Rheumatoid Arthritis 1

The patient comes to the clinic with symptoms of fatigue and hand and wrist pain for three
months. The patient reports the fatigue has started to interfere with sleep and NSAIDS have
provided minimal pain relief. The nurse assess that the proximal interphalangeal and
metacarpophalangeal joints of both hands are warm, swollen, and painful to touch with limited
ROM. Diagnostic tests reveal a positive rheumatoid factor, elevated antinuclear antibody
(ANA), and ESR of 32 mm/hr. The patient is diagnosed with RA, and the healthcare provider
prescribes a regimen of prednisone 10 mg orally daily, methotrexate (Rheumatrex) 15 mg orally
weekly, and folate once per day.

1. What clinical manifestations of RA did the patient exhibit? Explain the pathophysiologic
basis for these clinical manifestations. (List three and discuss completely)

a. Fatigue:

Fatigue is a subjective symptom; it is a sense of overwhelming tiredness that is not

completely relieved by sleep or rest. Fatigue may occur in patients with many different diseases
and thereby in patients with RA. Some studies have found evidence for the relationship between
disease-related variables and fatigue. For example, higher levels of fatigue were associated with
pain, disturbed sleep, increased physical effort (overdoing routine activities), absence of regular
exercise, gender, stress, depressive symptoms, medication side effects, poor nutrition and
inflammation. The relationship between these variables and fatigue in RA is not fully
understood. For example, disturbed sleep may be related to disease activity and consequently
related to fatigue. It appears that a combination of variables is the underlying reason for RA
fatigue.
One possible explanation of the pathophysiology of fatigue in RA involves inflammation.
The inflammation associated with RA produces chemicals called cytokines that commonly cause
fatigue. Cytokines are the chemical messengers of the immune system. There are over 150
different kinds of these protein-based molecules. Cells use these chemicals as a means of
communication. Cells can talk to each other through Cytokines, but in Rheumatoid Arthritis,
excess amounts of them are produced and dumped off into the bloodstream. In addition to
fatigue, some theorize that cytokines cause several RA symptoms, including anemia, sleep
problems, and skeletal muscle shrinkage. Cytokines are reduced by TNF blocking medications
 Rheumatoid Arthritis 2

(like Enbrel). Resulting is lessened fatigue. This is one of the reasons that fatigue is said by some
to mirror disease activity or reflect inflammation levels. When medications slow inflammation,
fatigue tends to moderate.
Other legitimate theories for explaining the fatigue of RA involves anemia and nutritional
deficiencies. Both the disease and some of its treatments can reduce red blood cells. In anemia,
the decrease in hematocrit, hemoglobin, and red blood cells leads to a decrease in oxygen
transported to cells consequently feelings of fatigue. Finally, people with RA tend to decrease
their exercise and thus lose stamina and muscle strength and this might also play a role in their
fatigue. The fatigue of Rheumatoid Arthritis is not caused by exertion. However, activity can
aggravate it. Rest is critical to surviving life with Rheumatoid Arthritis, but it will not prevent
the fatigue.
In spite of the sometimes inconsistent findings, consensus on the large impact fatigue has
on quality of life in RA patients exists. RA patients described fatigue as unpredictable,
overwhelming and different from normal tiredness because it is extreme. It is often unresolved
not earned, and has a greater impact on daily life than pain.
b. Pain:

“In early disease, the fingers may become spindle shaped from synovial hypertrophy and
thickening of the joint capsule. Joints become tender, painful, and warm to the touch. Joint pain
increases with motion, varies in intensity, and may not be proportional to the degree of
inflammation. Tenosynovitis frequently affects extensor and flexor tendons around the wrists,
producing manifestations of carpal tunnel syndrome and making it difficult for the patient to
grasp objects” (Roberts, 2007, p. 1703). Stiffness lasts 1 hour to all day and may decrease with
use. Pain is variable and may disrupt sleep.
Patients with long standing RA or untreated RA could also have pain because of the
nodular myositis and muscle fiber degeneration. This type of pain is similar to vascular
insufficiency. The nodular myositis occurs when the nodules within the muscles becomes
inflamed. Muscle degeneration occurs because of the systemic inflammatory process.
c. Swelling/tenderness of the joints:
Muscle and joint stiffness are usually most notable in the morning and after periods of inactivity.
Morning stiffness may last from 60 minutes to several hours or more, depending on disease
activity. Arthritis is common during disease flares. Also during flares, joints frequently become
 Rheumatoid Arthritis 3

red, swollen, painful, and tender. This occurs because the lining tissue of the joint (synovium)
becomes inflamed, resulting in the production of excessive joint fluid (synovial fluid). The
synovium also thickens with inflammation (synovitis).

2. What discharge teaching instructions should the nurse provide for prednisone,
methotrexate (Rheumatrex), and folate therapy? Be specific and thorough for each
medication.

a. Prednisone:

The nurse should teach the client that prednisone is a corticosteroid. It is used to decrease
inflammation and improve adrenal function. Prednisone helps to control the symptoms of RA
such as tenderness, joint swelling and heat. Instruct the patient that she should take 10 mg daily
by mouth. This dose is within therapeutic range. Patient teaching should include:
1. Use of an emergency ID that include information on product being taken. As
corticosteroid user, an emergency ID is needed as it will help medical personnel to decide
what medication can be administered to patient in an emergency situation as prednisone
reacts with certain medications such as, NSAIDS, barbiturates, cyclosporine, salicylates,
toxoids, troleandomcyin, and potassium depleting drugs such as thiazide.
2. Patient should be encouraged to talk with their doctor about the use of NSAIDS because
of the drug interaction with prednisone. NSAIDS could increase the risk of GI distress
and bleeding.
3. Notify prescriber if therapeutic response decreases as dosage adjustment may be needed.
Teach patient that a decreased therapeutic response may be evidenced by increase in heat,
swelling, and/or tenderness of joints.
4. Teach patient that they are not to receive any “live" vaccine which are : Rubella (German
measles) Oral polio vaccine (OPV) Varicella (chickenpox) vaccine while taking
prednisone as it could also result in serious complications such as infection. Also
vaccines may not work as well as they should while taking steroids.
 Rheumatoid Arthritis 4

5. Patient should be informed that they should not stop using prednisone suddenly as they
may experience unpleasant withdrawal symptoms such as rebound inflammation, fatigue,
weakness, fever, dizziness, fainting, orthostatic hypotension, dyspnea, and anorexia.
Patient should talk to their doctor about how to avoid withdrawal symptoms when
stopping prednisone.
6. Encourage patient to avoid OTC products while on prednisone; salicylates, cough
products with alcohol, cold preparations should be avoided unless directed by prescriber.
These products often results in negative interactions with prednisone. Alcohol may
increase the risk of stomach and intestinal bleeding because it irritates the mucosa.
7. Educate patient on cushingoid symptoms (moon face, weight gain). This is a possible
side effect of prednisone therapy. Prednisone therapy increases appetite; however inform
patient that the weight will slowly return to normal once the product is discontinued.
8. Prednisone can cause immunosuppressant; so report any symptoms of infection (fever,
sore throat, avoid being near people who are sick or have infections.
9. Patient should be made aware of the symptoms of adrenal insufficiency: nausea,
anorexia, fatigue, dizziness, dyspnea, weakness, joint pain. These symptoms indicate an
adverse reaction to the drug.
10. Notify all physicians providing treatment of the use of prednisone as the medicine can
cause unusual results with certain medical tests.
11. It is recommended that prednisone be taken with food. Taking the drug with food helps
to relief GI irritation.
12. Encourage patient to increase the intake of vitamin D and calcium to prevent the bone
loss/osteoporosis associated with prednisone use.
13. Take prednisone exactly as prescribed. Do not take the medication in larger amounts, or
take it for longer than recommended by the doctor. Follow the directions on the
prescription label.
14. Tell the patient to report slow wound healing as this could be an indication of a
suppressed immune system.
b. Methotrexate (Rheumatrex):

Methotrexate is the drug of choice for treating RA. Its functional class is an antineoplastic and
antimetabolite. Methotrexate is a non-biologic DMARD (disease-modifying anti-rheumatic drug)
 Rheumatoid Arthritis 5

used to treat certain types of arthritis and rheumatic conditions. Methotrexate is classified as a
DMARD because it decreases pain and swelling associated with arthritis, and also, methotrexate
can lessen joint damage and lower the risk of long-term disability. Improvement from
methotrexate may be seen at 6 weeks but it may take 12 weeks or even 6 months of treatment for
full benefit to be realized.
While the drug is effective for many arthritis patients, there are warnings to ensure safe
use of the drug. The usual dosage is taken orally, 7.5 mg/wk or divided doses of 2.5 mg every 12
hours three times every week, maximum of 20 mg/wk. Therefore, the prescribed dose of 15 mg
weekly is below toxic levels and safe. Proper patient teaching will include the following:
1. Instruct the patient to report any complaints or side effects to the nurse or
prescriber. Some of the side effects to report are black tarry stools, chills, fever, sore throat,
bleeding, bruising, cough, SOB, dark or bloody urine, and seizures. These signs and
symptoms indicate adverse reaction to the drug and needs to be closely monitored by
physician.
2. The patient should be reminded that hair may be lost during treatment; wig or
hairpiece may make patient feel better. This is done to help cope with the disturbed body
image experienced by many patients with RA.
3. Encourage patients to avoid foods with citric acids, hot or rough texture if they
have stomatitis. These types of food will irritate the mucosa and worsen the stomatitis.
4. Report stomatitis: any bleeding, white spots, or ulcerations in mouth to prescriber;
patient should examine their mouth daily, and use good oral hygiene. Impaired skin
integrity will increase susceptibility to infection. This is of particular concern because the
patient is taking immunosuppressant drugs that also increase susceptibility to infection.
5. Contraceptive measures are recommended during therapy and for at least 8 or 12
weeks following cessation of therapy as Methotrexate must not be used during pregnancy
as it may cause fetal harm. If patient becomes pregnant or think they may be pregnant, they
should inform their doctor immediately.
6. Advice women to discontinue breastfeeding during therapy because Methotrexate
passes into breast milk and toxicity to infant may occur.
7. Drink 10-12 glasses of fluid per day. Drinking plenty of fluids while taking
methotrexate helps the kidneys to remove the medication from the body and minimize
 Rheumatoid Arthritis 6

some of the side effects of the medication.

8. The nurse should teach the patient to avoid alcohol, salicylates, live vaccines,
theophylline (coffee, chocolate etc) because they increase the toxicity of methotrexate.
Folate on the other hand decreases the therapeutic effects of the drug. Therefore, patient
should take folate as prescribed and consult with physician regularly to monitor
methotrexate levels.
9. The nurse should encourage the patient to take precautions against bleeding by
avoiding use of razors, commercial mouthwash, aspirin, and NSAIDs.
10. Use sun block to prevent burns. This medication may make you more sensitive to
the sun. Therefore, patient should be encouraged to avoid prolonged sun exposure, tanning
booths or sunlamps. Use a sunscreen and wear protective clothing when outdoors.
11. Inform patient that while using methotrexate, they may become dizzy or drowsy
so use caution when engaging in activities requiring alertness such as driving or using
machinery. Avoid alcoholic beverages as when used with methotrexate will cause CNS
changes i.e. may make patient less alert and increase dizziness.
12. Patients should be reminded that methotrexate suppresses the immune system and
increases susceptibility to infections. Therefore, patients should be advised to report any
changes in breathing or coughing avoid persons with respiratory infections or crowed
places and implement proper hand washing practices, as washing hands will help to prevent
the spread of infections.
13. It is important to teach patient use each dose at the scheduled time. If dose is
missed, patient should contact the doctor or pharmacist immediately to establish a new
dosing schedule. Do not double the doses to catch up, as it could cause medication toxicity.
c. Folate Therapy:
Folate (folic acid) is a vitamin B complex. As a medication, folic acid is used to treat
folic acid deficiency and certain types of anemia (lack of red blood cells) caused by folic acid
deficiency. It increases RBC, WBC and platelet formations. The patient mentioned in the case
study was prescribed methotrexate. Since methotrexate is a folic acid antagonist, folic acid must
be replenished by taking a 1 mg folic acid supplement daily. Folic acid supplementation should
also minimize side effects associated with taking methotrexate.
Methotrexate is called a "folate antagonist" because it prevents the body from converting
 Rheumatoid Arthritis 7

folate to its active form. In fact, this inactivation of folate plays a role in methotrexate's
therapeutic effects. Methotrexate use can lead to folate deficiency. Individuals who take
methotrexate for rheumatoid arthritis, juvenile rheumatoid arthritis, or psoriasis can safely use
folate supplements; not only does the methotrexate continue to work properly, but its usual side
effects may decrease also.
1. The nurse should instruct the client to take one folate tablet daily. The patient should be
made aware that flushing and bronchospasm could occur, but are not common.
Bronchospasm is a serious side effect that prevents breathing and should be immediately
reported (go to the emergency room)
2. Notify prescriber of other allergic reactions, such as rash, itching/swelling (especially of
the face/tongue/throat), and dizziness.
3. Inform the patient of other medication side effects such as nausea, bloating, flatulence,
cramps, bitter taste, and diarrhea, irritability, excitability, general malaise, altered sleep
patterns, vivid dreaming, overactivity, confusion, impaired judgment, increased seizure
frequency, and psychotic behavior. Very high doses can cause significant central nervous
system (CNS) side effects. Supplemental folic acid might increase seizures in people with
seizure disorders, particularly in very high doses.
4. Take product exactly as prescribed to prevent adverse effects; periodic lab work will be
required to monitor red blood cells, hemoglobin, hematocrit, white blood cells and
platelet levels.
5. Patient should alter nutrition to include high folic acid foods: organ meats, vegetables,
fruit. Folic acid is normally found in foods such as dried beans, peas, lentils, oranges,
whole-wheat products, liver, asparagus, beets, broccoli, brussel sprouts, and spinach.
4. Urine may turn bright yellow because of the chemical compositon of the drug.
5. Folic acid may mask the symptoms of pernicious, aplastic, or normocytic anemias caused
by vitamin B12 deficiency and may lead to neurological damage.
7. Avoid breastfeeding because it could cause toxicity in the infant.
3. What are four minimum interventions the nurse can suggest to manage the patient's
fatigue?

In inflammatory arthritis, such as rheumatoid arthritis or lupus, the disease may be causing the
 Rheumatoid Arthritis 8

fatigue. This is a more serious kind of fatigue, and improving living patterns will not help much.
In such cases the sedimentation rate is elevated and there may be a low-grade fever. A
hematocrit test may show the anemia of chronic disease. There may be some weight loss.
Treatment in these cases is directed at the disease causing the fatigue and may take some time.
However, there are some therapeutic interventions meant to assist the patient:
1) Assess patient’s signs and symptoms of pain and administer pain medication as
prescribed. Monitor and record the medication’s effectiveness and adverse effects. Assessment
allows for care plan modification as needed. Collaborate with patient in administering prescribed
analgesics when alternative methods of pain control are inadequate. Gaining patient’s trust and
involvement helps ensure compliance and may reduce medication intake. Perform comfort
measures to promote relaxation, such as massage, bathing, repositioning, and relaxation
techniques. These measures reduce muscle tension or spasm, redistribute pressure on body
parts, and help patient focus on non-pain-related subjects.
2) Encourage the patient to keep a 24-hour fatigue/activity log for at least 1 week.
Recognizing relationships between specific activities and levels of fatigue can help the patient
identify excessive energy expenditure. The log may indicate times of day when the person feels
the least fatigued. This information can help the patient make decisions about arranging his or
her activities to take advantage of periods of high energy levels.
3) Assist the patient to develop a schedule for daily activity and rest. A plan that
balances periods of activity with periods of rest can help the patient complete desired activities
without adding to levels of fatigue.
4) Refer the patient to an occupational therapist. The occupational therapist can provide
the patient with assistive devices and teach the patient energy conservation techniques.
5) Encourage the patient to use assistive devices for ADLs and IADLs:
-Long-handled sponge for bathing
-Long shoehorn
-Sock-puller
-Long-handled grabber
The use of assistive devices can minimize energy expenditure and prevent injury with activities.
6) Monitor the patient’s nutritional intake for adequate energy sources and metabolic
requirements. The patient will need adequate intake of carbohydrates, protein, vitamins, and
 Rheumatoid Arthritis 9

minerals to provide energy resources. Encourage nutritional foods and refer to a dietitian as
necessary; nutritionally balanced diets may boost energy; frequent, small meals and simple-to-
digest foods are beneficial when combating fatigue; reduce amounts of caffeine and sugar can
improve sleep and energy.
4. Choose two nursing diagnosis appropriate for a patient with RA. One should be
physiologic and the other psychosocial. Be sure to explain why you have chosen them. .

a. Chronic pain
Chronic pain is described as unpleasant sensory and emotional experience arising from
actual or potential tissue damage. Pain can appear suddenly or have a slower onset with an
intensity range from mild to severe. Pain may be constant or recurring without an anticipated or
predictable end and a duration of greater than six months. It can be periodically disabling.
The client is presenting with symptoms indicative of chronic pain as evidenced by reports
of hand/wrist pain active for the last three months with minimal relief from NSAID use. Since
rheumatoid arthritis is a chronic, systemic, autoimmune disorder with progressive inflammation,
it can be predicted that the client’s pain will meet the criteria of duration and intensity. The joint
pain associated with rheumatoid arthritis increases with motion and may decrease with use; so,
the client may be susceptible to activity intolerance and substantial loss of functioning and
mobility. Chronic pain can also affect sleep/rest patterns and appetite (anorexia), further
increasing fatigue and potentially contributing to activity intolerance and functioning/mobility
loss. Additionally, debilitating pain can impair the client’s ability to self-care, perform ADL’s, as
well as alter current role performance.
By utilizing interventions aimed at dealing with the client’s pain, the nurse can promote
activity tolerance and help maintain joint motion and muscle strength. Depression related to the
chronicity of the pain and the associated debilitation may be avoided as pain and its related
stress/anxiety can alter a client’s affect negatively, straining the nurse-client relationship and
potentially limiting compliance to treatment. NSAID's have not been working to provide
effective pain relief. Thus, a combination of drugs including prednisone, methotrexate, and folate
is prescribed at the time of diagnosis, aimed at controlling inflammation, slowing symptoms and
joint damage, and lessening the permanent effects of rheumatoid arthritis. Nonpharmacologic
pain relief techniques should also be utilized and taught, including therapeutic head and cold,
rest/activity balance, relaxation techniques, and joint protection.
 Rheumatoid Arthritis 10

b. Risk for disturbed body image

Disturbed body image is described as confusion and/or dissatisfaction in the mental
picture of one’s physical self. This may be due to an altered view of the body’s appearance,
structure, or functioning. And, it may be accompanied by overall negative feelings about the
body including feelings of helplessness, hopelessness, or powerlessness.
Because the client is newly diagnosed with rheumatoid arthritis, the client is just now
beginning to show clinical manifestations of the chronic condition including symmetrical
inflammation to the proximal interphalangeal and metacarpophalangeal joints of both hands as
evidenced by warm, swollen joints that are painful to the touch and exhibiting limited ROM
within the last three months. Recognizable manifestations associated with rheumatoid arthritis,
such as muscle atrophy and joint subluxation, have yet to present. So, as of now, only the risk for
disturbed body image exists. As the inflammatory response progresses, joint changes will begin
when the hypertrophied synovial membrane invades the surrounding cartilage, ligaments,
tendons, and joint capsules. Pannus forms within the joint, eventually scarring and shortening the
supporting structures and causing the aforementioned subluxation, as well as laxity and
contracture. This chronic inflammation and fibrosis may lead to the deformity and disability that
can cause the client to experience disturbed body image. In addition, 25% of clients with
rheumatoid arthritis may develop rheumatoid nodules, which can further affect joints creating
visible masses over joints, at the base of the spine, and back of the head. Nodules on the skin can
also ulcerate, similar to pressure ulcers. Vocal cord nodules can lead to progressive hoarseness.
Potential complications and side effects from recommended treatment can also lead to
dissatisfaction of the body, as the client’s current prescription of methotrexate can potentially
lead to alopecia. Hair loss is a devastating event for many, especially in the younger population
affected by the disease.
Emotional support should be integral to any treatment plan. Interventions aimed at
improving the client’s positive perception of his/her own appearance and body functions can go a
long way to improve the client’s psychological health. Self-esteem should be evaluated and the
client’s fears of future disability/deformity, as well as possible alterations in sexuality should be
discussed. The client should have a full understanding of the course of his/her condition. Before
disturbed body image has a chance to set in, the nurse can also work with the client to promote
activity tolerance and help maintain joint motion and muscle strength, through individualized
 Rheumatoid Arthritis 11

exercise and gentle ROM exercises. This can help slow down any muscle atrophy associated
with disuse, and subsequently the characteristic joint deformity that progression of rheumatoid
arthritis often leads to.

1. Which statements regarding rheumatoid arthritis (RA) are true? (Select all that apply)

a) It is a chronic, progressive, systemic inflammatory process

b) It primarily affects the synovial joints

c) It is known to have periods of remission

d) It occurs most often in older men and women

e) It often involves an inflamed, red rash

2. Because of the inflammatory process in RA, a pannus forms in the joint. What is pannus?

a) Scar tissue restricting the joint

b) Vascular granulation tissue in the joint

c) Necrotic tissue sloughing into the joint

d) Fluid encapsulated in the joint

3. What common musculoskeletal health problem is often associated with RA?

a) Paget's disease

b) Fibromyalgia

c) Marfan syndrome

d) Osteoporosis

4. Although the etiology of RA is unknown for certain, it is considered to be what type of

disorder?
a) An autoimmune disease

b) Associated with aging

 Rheumatoid Arthritis 12

c) Genetic

d) The result of joint misuse

5. In RA, autoantibodies (rheumatoid factors [RFs]) are formed that attack healthy tissue,
especially synovium, causing which condition?

a) Nerve pain

b) Bone porosity

c) Ischemia

d) Inflammation

6. Which CBC laboratory finding values does the nurse expect for the patient with RA? (Circle
high or low for each value).

a) Hemoglobin: LOW Low due to blood loss indication anemia

b) Hematocrit LOW Low due to blood loss indication anemia
c) RBC: LOW Low due to blood loss indication anemia
d) WBC: HIGH High in RA patients, signaling that infection is
present.
e) Platelets: HIGH Platelet counts are elevated when inflammation is
present in the body. (However it can be low be
lowered by certain drugs).