•Auto immunity
• Pearson, 3rd ed. P. 540
• Janice James is a 42-year-old high
school science teacher who began
noticing vague joint pain and
general malaise, which she initially
attributed to a case of the flu. She
then noticed aching in hands and
Case wrists, which she attributed to the
quilting she loves to do in the
scenario evenings. She presented to her
provider office after noticing
swelling and warmth, reporting
that it is especially stiff in the
mornings. She also reports a 10-
pound weight loss
• What cues require follow up?
• At this point, what might the
patient be experiencing?
Application of NGN- Bow tie question:
Complete the diagram by dragging or selecting from the choices below to specify which
potential condition the patient is experiencing, two findings that support this condition
and two potential medications to treat that condition.
Supportive Potential
assessment finding intervention
Condition most likely
experiencing
Supportive Potential
assessment finding intervention
Supportive assessment Condition most likely Potential medications
finding experiencing
Stiffness in the mornings Osteoarthritis Ibuprofen
Weight loss Rheumatoid arthritis Alendronate
Joint pain Osteoporosis Methotrexate
pharmacologic Non-pharmacologic
patho Rheumatoid arthritis
Manifestations:
Articular Extra-articular
Nursing considerations:
pharmacologic Non-pharmacologic
Patho Rheumatoid arthritis
Auto immune-
auto antibodies attack
synovium-ongoing
inflammatory process
– causes degradation
of cartilage and bone
Manifestations:
Articular Extra-articular
Nursing considerations:
pharmacologic Non-pharmacologic
Patho Rheumatoid arthritis
Auto immune- auto
antibodies attack
synovium-ongoing
Inflammatory
process – causes
degradation of
cartilage and bone
Labs: Rheumatoid
factors
ESR (elevated), CBC
(WBC
Manifestations:
Articular Extra-articular
Nursing considerations:
Physical findings
• What will be expected findings on physical
assessment?
pharmacologic Non-pharmacologic
Patho Rheumatoid arthritis
Auto immune- auto
antibodies attack
synovium-ongoing
Inflammatory
process – causes
degradation of
cartilage and bone
Labs: Rheumatoid
factors
ESR (elevated), CBC
(WBC
Manifestations:
Articular Extra-articular
Nursing considerations:
-Edema, pain in affected
joints- warm to touch
and boggy, spongy feel
-erythema in joints
-stiffness in mornings
-pain in joints at rest
-Classic joint
deformities (later signs)-
Boutinniere, Swan
Neck, ulnar deviation
pharmacologic Non-pharmacologic
Patho Rheumatoid arthritis
Auto immune- auto
antibodies attack
synovium-ongoing
Inflammatory
process – causes
degradation of
cartilage and bone
Labs: Rheumatoid
factors
ESR (elevated), CBC
(WBC
Manifestations:
Articular Extra-articular
Nursing considerations:
-Low grade fever
-Anorexia/ weight
-Edema, pain in affected
joints- warm to touch loss
and boggy, spongy feel -Fatigue
-erythema in joints -Muscle
-stiffness in mornings
weakness/atrophy
-pain in joints at rest
-
-Classic joint Lymphadenopathy
deformities (later signs)- -Iron resistant
Boutinniere, Swan
Neck, ulnar deviation
anemia
-Subcutaneous
nodules
What pharmacologic
treatments would you expect
for treatment of a condition
that involves inflammation and
an overactive immune system?
Treatments
What non-pharmacologic
treatments might be indicated
here?
pharmacologic Non-pharmacologic
Patho Rheumatoid arthritis NSAIDs- anti-inflammatory,
Auto immune- auto long term adverse effects
antibodies attack
synovium-ongoing
Inflammatory
process – causes
degradation of
cartilage and bone
Labs: Rheumatoid
factors
ESR (elevated), CBC
(WBC
Manifestations:
Articular Extra-articular
Nursing considerations:
-Low grade fever
-Anorexia/ weight
-Edema, pain in affected
joints- warm to touch loss
and boggy, spongy feel -Fatigue
-erythema in joints -Muscle
-stiffness in mornings
weakness/atrophy
-pain in joints at rest
-
-Classic joint Lymphadenopathy
deformities (later signs)- -Iron resistant
Boutinniere, Swan
Neck, ulnar deviation
anemia
-Subcutaneous
nodules
pharmacologic Non-pharmacologic
Patho Rheumatoid arthritis NSAIDs- anti-inflammatory,
Auto immune- auto long term adverse effects
-DMARDs*
antibodies attack *Disease modifying anti-
synovium-ongoing rheumatic drugs*
1.Hydroxychloriquine-
Inflammatory antimalarial agent- anti-
process – causes inflammatory- need dilated
eye exam q 6 months
degradation of
cartilage and bone 2. methotrexate-
immunosuppressant- bone
Labs: Rheumatoid marrow suppression
factors
ESR (elevated), CBC 3. Biologic response modifiers-
target specific cytokines- “-
(WBC imabs”, “umabs”, “cepts”
-etanercept
-adalimimub, -infliximabs
Manifestations:
4. corticosteroids
Articular Extra-articular
Nursing considerations:
-Low grade fever
-Anorexia/ weight
-Edema, pain in affected
joints- warm to touch loss
and boggy, spongy feel -Fatigue
-erythema in joints -Muscle
-stiffness in mornings
weakness/atrophy
-pain in joints at rest
-
-Classic joint Lymphadenopathy
deformities (later signs)- -Iron resistant
Boutinniere, Swan
Neck, ulnar deviation
anemia
-Subcutaneous
nodules
Nursing actions
• What actions are indicated for Ms. James?
• Is there any action that needs to be prioritized?
• What do you think will be most important to
include in the Ms. James’ education?
pharmacologic Non-pharmacologic
Patho Rheumatoid arthritis NSAIDs- anti-inflammatory,
Auto immune- auto long term adverse effects 1.Physical
-DMARDs* therapy- promote
antibodies attack *Disease modifying anti- strength and
synovium-ongoing rheumatic drugs* mobility
1. methotrexate-
Inflammatory immunosuppressant- bone 2. Occupational
process – causes marrow suppression therapy- ADL
assistance
degradation of 2. Hydroxychloriquine- 3. Exercise
cartilage and bone antimalarial agent- anti-
balanced with
inflammatory- need dilated
Labs: Rheumatoid eye exam q 6 months rest
factors 4. Psychosocial
ESR (elevated), CBC 3. Biologic response support
modifiers- target specific 5. Mind-body
(WBC cytokines, like tumor necrosis
factor- “-imabs”, “umabs”, therapies-yoga,
“cepts” Tai Chi
Manifestations: -etanercept, abatacept 6. alt. rx-
-adalimimub, -infliximabs acupuncture,
Articular Extra-articular Reiki
4. corticosteroids
Nursing considerations:
-Low grade fever
-Anorexia/ weight
-Edema, pain in affected
joints- warm to touch loss
and boggy, spongy feel -Fatigue
-erythema in joints -Muscle
-stiffness in mornings
weakness/atrophy
-pain in joints at rest
-
-Classic joint Lymphadenopathy
deformities (later signs)- -Iron resistant
Boutinniere, Swan
Neck, ulnar deviation
anemia
-Subcutaneous
nodules
pharmacologic Non-pharmacologic
Patho Rheumatoid arthritis NSAIDs- anti-inflammatory,
Auto immune- auto long term adverse effects 1.Physical
-DMARDs* therapy- promote
antibodies attack *Disease modifying anti- strength and
synovium-ongoing rheumatic drugs* mobility
1.Hydroxychloriquine-
Inflammatory antimalarial agent- anti- 2. Occupational
process – causes inflammatory- need dilated therapy- ADL
eye exam q 6 months assistance
degradation of
3. Exercise
cartilage and bone 2. methotrexate-
balanced with
immunosuppressant- bone
Labs: Rheumatoid marrow suppression rest
factors 4. Psychosocial
ESR (elevated), CBC 3. Biologic response modifiers- support
target specific cytokines- “- 5. Mind-body
(WBC imabs”, “umabs”, “cepts”
-etanercept therapies-yoga,
-adalimimub, -infliximabs Tai Chi
Manifestations: 6. alt. rx-
4. corticosteroids acupuncture,
Articular Extra-articular Reiki
Nursing considerations:
-Low grade fever
-Anorexia/ weight 1. Physical assessment: focus on MS
-Edema, pain in affected
joints- warm to touch loss system, joint deformities,
functionality, dexterity (ADLs)
and boggy, spongy feel -Fatigue
2. Safety: ambulation, reduce risk of
-erythema in joints -Muscle injury, safe environment
-stiffness in mornings
weakness/atrophy 4. Nutrition: encourage foods high in
-pain in joints at rest
- vitamins, protein and iron (healing),
small frequent meals
-Classic joint Lymphadenopathy 5. Interdisciplinary collaboration: PT,
deformities (later signs)- -Iron resistant OT, home care, assistive devices
Boutinniere, Swan
Neck, ulnar deviation
anemia 6. Encourage as much independence
-Subcutaneous as possible- adaptive devices
7. Patient teaching
nodules
