Nursing > Case Study > HESI Case Study Meet the Client: Terry Bames Terry Barnes a 35-year-old mother | Rheumatoid Arthriti (All)
Rheumatoid Arthritis with Joint Arthroplasty Instructions Meet the Client: Terry Barnes Terry Barnes, a 35-year-old mother of three young children, visits the healthcare clinic. She reports experi... encing increasing bilateral joint pain, especially in her hands, wrists, and knees. She also reports increasing fatigue and a weight loss of 5 pounds over the last 2 months. She states she has been taking a couple of aspirins a day, but the joint pain is increasing, and she is hesitant to take more medication without a medical evaluation. She 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 her three children. She states, "I'm too young to have arthritis. That's something you get when you're old." Terry's initial medical diagnosis is rheumatoid arthritis, and she is scheduled for diagnostic evaluation. Diagnostic Evaluation Terry is scheduled for a CBC (complete blood count), RF (rheumatoid factor), ESR (erythrocyte sedimentation rate), joint x-rays, and a bone scan. Additional diagnostic tests, which may be performed to help diagnose rheumatoid arthritis, include MRI and synovial fluid analysis, or synovial biopsy. 1. Which nursing intervention related to the scheduled bone scan is most important to implement? A) Ask the client if she has any internal metal devices. This is an important measure prior to an MRI, because the magnetic force may cause movement of internal metal devices. B) Assess the joint puncture site for signs of inflammation. This is an important intervention after synovial joint fluid analysis. Joint fluid for analysis is obtained using sterile procedure, but the client should be monitored carefully after the procedure for any signs of bleeding or infection at the site of the needle insertion. C) Advise the client that the test requires lying still in an enclosed cylinder. This is an important intervention prior to an enclosed MRI, since clients with claustrophobia may have difficulty in an enclosed space. D) Instruct Terry to increase fluid intake after the test. Increasing fluid intake after a bone scan will help with elimination of the injected radioisotope. Terry should also be instructed that because the dose of radioisotope is minimal, no special precautions are necessary. Etiology/Risk Factors Terry's test results confirm the diagnosis of rheumatoid arthritis. Her CBC shows normochromic anemia, her RF is positive, and her ESR is elevated. The x-rays and bone scan show evidence of rheumatoid arthritis. Terry is told of her diagnosis of rheumatoid arthritis (RA). She expresses confusion, and states, "How did I get this? What is it? How long will I be like this?" The nurse provides the following explanation: Rheumatoid arthritis is an autoimmune disease affecting not only joints, but organ systems as well. The symptoms of this inflammatory disease can often be controlled, but the disease itself cannot be cured. It is a chronic, progressive disease that seems to affect women more often than men. 2. Which etiologic factor is related to the onset of rheumatoid arthritis? A) Increasing age. The onset of rheumatoid arthritis (RA) occurs primarily between the ages of 35-45, although it can occur at any age. B) Genetic predisposition. Because the incidence of RA in persons with a positive family history is significantly greater than for the general population, genetic predisposition is probably a significant etiologic factor. In addition, increased stress has been linked to RA, and viral infections are believed to be a trigger for the onset of this autoimmune disease. C) Environmental exposure to carcinogens. Although environmental factors may be involved, there is no clear evidence to link specific exposure to carcinogens to the onset of RA. D) History of osteoarthritis. Osteoarthritis is a degenerative joint disease, and although it is not related to RA as an etiologic factor, persons with RA may develop secondary degenerative joint disease. Clinical Manifestations The nurse completes an assessment of Terry. 3. In addition to the bilateral swollen tender joints, weight loss, and fatigue, what additional manifestation(s) of RA might Terry exhibit? (Select all that apply.) A) Finger tophi. Finger tophi are typically seen in the client with gout. B) Joint deformities. Joint deformities and subcutaneous nodules are common in advanced RA. C) Butterfly rash. A butterfly rash on the face is a classic manifestation of systemic lupus erythematosus (SLE) rather than RA. D) 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. E) Drooling. In fact, the client with RA is likely to experience dry mouth, which along with dry eyes, are the hallmark symptoms. In addition, Sjogren’s syndrome may cause skin, nose, and vaginal dryness. Of the several syndromes associated with advanced RA, Sjogren’s syndrome is the most common. Pharmacologic Therapy The nurse's assessment findings for Terry include stiffness and swelling of her 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. Terry indicates that she has experienced a slight fever, run-down feeling, and a loss of appetite that has resulted in her 5-pound weight loss. Terry's healthcare provider prescribes the following medications: Buffered aspirin 500 mg PO daily. Auranofin (Ridaura) 6 mg PO daily. Methotrexate (Mexate) 2.5 mg PO every 12 hours for 3 doses, then 7.5 mg weekly. Ridaura is a gold compound used in RA for its antiinflammatory, antiarthritis, and immunemodifying 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 antiinflammatory, antipyretic, 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? A) Diminished bowel sounds and constipation. These are not manifestations of aspirin toxicity. B) Hypoventilation and altered breath sounds. These are not manifestations of aspirin toxicity. C) Halo vision and green-blue visual changes. These are not manifestations of aspirin toxicity. D) Ringing in the ears and confusion. Symptoms of aspirin toxicity include tinnitus, confusion, weakness, GI bleeding, and diarrhea. Methotrexate (Mexate) 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. 5. Which adverse effect of methotrexate places Terry at the highest risk for infection? A) Neutropenia. Decreased levels of neutrophils place the client at high risk for infection. The client with neutropenia should be instructed to institute measures to avoid infections. B) Anemia. Anemia causes fatigue, which places the client at risk for injury. C) Thrombocytopenia. A decreased platelet level increases the client's risk for bleeding. D) Alopecia. Hair loss may place the client at risk for altered body image. Nursing Diagnoses and Interventions Over the next several months, Terry returns regularly to the clinic for ongoing management of her RA, but her pain, fatigue, and joint mobility continue to worsen. Terry cries during every clinic visit, and expresses to the nurse that she can't take care of her children without help because of her physical limitations. The nurse establishes a plan of care for Terry, based on the following priority nursing diagnoses: Pain related to inflammation. Impaired physical mobility related to pain and reduced joint motion. Impaired parenting related to physical limitations. Ineffective coping related to dependence on others. 6. Which information should be included when teaching Terry how to manage her chronic pain? A) Remember that the pain will never be fully controlled. While RA is a progressive chronic disease, pain control measures can be implemented to ensure that Terry feels a sense of control regarding pain management. B) Apply warm packs to affected joints. Heat applications will increase blood supply to the joints, decrease pain, and increase mobility. Cold applications may also be used, primarily for acute pain flare-ups. C) Keep the affected extremities elevated. This will not help to manage the chronic pain related to RA. D) Only use analgesics for severe pain episodes. Some pain medication can be used on a regular basis in divided doses to ensure a constant therapeutic level of the analgesic in the bloodstream. Terry is experiencing impaired mobility. 7. Which nursing intervention is best to implement for this nursing diagnosis? A) Advise Terry to soak in a hot tub before bedtime to prevent morning stiffness. This will not prevent morning stiffness, a common problem in RA. However, morning stiffness can be reduced by taking a hot shower in the morning. B) Consult a physical therapist regarding crutch-walking techniques. RA is a disease that requires the expertise of the entire interdisciplinary team. Occupational and physical therapists can teach Terry to use a wide variety of assistive equipment, such as raised commode seats and walkers, as well as fine motor adaptive equipment, such as special zipper pulls and shoe horns. However, crutch-walking is not a form of assistance that is valuable for the client with RA, since crutches require strong upper arm strength. C) Discourage Terry from resting during the daytime. It is important for the client with RA to obtain adequate rest, since fatigue is a significant manifestation. Rest periods and planning activities to conserve energy should be encouraged rather than discouraged. D) Instruct Terry regarding the use of joint splints. Joint splints provide rest and support for the joints while maintaining good anatomical alignment. 8. Which nursing intervention will promote improved coping for Terry? A) Instruct Terry to minimize contact with her children to reduce stress. Although stress management is an important intervention to reduce chronic pain and fatigue, minimizing contact with her children is more likely to increase Terry's stress level and reduce her coping ability. B) Advise Terry not to burden others with her concerns. Clients with limited coping ability need support. Terry may need referral to a social worker or mental health counselor if she is unable to discuss her concerns with friends or family members. C) Encourage Terry's husband to make all major decisions. Terry's husband may need to assist Terry while her coping is ineffective, but she should not be excluded from the decision-making process. D) Help Terry practice problem-solving techniques. 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. At the next clinic visit, Terry reports that her pain is better controlled, and she is able to move her joints more freely. She reports that she is less fatigued and that she is coping better on a day-to-day basis. Therapeutic Communication: Depression For the next 2 years, Terry experiences several exacerbations of her symptoms, followed by lengthy periods of remission. During a routine visit to the clinic, Terry states, "I'm having more bad days than good days lately. My knees are so swollen and painful that it is hard to walk. I'm spending all my time in this wheelchair. I just don't think life is worth living if I have to live like this forever. All I can think about is how my children don't have a mother anymore. My husband has to do everything. What's the point of trying anymore? They would be better off without me." 9. What is the nurse's best response? A) "You seem very overwhelmed right now." Clarification of Terry's feelings is a therapeutic technique which will encourage further communication. B) "We will discuss this when you are not so depressed." This response is a block to further communication. C) "If I were in your situation, I'd be depressed, too." This response is not therapeutic and may block further communication. D) "I will call the hospital chaplain to talk with you." Spiritual support may be included in the plan of care, but the nurse should ask first if Terry would like to speak with a spiritual advisor. Terry continues, "It is so hard on my husband. It seems I have no options in my life." 10. What is the nurse's best response to this remark? A) "Since you are so depressed right now, you should reduce your dose of pain medication." The use of the phrase "you should" is a signal of a non-therapeutic response. Giving advice is non-therapeutic and discourages the client from sharing further concerns. In addition, reducing Terry's dose of analgesia will increase her pain and worsen her depression. Terry needs to be referred for evaluation of her depression. B) "Have you considered the possibility of surgical joint replacement?" Making a client-focused suggestion offers Terry an alternative without being confrontational or belittling. C) "You will feel better if you focus on positive things rather than negative things." Telling Terry how she will feel belittles her actual feelings and is a block to further communication. This also offers false reassurance. D) "I'm sure your husband is really very glad to be able to do things for you." This is an assumption and a platitude which blocks further communication. It does not address Terry's desire to have options. Surgical Management: Joint Arthroplasty After further discussion with her husband and the nurse, Terry expresses interest in learning more about the possibility of joint replacement. After consulting with a surgeon, Terry decides to undergo bilateral knee arthroplasty. 11. What is the best definition of arthroplasty? A) Observation of the joint through a scope. This is called joint arthroscopy. A number of procedures can be done through an arthroscope, including ligament repair. B) Surgical joint replacement. 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. C) Surgical Arthrodesis. Surgical repair would have a more specific name defining the repair done, such as repair of a torn ligament, fracture fixation, etc. D) Surgical removal of a body part. Terms used to describe cutting out, or surgical removal, end with the suffix "ectomy," as in appendectomy, cholecystectomy, or lumpectomy. Following surgery, Terry is transferred to the Surgical Nursing Unit. She is placed on a continuous passive motion (CPM) machine to begin her rehabilitation. 12. Which postoperative intervention should the nurse expect to implement? A) Use an abduction pillow to maintain abduction of both legs. Abduction is maintained following total hip replacement to ensure that the joint replacement does not become dislodged, but this is not necessary following knee arthroplasty. B) Ensure that the weights are hanging freely on the traction. Traction is not used following knee arthroplasty. C) Monitor cast for drainage and signs of infection. A cast is not used following knee arthroplasty. A surgical compression dressing is used. D) Empty drainage from the suction device and record the output. A drainage device, such as a Hemovac or Jackson-Pratt suction device, is put in place during surgery. The nurse should monitor the amount and nature of the drainage, and report excessive or abnormal drainage to the surgeon. In addition, the nurse should assess the surgical compression dressing, and mark any areas of drainage on the dressing. The nurse performs neurovascular assessment of Terry's feet every 2 hours. 13. Which assessment finding should be reported to the healthcare provider? A) 3+ dorsalis pedis pulses bilaterally. The presence and character of pulses is an important part of a neurovascular assessment, but this assessment finding is normal. B) Presence of paresthesia bilaterally. Paresthesia is an abnormal sensation such as numbness or tingling that may indicate neurovascular compromise. Following any trauma or invasive procedure of a lower extremity, adequacy of neurovascular function distal to the site must be assessed regularly. This includes assessment for the six Ps: Pulselessness, Pain, Palor, Paresthesia, and Paralysis, as well as Prolonged (> 3 seconds) capillary refill. C) Lack of pedal edema bilaterally. This is a normal assessment finding. D) Capillary refill of 2 seconds bilaterally. The rate of capillary refill is an important part of a neurovascular assessment, but capillary refill of less than 3 seconds is a normal assessment finding. Client Teaching: Patient-Controlled Analgesia Terry'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 10 minutes. Patient-controlled analgesia via intravenous infusion is used to allow clients ready access to analgesia. Terry can receive analgesia more rapidly, which makes her feel more in control of her pain management. 14. Which instruction should the nurse include when teaching Terry about the PCA pump? A) "If you press the button too often, an alarm will sound." The pump will record the number of times Terry presses the button, but it will not sound an alarm. The nurse can review the history to obtain information about Terry's use of the PCA to assess the effectiveness of the analgesia. B) "The pump is set to prevent you from receiving an overdose." Terry needs to know that the lockout feature prevents an overdose of the analgesic, since this is often a fear that prevents adequate analgesia. However, the nurse will still need to monitor Terry for indications that the prescribed dose is not excessive. C) "The pump will track and record your level of pain regularly." It is the nurse's responsibility to assess Terry's response to the analgesia, including assessment of vital signs, level of consciousness, and effectiveness of the pain control. D) "The pump will ensure that you get plenty of pain medication." As with any type of analgesic prescription, the dose may be insufficient to control Terry's pain. The nurse should instruct Terry to notify the nurse if the pain control is inadequate. Four hours later, Terry notifies the nurse that she is having pain in both of her knees, even with the PCA pump. Terry reports that the pain is an 8 on a scale of 1-10 with 10 being the worst pain that Terry has every had. 15. Which intervention should the nurse implement first? A) Administer a rescue dose of morphine 5 mg IVP. Although the nurse may eventually need to administer a rescue dose of an analgesic, another intervention should be done first. B) Assess Terry and rule out any possible complications. The nurse should always assess the client first because pain may indicate a complication that requires medical intervention. C) Stop the continuous passive motion machine and notify the physical therapist. The CPM machine may need to be stopped, but not prior to implementing another intervention first. D) Evaluate Terry's blood work including WBC, hemoglobin, and hematocrit. The nurse may need to evaluate the blood work, but it is not the first nursing intervention. Management Considerations: Delegation During Terry's postoperative period, the nurse assigned to Terry is also providing care for four other postoperative clients with the assistance of an unlicensed assistive personnel (UAP). 16. Which task can be delegated to the UAP? A) Teach Terry how to use her incentive spirometer. Teaching the client is a nursing responsibility and should not be delegated to a UAP. B) Empty Terry's catheter drainage bag and record her urinary output. 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. C) Revise Terry's care plan to include frequent rest periods. Development and revision of the plan of care is the responsibility of the RN. D) Change Terry's postoperative dressing. As a general rule, non-licensed nursing personnel do not perform sterile procedures such as a postoperative dressing change. Ethical-Legal Issues: Prescriptive Authority On her second postoperative day, Terry's IV is converted to a saline lock, her PCA pump is discontinued, and she is started on hydrocodone/acetaminophen (Lortab) by mouth, every 6 hours PRN. Terry reports her incisional pain is a 6 on a 10-point scale during her physical therapy, despite receiving her analgesic prior to the scheduled therapy. 17. Which professional has prescriptive authority that can provide a prescription for a different analgesic? A) Physical therapist. Physical therapists may not legally prescribe medications. B) House nursing supervisor. An RN acting in a house supervisor role may not legally prescribe medications. C) Physician's assistant. A physician's assistant (PA), working in collaboration with a physician, may legally prescribe medications. D) Hospital pharmacist. Pharmacists are licensed to dispense medications, but not to prescribe them. The nurse contacts the surgical physician's assistant (PA), who provides the following verbal prescription: Hydrocodone/acetominophen (Lortab) 7.5/500 mg, 2 tabs PO PRN for pain. 18. What is the best nursing action in response to this prescription? A) Contact Terry's rheumatologist to report an ly written prescription. The person prescribing the medication should be contacted by the nurse for clarification of a prescription. B) Notify the PA that the prescription must be written, rather than verbal, to be legal. Verbal prescriptions are legal prescriptions. However, they should be cosigned by the prescriber within 24 hours. Although legal, remember that verbal prescriptions are a significant cause of medication errors and should be avoided if at all possible. C) Contact the PA for clarification of this incomplete prescription. This prescription is incomplete and requires clarification from the prescriber. Remember the five rights: right client, drug, dose, route, and time. The PRN frequency (right time) is missing from this prescription. A medication prescription includes not only the five rights, but also the prescriber's signature and the date and time written. D) Administer the prescription, which is a legally prescription. This prescription is not complete. A complete prescription not only meets legal standards, but provides sufficient direction to the nurse administering the medication. A Complication Occurs The evening of Terry's second postoperative day, the UAP reports to the nurse that Terry is complaining of extreme fatigue. She has asked for several additional blankets and told the UAP, "Just leave me alone. I don't feel good. I'm so cold, and my knees hurt terribly." 19. Which intervention should the nurse implement first? A) Cancel Terry's evening physical therapy session. If Terry is developing a postoperative complication, her therapy may need to be cancelled. However, this is not the highest priority nursing action. B) Administer a PRN dose of hydrocodone/acetominophen. Prior to administration of an analgesic/antipyretic, the nurse has a more important priority. C) Assess Terry's vital signs, including her temperature. Further assessment of Terry's condition is the highest priority. The nurse should first assess Terry's vital signs and the appearance of the surgical dressing. D) Obtain a pulse oximeter and measure Terry's oxygen saturation level. Terry is not exhibiting overt indications of a respiratory problem. The nurse will obtain this data, but it is not the highest priority intervention. Sepsis The nurse's assessment findings include: T 103° F, P 132, R 18, BP 102/56. Terry complains of having chills and increased incisional pain. Her breath sounds are clear, and her oxygen saturation is 97% on room air. Her surgical dressings are dry and intact. Her pedal pulses are 2+ bilaterally, and her capillary refill is 2 seconds in both feet. The nurse notifies the surgeon of the changes in Terry's condition. 20. Which intervention should the nurse prepare to implement? A) Obtain wound and blood cultures. Terry 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. B) Elevate both legs on pillows. There is no reason to initiate this intervention at this time. However, Terry should be monitored closely for the onset of septic shock. If shock develops, she should be positioned with her feet slightly elevated. C) Administer a unit of packed red blood cells. Although her blood pressure is a little low, there is no indication that bleeding is occurring, since the dressing is dry. Terry's RBC, hemoglobin and hematocrit should be obtained to assess for bleeding. D) Administer oxygen per nasal cannula. Oxygen is not needed at this time, since she is not exhibiting respiratory distress and her oxygen saturation is within normal limits (WNL). However, her respiratory status should be monitored carefully for the onset of septic shock. 21. Which manifestation may indicate the onset of septic shock? A) Hypertension. The client in shock will exhibit hypotension rather than hypertension. B) Restlessness. Early signs of shock include 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. C) Polyuria. The client in shock will exhibit diminished urinary output rather than increased output. D) Rash and itching. These are manifestations of an allergic response rather than septic shock. The nurse notifies the healthcare provider, and obtains wound and blood cultures. Terry is started on IV gentamicin (Garamycin) 250 mg every 6 hours, a primary IV of Ringer's Lactate at 125 ml/hour and a cooling blanket. 22. The prescription for gentamicin (Garamycin) is in a 50 mL piggyback bag of 0.9% normal saline. How many mL/hour would the nurse set the infusion pump on to deliver the IV gentamicin (Garamycin) over 30 minutes? (Enter numerical value only. If rounding is necessary, round to the whole number.) 100 50 mL/30 minutes = X mL/60 minutes 300 = 30X X = 100 mL hour The nurse continues to monitor Terry closely for symptoms of septic shock, and to monitor the patient’s renal function while on gentamicin. Discharge Preparation: Crutch Walking Terry'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 in the discharge teaching plan. 23. Which outcome is most important for this portion of the teaching plan? A) Terry states that her children will enjoy helping her. This is a positive outcome, but is not the most important outcome for the skill of crutch walking. B) Terry reports that she feels confident she can use crutches ly. This is a relevant outcome statement, but it is not the most important for the skill of crutch walking. C) Terry describes the use of crutches for ambulation and transfers. This is a relevant outcome statement, but it is not the most important outcome for the skill of crutch walking. D) Terry demonstrates the 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. Crutches require strong upper arm strength. Terry's use of crutches will be primarily for transfers, since her rheumatoid arthritis limits extensive use of crutches for ambulation. The nurse observes Terry standing with her crutches. 24. Which positioning indicates that the crutches are sized ly? A) Arms fully extended, crutch top secure under the axilla. This positioning indicates the crutches are too long for Terry. B) Arms flexed 20 degrees, crutch top two finger-widths from axilla. positioning includes the arms flexed at no more than 30 degrees, with the tops of the crutches 2 – 3 finger-widths from the axilla when the crutch tips are at least 6 inches in front of the foot. C) Arms flexed 45 degrees, crutch top 4 inches from axilla. This positioning indicates the crutches are too short for Terry. D) Arms flexed 90 degrees, crutch top 6 inches from axilla. This positioning indicates the crutches are too short for Terry. The nurse observes crutch positioning, observes Terry using the crutches ly 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. Case Outcome Terry is discharged from the hospital. When her husband and children arrive to take her home, the older children excitedly tell Terry how they have helped prepare her room. Terry will receive postoperative care from the home health nurse until she is able to resume her regular visits to the healthcare clinic for management of her rheumatoid arthritis. Continue [Show More]
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