid arthritis? 

2. What are the important teaching points for her medication? 

3. What are the recommendations to manage her joint pain during remission? During exacerbation?

Exemplar (This is an example of a finished work)

Rheumatoid Arthritis Patient Education Activity

A 48-year old female presents stiffness in both hands in the morning for last 7 months. Stiffness now lasted more than 1 hour every morning and includes hands, wrists and ankles. She also had increasing difficulty standing for long periods at work or at home due to foot and ankle pain. She began taking ibuprofen 800mg 3 times daily and found it helped her get through her day with less pain and stiffness. Three months ago, Joy noticed pain in her right and left shoulders when she would cut or blow dry her client’s hair. She also began feeling extremely tired and short tempered. She had no energy to do her usual activities. Ibuprofen was no longer very effective for her pain or stiffness. One morning, Joy could not lift her arms at all without extreme shoulder pain. She knew it was time to get help.

Pt is married with 3 teenagers, and works part time as a hairdresser.

Dx: Rheumatoid Arthritis (RA)

Rx: methotrexate, Physical Therapy

You are providing the patient with education on her new diagnosis. Create a patient teaching plan that covers the following questions. 

1. What is rheumatoid arthritis? 

Rheumatoid arthritis (RA) is a chronic, progressive inflammatory disease that can affect tissues and organs but principally attacks the joints, producing an inflammatory synovitis. It involves joints bilaterally and symmetrically, and typically affects several joints at one time. RA typically affects upper joints first.

2. What are the important teaching points for her medication? 

● Take the medication with food or with a full glass of water or milk. If taking routinely, an H2receptor antagonist can also be prescribed.

● Observe for GI bleeding (coffeeground emesis; dark, tarry stools).

● Avoid alcohol, which can increase the risk of GI complications

3. What are the recommendations to manage her joint pain during remission? During exacerbation?

During remission:

● Apply heat or cold to the affected areas as indicated based on client response

◯ Morning stiffness (hot shower)

◯ Pain in hands/fingers (heated paraffin)

◯ Edema (cold therapy)

● Conserve energy (space out activities, take rest periods, ask for additional assistance when needed).

● Follow routine health screenings.

● Use progressive muscle relaxation.

● Report manifestations that can indicate early or late exacerbation of the RA that need to be reported immediately (fever, infection, pain upon inspiration, pain in the substernal area of the chest).

● Express feelings regarding effect of the disease on body image and self-esteem.

● Use nonpharmacologic pain relief through therapies such as hypnosis, acupuncture, imagery, music therapy, and spiritual practices.

During Exacerbation:

● Avoid crowds, which increase the risk of infection.

● Monitor for an allergic reaction.

● If taking leflunomide, report hair loss or diarrhea to the provider.

● Leflunomide is contraindicated during pregnancy, because it increases the risk of fetal birth defects.

● Many DMARDs can affect the liver; avoid alcohol consumption to prevent additional harm to the liver.

Immune System: Rheumatoid Arthritis

Adult Health 2 Teaching Team

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RA: autoimmune disease that starts in synovial tissue

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Swan neck deformity

Ulnar deviation

Rheumatoid nodules

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Diagnostic and Monitoring Labs

LabNormal RangeChange in RA
Anti-CCP antibodiespositive
Rheumatoid factor antibody1:20 or less1:40 to 1:60 for diagnosis
Erythrocyte sed rate (ESR)< 2020 to 40 = mild 40 to 70 = moderate 70 to 150 = severe
C-reactive protein< 1.00elevated
Anti-nuclear antibody (ANA)negativepositive
WBCsElevated during exacerbation
RBCsdecreased

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Diagnostic Procedures

X-rays

Arthrocentesis

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MedicationActionNursing Implications
NSAIDsAnti-inflammatory, analgesic, anti-pyreticAdmin w/ food Teach s/s of GI bleeding and precautions Avoid concurrent use of salicylates Monitor for fluid retention, hypertension, and renal dysfunction
Corticosteroids (prednisone)Anti-inflammatory (for acute flares or advanced disease only)Short-term; tapered off. Monitor weight and blood pressure AEs are cataracts, osteoporosis, hyperglycemia, GI distress
DMARDs (all suppress immune system)
methotrexateTeratogenic; should use contraception or abstinence Teach s/s of infection avoid alcohol due to liver effects lab monitoring (liver, kidney)
hydroxychloroquineReport vision changes Ophthalamic exams q 6-12 months May cause GI upset; take with food
leflunomideLab monitoring (liver enzymes) Teach reporting of hair loss or diarrhea Teratogenic; should use contraception or abstinence

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RA Complications

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Sjogren’s syndrome

Secondary osteoporosis

Vasculitis

Respiratory

Cardiac

Infection

Nursing Management

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Pain and discomfort

Warm showers for morning stiffness

Heat for pain (paraffin baths for hands), stiffness

Cold for swelling

Alternative pain relief practices

Maintain Mobility

PT/OT referral

Promote and reinforce assistive device use

Low impact exercise and ROM

Resting acutely inflamed joints

Splinting affected joints

Nursing Management Goals

11

Fatigue

Sleep routine

Pacing/alternating activities w/ rest

Maintain nutrition

Dietary consult

Vitamins, protein, iron

Small frequent meals

Supplements, as prescribed