HESI Case Study: Rheumatoid Arthritis with Joint Arthroplasty
At the next clinic visit, the client reports that the pain is better controlled, and they can move their joints more freely. The client reports that they are less fatigued and that they are coping better on a day-to-day basis.
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The client's healthcare provider prescribes morphine via patient-controlled analgesia (PCA) intravenous infusion pump with a demand dose of 1 mg and a lockout interval of 6 minutes. Patient-controlled analgesia via intravenous infusion is used to allow clients ready access to analgesia. The client can receive analgesia more rapidly, which makes her feel more in control of her pain management.
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The nurse's assessment findings include the following: temperature 102.6° F (39.2°C), pulse 128 beats/minute, respiratory rate 22 breaths/minute, blood pressure 102/56 mmHg. The client reports having chills and increased incisional pain. Breath sounds are clear, and oxygen saturation is 97% on room air. The client's surgical dressings are dry and intact. Pedal pulses are 2+ bilaterally, and capillary refill is 2 seconds in both feet. The nurse notifies the surgeon of the changes in the client's condition.
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19. Which intervention should the nurse implement first?
Assess the client's vital signs and check the surgical dressings. Further assessment of the client's condition is the highest priority. The nurse should first assess the client's vital signs and the appearance of the surgical dressings.
10. The client continues to express how hard it is on their spouse and children. The client feels they have no options in life. What is the nurse's best response to this remark?
"There are surgical options that may help. Would you like to discuss those options?" Making a client-focused suggestion offers the client an alternative without being confrontational or belittling.
After further discussion with the spouse and the nurse, the client expresses interest in learning more about the possibility of joint replacement. After consulting with a surgeon, the client decides to undergo bilateral knee arthroplasty.
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For the next 2 years, the client experiences several exacerbations of symptoms, followed by lengthy periods of remission. During a routine visit to the clinic, the client states that they are having more bad days than good days lately and their knees are so swollen and painful that it is hard to walk. The client conveys that they are spending all their time in a wheelchair and they just don't think life is worth living if they have to live like this forever. The client is concern about the children. The client states that their spouse has to do everything and they would be better off without them.
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Four hours later, the client notifies the nurse that they are having pain in both knees, even with the PCA pump. The client reports that the pain is an 8 on a scale of 1 to 10 with 10 being the worst pain that they have ever had.
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Methotrexate is an immunosuppressive agent. This cytotoxic drug is administered weekly in the treatment of RA. The client must be monitored carefully for side effects and toxic effects, including mouth sores, pneumonitis, liver inflammation, and bone marrow suppression.
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The nurse contacts the surgical physician's assistant (PA), who provides the following verbal prescription: hydrocodone/acetominophen 7.5/500 mg, 2 tablets by mouth for pain.
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The nurse observes correct crutch positioning, observes the client using the crutches correctly for bed to chair transfers, and reviews the technique for a four-point gait, which is used when partial weight-bearing on both feet is allowed and provides maximum support for the client.
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Following surgery, the client is transferred to the Surgical Nursing Unit. She is placed on a continuous passive motion (CPM) machine to begin her rehabilitation.
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On the second postoperative day, the client's IV is converted to a saline lock, the PCA pump is discontinued, and the client is started on hydrocodone/acetaminophen by mouth, every 6 hours PRN. The client reports that the incisional pain is a 6 on a 10-point scale during physical therapy, despite receiving analgesic prior to the scheduled therapy.
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The client's infection is successfully resolved without the onset of septic shock, and she is preparing for discharge. The nurse includes a review of crutch walking techniques taught by physical therapy in the discharge teaching plan.
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Crutches require strong upper arm strength. The client's use of crutches will be primarily for transfers, since the rheumatoid arthritis limits extensive use of crutches for ambulation. The nurse observes the client standing with her crutches.
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During the client's postoperative period, the nurse assigned to the client is also providing care for four other postoperative clients with the assistance of an unlicensed assistive personnel (UAP).
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The evening of the client's second postoperative day, the UAP reports to the nurse that the client is complaining of extreme fatigue. The client has asked for several additional blankets and told the UAP that they wanted to be left alone. The clients explains that they are cold and their knees hurt terribly.
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22. The nurse notifies the healthcare provider and obtains wound and blood cultures. The client is started on levofloxacin 750 mg every 24 hours, a primary IV of Ringer's Lactate at 125 mL/hour, and a cooling blanket. The prescription for levofloxacin is in a 100 mL piggyback bag of sodium chloride 0.9%. How many mL/hour would the nurse set the infusion pump on to deliver the IV levofloxacin over 2 hours? (Enter numerical value only. If rounding is necessary, round to the whole number.)
50 ml/hr -- Formula: Amount of solution (mL)/time in hours = mL/hr 100 mL/2 hours = 50 mL/hour
Meet the Client
A client visits the healthcare clinic. The client reports experiencing increasing bilateral joint pain, especially in her hands, wrists, and knees. The client also reports increasing fatigue and a weight loss of 5 pounds (2.3 kg) over the last 2 months and states she has been taking a couple of aspirins a day, but the joint pain is increasing. The client is hesitant to take more medication without a medical evaluation. The client appears tense and anxious, and states that she is upset because it is becoming increasingly more difficult to do all the little things necessary to care for three children. The client states she is too young to have arthritis. The client's initial medical diagnosis is rheumatoid arthritis, and she is scheduled for diagnostic evaluation.
7. The client is experiencing impaired mobility. Which nursing intervention is best to implement for this nursing problem?
Advise the client to take a hot shower in the morning to prevent morning stiffness. Morning stiffness can be reduced by taking a hot shower in the morning.
Which tasks can be delegated to the UAP? (Select all that apply. One, some, or all options may be correct.)
Apply antiembolic hose. This is an activity that can be delegated to a UAP. Activities delegated to a UAP should fall within the intervention component of the nursing process, and should not require the expertise of a licensed nurse. Remove the CPM machine while assisting the client to bathe. The UAP can remove the CPM machine while performing hygiene.
Which positioning indicates that the crutches are sized correctly?
Arms flexed 30 degrees, crutch top 3 finger-widths from axilla. Correct positioning includes the arms flexed at no more than 30 degrees, with the tops of the crutches 2 to 3 finger-widths from the axilla when the crutch tips are at least 6 inches in front of the foot.
21. Which manifestations may indicate the onset of septic shock? (Select all that apply. One, some, or all options may be correct.)
Decreased urinary output. Decreased urinary output is a sign of septic shock. Altered mental status. Early signs of shock include altered mental status, agitation, and restlessness resulting from cerebral hypoxia. The nurse should assess carefully for these early symptoms. Other manifestations may include pallor, diaphoresis, hypotension, tachypnea, and tachycardia.
8. Which nursing intervention will promote improved coping for the client?
Discuss with the client how to work through problems that can arise while managing her condition. This is an important nursing intervention. Clients experiencing a high level of stress may need guidance to solve even simple problems. In addition, support groups are often beneficial for clients coping with chronic disease.
2. Which etiologic factor is related to the onset of rheumatoid arthritis?
Genetic predisposition. It likely results from a combination of genetics and environmental triggers. An autoimmune cause is currently the most widely accepted theory. This theory suggests chances of RA begin when a genetically susceptible person has an initial immune response to an antigen. Although a bacterium or virus could be the possible antigen, no infection or organism has been found to date.
1. Which nursing intervention related to the scheduled bone scan is most important to implement?
Inform the client that radioisotope will be administered 2 hours before the procedure. Radiosotope is given 2 hours before the bone scan. The client should also be instructed that because the dose of radioisotope is minimal, no special precautions are necessary.
3. The nurse completes an assessment of the client. In addition to the bilateral swollen tender joints, weight loss, and fatigue, what additional manifestations of RA might the client exhibit? (Select all that apply. One, some, or all options may be correct.)
Joints tender, painful, and warm to the touch. In RA, joints are tender, painful, and warm to the touch. Fever. A persistent low-grade fever is a common early manifestation of this inflammatory disease. Remember, RA is both a local and systemic inflammatory disease with many generalized symptoms such as fever, fatigue, and weakness, along with multiple lung, cardiac, and renal manifestations. Swan neck deformity of fingers. Swan neck deformity of the fingers is one of several types of deformities that can be manifested in RA. Bilateral symmetric joint involvement. The symptoms usually include bilateral, symmetric joint involvement.
5. Which adverse effect of methotrexate places the client at the highest risk for infection?
Leukopenia. Methotrexate is a drug that suppresses immune function, placing the client at high risk for infection due to a decrease of leukocytes. The client with leukopenia should be instructed to institute measures to avoid infections.
Which professionals have prescriptive authority that can provide a prescription for a different analgesic?
Nurse practitioner. A nurse practitioner, an advanced practiced registered nurse, may legally prescribe medications either autonomously or as outlined in a collaboration practice agreement based on the state requirements. Physician's assistant. A physician's assistant (PA), working in collaboration with a physician, may legally prescribe medications.
Which intervention should the nurse prepare to implement?
Obtain cold packs or a cooling blanket. The client is exhibiting symptoms of sepsis. Infection is a significant postoperative problem following joint replacement. Wound and blood cultures should be obtained, antipyretics administered, and cooling packs applied to reduce the fever.
Nursing Problems and Interventions
Over the next several months, the client returns regularly to the clinic for ongoing management of the RA, but their pain, fatigue, and joint mobility continue to worsen. The client cries during every clinic visit, and expresses to the nurse that they can't take care of their children without help because of their physical limitations. The nurse establishes a plan of care for the client, based on the following priority nursing problems: Pain due to inflammation. Altered physical mobility due to pain and reduced joint motion. Altered parenting due to physical limitations. Ineffective coping related to dependence on others.
The nurse performs neurovascular assessment of the client's feet every 2 hours. Which assessment finding should be reported to the healthcare provider?
Pallor to right foot only. Pallor to an affected extremity may indicate neurovascular compromise. Following any trauma or invasive procedure such as join arthroplasty, adequacy of neurovascular function distal to the site must be assessed regularly. This includes assessment for the six Ps: Pulselessness, Pain, Pallor, Paresthesia, and Paralysis, as well as Prolonged (> 3 seconds) capillary refill.
15. Which intervention should the nurse implement first?
Perform a neurovascular assessment. The nurse should always assess the client first because pain may indicate a complication that requires medical intervention.
Which postoperative intervention should the nurse expect to implement?
Perform regular neurovascular assessment. Postoperatively, regular neurovascular assessments must be performed.
6. Which information should be included when teaching the client how to manage her chronic pain? (Select all that apply. )
Protect joints from stress. While RA is a progressive chronic disease, emphasis needs to be made to help the client identify ways to alter her tasks to put less stress on joints. Apply cold packs to affected joints. Heat applications will increase blood supply to the joints, decrease pain, and increase mobility and are recommended for chronic pain. Cold applications may also be used, primarily for acute pain flare-ups. Alternate scheduled rest period with activity throughout the day. This will help to relieve fatigue and pain. Avoid topical analgesics when using heat therapy. A topical analgesic such as capsaicin cream provides significant reduction of knee pain when used in conjunction with regular arthritis medications. Topical analgesics should NOT be used in combination with heat treatments.
18. What is the best nursing action in response to this order?
Repeat the verbal order back to the PA for clarification and completeness of the order. The nurse should repeat the verbal order back to the prescriber for clarification and to verify that the order is complete. This order is incomplete and requires clarification from the prescriber. Remember the six rights: right client, drug, dose, route, time, documentation. The PRN frequency (right time) is missing from this order. A correct medication order includes not only the six rights, but also the prescriber's signature and the date and time written.
11. Which best describes arthroplasty?
Surgical reconstruction or replacement of a joint. Arthroplasty is the term used for total joint replacement. Hip replacement is the most common joint arthroplasty, followed by knee replacement. Clients with rheumatoid arthritis may also benefit from elbow, wrist, or finger arthroplasty.
Diagnostic Evaluation
The client is scheduled for a Complete Blood Count (CBC), rheumatoid factor (RF), erythrocyte sedimentation rate (ESR), joint x-rays, and a bone scan. Additional diagnostic tests, which may be performed to help diagnose rheumatoid arthritis, include an MRI, synovial fluid analysis, or a synovial biopsy.
23. Which outcome is most important for this portion of the teaching plan?
The client successfully demonstrates the correct use of crutches for ambulation and transfers. The best method to evaluate that a skill has been learned is by the performance of a return demonstration by the client.
Pharmacologic Therapy
The nurse's assessment findings for the client include stiffness and swelling of wrists and elbows, with a decreased range of motion in these joints. On palpation of the joints, the nurse notes that the joints feel somewhat soft. The client indicates that they have experienced a slight fever, run-down feeling, and a loss of appetite that has resulted in her 5 pound (2.3 kg) weight loss. The client's healthcare provider (HCP) prescribes the following medications: - Buffered aspirin: 500 mg by mouth (PO) daily. - Auranofin: 6 mg by mouth (PO) daily. - Methotrexate: 2.5 mg by mouth (PO) every 12 hours for 3 doses, then 7.5 mg by mouth (PO) weekly. Auranofin is a gold compound used in RA for its anti-inflammatory, anti-arthritis, and immune-modifying effects. In addition to these medications, corticosteroids such as prednisone may be prescribed in the treatment of rheumatoid arthritis. The nurse is aware that aspirin is a salicylate with excellent anti-inflammatory, anti-pyretic, and analgesic properties. However, it does have the potential for causing significant side effects and toxicity, especially in the high doses needed to manage the symptoms of rheumatoid arthritis.
4. Which assessment findings may indicate aspirin toxicity (salicylism)? (Select all that apply.)
Tinnitus and headache. Symptoms of aspirin toxicity include tinnitus, sweating, headache, and dizziness. Sweating and dizziness. Symptoms of aspirin toxicity include tinnitus, sweating, headache, and dizziness.
14. Which instruction should the nurse include when teaching the client about the PCA pump?
You can request additional pain medication if your pain is not controlled with the pump. It is the nurse's responsibility to assess the client's response to the analgesia, including assessment of vital signs, level of consciousness, and effectiveness of the pain control.
9. What is the nurse's best response?
You seem very concerned about how this is impacting your family and you. Clarification of the client's feelings is a therapeutic technique which will encourage further communication.
