Question

H.M. is a 32-year-old female who presents for her annual physical examination and mentions to the health care provider that she has been having pain in her toes when she gets up during the night and first thing in the morning.

Subjective Data

• Wife and mother of a seven-month-old son
• Works part-time as a registered nurse
• Her mother recently passed away and she has been experiencing tension headaches
• States has been having difficulty walking, sometimes needing to crawl, due to pain in toes when she gets up during the night to go to the bathroom and the first couple of hours in the morning
• Has noticed pain in her fingers in the morning when she tries to open baby food jars

Objective Data

Physical Examination

• Temperature 98.6° F, pulse 76, respirations 16, blood pressure 114/68
• Swelling and tenderness to palpation of the proximal interphalangeal (PIP) jointof the bilateral second and third digits of hands, metacarpophalangeal (MCP) joint of bilateral thumbs, and the metatarsophalangeal (MTP) joint (Links to an external site.) of bilateral great toes

Diagnostic Studies

• Rheumatoid factor (RF) positive
• X-rays of bilateral hands and feet reveal soft tissue swelling; without any evidence of bone or cartilage destruction or joint deformities
• Bone density T-score of +1

Discussion Questions

1. The health care provider diagnoses H.M. with Stage I rheumatoid arthritis. Explain the pathophysiology of rheumatoid arthritis and the classification criteria that H.M. demonstrates that determined this diagnosis.

2. How could H.M.’s recent childbirth and death of her mother be related to her rheumatoid arthritis?

3. Describe some of the extraarticular manifestations of rheumatoid arthritis H.M. may develop.

4. a) What are some priority nursing diagnoses for H.M. at this time?

b) What are the overall goals of H.M.’s care?

5.

a) What treatment and inter professional care are involved in managing a patient with rheumatoid arthritis?

b) M. is started on methotrexate. What instructions should you give H.M. regarding this medication?

Answer 1

Rheumatoid disease is a systemic autoimmune disease that particulary affects the joints ,leading to arthritis . RA is a common and important cause of inflammatory joint disease . It is characterised by the presence of a circulating autoantibody - "rheumatoid factor " which distinguish this form of disease from the several other inflammatory joint disease . the affected joints become swollen , painful and warm often with the redness of the overlying skin.RA mainly affects the [eripheral synovial joints such as fingers and wrist .

The main pathological changes are ;-

(a) Rheumatoid synovitis ;- this is the early pathological change in which the synovium is swollen and shows a villcus ( think villi ) pattern. There is a great increase in chronic inflammatory cells ( mainly lymphocytes and plasma cells ) inthe synovial stoma , often with the exudate comprising fluid which produces effusion in the joint space .Fibrin is deposited on the synovial surface . Soft tissue swelling from synovial inflammation can be marked .

(b) Articular cartilage destruction ;- vascular granulation tissue grows across the surface of the cartilage ( pannus ) from the edges of the joint and the articular surface shows loss of cartilage beneath the extending panes , most marked at the jont margins .Synovial lining cells , normally 1-3 layers thick , undergo hyperplasia and form layers 8 -0 cells deep.

(c) Focal destruction of bone ;- The inflammatory pannus causes focal destruction of the bone ( pannus penetrates the subchondral bone ) . At the edges of joint there is osteolytic destruction of bone , responsible for erosion seen on radiographs. this phase is associated with the joint deformity .

The classification criteria for rheumatoid arthritis the ultimate goal is to identify  possible rheumatoid arthritis early so there is no delay in starting the treatment . The classification criteria are used to evaluate in those people who have swelling in at least one joint that is not explained by another disease such as lupus or gout .An evaluation results in a score between 0 to 0 . Rheumatoid arthritis is diagnosed if the score is 6 or more .

INVOLVEMENT OF SWOLLEN AND TENDER JOINTS	POINTS
1 medium - large joint	0
2-10 medium - large joints	1
-3 small joints	2
4-10 small joints	3
greater than 10 joints ( at least 1 must be small)	5
SEROLOGY
neither RF nor ACPA positive	0
one low positive titer on at least one test	2
one high postive titer on at least one test	3
DURATION OF SYNOVITIS
less than 6 weeks	0
6 week s or longer	1
ACUTE _ PHASE REACTANTS
neither CRP nor ESR abnormal	0
Abnormal CRP or Abnormal ESR	1

As H.M with recent childbirth affect on both the mother and child as well . it increased the rsik of complication such as preterm birth and babies that are small for the gestational age this likelihood that the baby requires more medical care early in life

During the pregnancy , when the fetus grow it may notice pain on the back and the hips . and plus more stress on the joints . RA patient more commonnly affect the ability to have a normal vaginal delivery THe high disease activity during pregnancy increase the risk for pre term , low birth weight babies and the ned for a cesarean delivery . it leads to mother more fatigue than the other new mothers .

As the family issues related to the love one 's death ( Mother) can give a psychological affect on the RA patient .As the pain from physical plus pain from emotions increase the intensity of the pain and that leads to the progression on the disease process with high speed .

The extrarticular involvement is more likely in those patient who have RF or HLA - DR 4 positive . the extrarticular manifestation in the H.M are characterised by the destructive polyarthritis and extraocular organ is skin . ,Occasionally there are also systemic manifestations suchas vasculitis , visceral nodules , pulmonary fibrosis present . Noduales are the most common extra - articular feature

(a) The priortity nursing diagnosis in RA for the H.M are as listed ;-

Acute pain related to inflammation and increase disease activity , tissue damage , fatigue or lowered tolerance level

Impaired physical mobility is related to intolerance to activity or decreased muscle strength as evidence by limited ROM , impaired coordination , decreased muscle strength / contol and mass

Disturebed body image as related to changes in the ability to perform usual task possible evidence by negative self talk , focus on past strength / function , appearance

self- care deficit as related to decreased strength / endurance , pain on movement possible evidence by Inability to manage ADLs ( feeding ,bathing, dressing and toileting )

risk for impaired home maintenance as related to the inadequate support system

deficient knowledge as related to the information misinterpretation as evidence by questions / requset for te information , statement of misconception .

(b) the overall goals for the H.M with RA are ;-

improvement in comfort level.

Incorporation of pain management techniques into daily life .

Incorporation of strategies necessary to modify fatigue as part of the daily activities

attain a nd maintain optimal functional mobility

adapt to physical and psychological changes imposed by the Rheumatic disease .

ues of effective coping behaviours for dealing with the actual or percieved limitations and role changes .

( 5) (a) medical management is alligned with phase of RA are ;-

rest and excercise ;- there should be a balanced of rest and exercise planned for the RA patient .

referral to community agencies such as the Arthiritis foundation could help the patient gain more support

Biologic response modifiers ;- group of agents consist of teh molecules produced by the cells of the immune system participate in the inflammatory reaction

Therapy ;- a formal program with occupational a nd physical therapy si prescribed to educate the patient ,about the principle of joint protection , pacing activities , work simplification ,range of motion and muscle strengthening exercises .

Nutrition ;- food selection should include the daily requirements from the basic food groups , with emphasis on foods high in the vitamin , iron,, and protein for the tissue buildding and repair /

PHARMACOLOGIC THERAPY ;-

the drugs used in RA phases are include ;- NSAID.COX- 2 , Methotrexate and analgesic ,cyclosporine and corticosteroids , immunosuppressants and antidepressants

(b) As most of the arthritis patient take methotrexate orally , in a dose consisting of several pills ,but some there findings that splitting the dose eases GI side effects .So we instruct the H.M to take this medicine half in the morning and the other half 12 hours later , preferably with the food , also along with this recommended anti- nausea medication.