Rheumatoid Arthritis Case Analysis
Content
Bingcang, April Ann C. Bramaje, Jomalyn H. Carpo, Czoren John Casaclang, Eryn Maryse Raizel A. del Rosario, Robea Mae A. Dela Cruz, Cristine Joy S. Dunuan, Jovelyn T. Lopez, Jeffordson B.
Maria Chavez is a 67 year old widow who has been using 6g (18 tablets) of aspirin daily for the past 2 years for the treatment of rheumatoid arthritis. During the last 3 weeks she has gradually become more lethargic. Friends have indicated that she does not appear well. Diagnostic testing reveals the presence microcytic, hypochromic RBCs accompanied by a hemoglobin level of 8mg/dl. The physician prescribes: > Ferrous sulfate tablets 300mg, 1 tab 3 times a day Several weeks late Mrs. Chavez complains of constipation and darkened stools.
1. What circumstances may have contributed to the development to the development of Mrs. Chavez’ anemia? 2. What is the probable cause of the lethargy? 3. How long must her iron therapy be continued? 4. How could the client’s most recent symptoms be explained? 5. What nursing interventions would be appropriate in caring for this client?
1.
Mrs. Chavez’ anemia is caused by taking aspirin for 2 years for the treatment of her rheumatoid arthritis. Aspirin is used to control inflammatory process and the side effect of this drug is Bone marrow suppresion and increase bleeding tendencies. If there is a bone marrow suppresion, the erythropoietin levels will reduce and bone marrow suppresion can lead to decrease production of RBC, the hemoglobin level will then decrease leading to anemia as showned to Mrs. Chavez’ laboratory result, her hemoglobin level was 8gm/dl (Normal value: for female,12 to 16gm/dl). In addition to Mrs. Chavez’ with rheumatoid arthritis taking up Ferrous sulfate, she do not have enough iron available to get into RBCs. This iron deficiency is usually caused by a problem getting the iron from within the bone marrow into the RBCs leading again to anemia.
2. The probable cause of lethargy on the case of Mrs. Chavez was her anemia. Hemoglobin is carried by red cells, but when there are not enough red cells, your body’s organs do not get enough oxygen and can lead to lethargy or fatigue. Another is Mrs. Chavez’ joint pains because of her rheumatoid arthritis.
3. For Mrs. Chavez, her blood counts should return to normal after 2 months of iron therapy. However, iron therapy should be continued for another 6 - 12 months to replenish the body's iron stores in the bone marrow.
4. Absorption of iron from the intestinal tract is affected by several factors. When your body is unable to absorb all of the iron from the pills, you will excrete more of it through your stool. This changes the color of your stool, making it blacker, and reduces the amount of water the stool can retain. With a reduced amount of water, you are at higher risk of constipation.
5. Nursing interventions for rheumatoid arthritis: Pain
› Help manage pain by responding immediately to
complaints, providing medication as ordered by physician, encouraging frequent rest between activities and providing distractions. Hot or cold compresses may also provide relief.
Daily Living Activities
› The patient may need help dressing, bathing,
performing range of motion exercises and other daily activities. If muscle weakness is present, the patient may be unsteady and require assistance walking.
Emotional Support
› Encourage the patient to talk about feelings and
promote a sense of independence by allowing her to perform as many tasks as possible. Monitor for signs of depression and low self-esteem.
Nursing interventions for Anemia:
Measure temperature of bath water with thermometer because anemia may cause poor circulation. Provide blankets and warm clothing to increase comfort and aid circulation. Notify physician if excessive vomiting, coughing or straining at stools occurs so that medication can be prescribed to alleviate symptom. Avoid aspirin-containing products to prevent bleeding. Avoid forceful blowing. Avoid contact on gingival when brushing and flossing teeth. Avoid situations in which trauma may occur, such as shaving with straight-edge razor, ambulating after taking medication that may cause orthostasis, or using sharp utensils.
Avoid purseful sexual intercourse and use adequate lubrication. Avoid rectal thermometers, suppositories, and enemas. Avoid heating pads or hot water bottles. Iron salts are gastric irritants and should always be taken following meals. Iron preparation taken on empty stomach cause dyspepsia, abdominal discomfort, and diarrhea Liquid iron preparations should be well diluted and taken through a straw (undiluted liquid iron stains teeth). Use of stool softeners or laxative to avoid PRN to avoid straining.
Ascorbic acid (Vitamin C) promotes iron absorption, thus iron preparations should be taken with orange juice. Bowel movements will be black from excess iron excretion. Iron supplements usually given for at least 6 months to restore body stores. Keep skin clean and bedclothes dry. Encourage diet high in protein, vitamins, and minerals. Encourage cool, bland foods; flavored ices and ice cream are well tolerated. Monitor Hb/Hct and assess whether other factors (e.g., nutritional deficiencies, fluid and electrolyte disorders, depression, etc.) are contributing to symptomatology. Assess activity schedule and suggest daily activities that allow for rest periods. Transfuse whole blood and packed red blood cells as ordered by physician
Nursing interventions for Constipation:
Observe usual pattern of defecation including time of day, amount and frequency of stool, consistency of stool, history of bowel habits or laxative use; diet including fluid intake; exercise patterns; personal remedies for constipation. Review client's current medications. Many medications affect normal bowel function, including ferrous sulfate Palpate for abdominal distention, percuss for dullness, and auscultate bowel sounds. In clients with constipation the abdomen is often distended with a palpable colon Provide privacy for defecation. Assist the client to the bathroom and close the door if possible. Bowel elimination is a very private act, and a lack of privacy can contribute to constipation.
Encourage fiber intake of 25 g/day for adults. Emphasize foods such as fresh fruits, beans, vegetables, and bran cereals. Add fiber to diet gradually. Fiber helps prevent constipation by giving stool bulk. Add fiber to diet gradually because a sudden increase can cause bloating, gas, and diarrhea. A daily fiber intake of 25 g can increase frequency of stools in clients with constipation. Encourage a fluid intake of 1.5 to 2 L/day (6 to 8 glasses of liquids per day). If oral intake is low, gradually increase fluid intake. Fluid intake must be within the cardiac and renal reserve. Adequate fluid intake is necessary to prevent hard, dry stools. Increasing fluid intake to 1.5 to 2 L/day along with fiber intake of 25 g can significantly increase frequency of stools in clients with constipation.
Initiate a regular schedule for defecation, using the client's normal evacuation time whenever possible. Offer hot coffee, hot lemon water, or prune juice before breakfast, or while sitting on the toilet if necessary. An optimal time for many individuals is 30 minutes after breakfast because of the gastrocolic reflex. A schedule gives the client a sense of control, but more importantly it promotes evacuation before drying of stool and constipation occur. Hot liquids can stimulate peristasis and result in defecation Provide laxatives, suppositories, and enemas as needed and as ordered only; establish a client goal of eliminating their use. Avoid soapsuds enemas, or use a low concentration of castile soap only. Use of laxatives should be avoided. Soapsuds enemas can cause damage to the colonic mucosa. The use of a soapsuds enema was shown to increase stool output as compared with tap water enemas in preoperative liver transplant patients; amount of mucosal irritation was unknown.
Maria Chavez is a 67 year old widow who has been using 6g (18 tablets) of aspirin daily for the past 2 years for the treatment of rheumatoid arthritis. During the last 3 weeks she has gradually become more lethargic. Friends have indicated that she does not appear well. Diagnostic testing reveals the presence microcytic, hypochromic RBCs accompanied by a hemoglobin level of 8mg/dl. The physician prescribes: > Ferrous sulfate tablets 300mg, 1 tab 3 times a day Several weeks late Mrs. Chavez complains of constipation and darkened stools.
1. What circumstances may have contributed to the development to the development of Mrs. Chavez’ anemia? 2. What is the probable cause of the lethargy? 3. How long must her iron therapy be continued? 4. How could the client’s most recent symptoms be explained? 5. What nursing interventions would be appropriate in caring for this client?
1.
Mrs. Chavez’ anemia is caused by taking aspirin for 2 years for the treatment of her rheumatoid arthritis. Aspirin is used to control inflammatory process and the side effect of this drug is Bone marrow suppresion and increase bleeding tendencies. If there is a bone marrow suppresion, the erythropoietin levels will reduce and bone marrow suppresion can lead to decrease production of RBC, the hemoglobin level will then decrease leading to anemia as showned to Mrs. Chavez’ laboratory result, her hemoglobin level was 8gm/dl (Normal value: for female,12 to 16gm/dl). In addition to Mrs. Chavez’ with rheumatoid arthritis taking up Ferrous sulfate, she do not have enough iron available to get into RBCs. This iron deficiency is usually caused by a problem getting the iron from within the bone marrow into the RBCs leading again to anemia.
2. The probable cause of lethargy on the case of Mrs. Chavez was her anemia. Hemoglobin is carried by red cells, but when there are not enough red cells, your body’s organs do not get enough oxygen and can lead to lethargy or fatigue. Another is Mrs. Chavez’ joint pains because of her rheumatoid arthritis.
3. For Mrs. Chavez, her blood counts should return to normal after 2 months of iron therapy. However, iron therapy should be continued for another 6 - 12 months to replenish the body's iron stores in the bone marrow.
4. Absorption of iron from the intestinal tract is affected by several factors. When your body is unable to absorb all of the iron from the pills, you will excrete more of it through your stool. This changes the color of your stool, making it blacker, and reduces the amount of water the stool can retain. With a reduced amount of water, you are at higher risk of constipation.
5. Nursing interventions for rheumatoid arthritis: Pain
› Help manage pain by responding immediately to
complaints, providing medication as ordered by physician, encouraging frequent rest between activities and providing distractions. Hot or cold compresses may also provide relief.
Daily Living Activities
› The patient may need help dressing, bathing,
performing range of motion exercises and other daily activities. If muscle weakness is present, the patient may be unsteady and require assistance walking.
Emotional Support
› Encourage the patient to talk about feelings and
promote a sense of independence by allowing her to perform as many tasks as possible. Monitor for signs of depression and low self-esteem.
Nursing interventions for Anemia:
Measure temperature of bath water with thermometer because anemia may cause poor circulation. Provide blankets and warm clothing to increase comfort and aid circulation. Notify physician if excessive vomiting, coughing or straining at stools occurs so that medication can be prescribed to alleviate symptom. Avoid aspirin-containing products to prevent bleeding. Avoid forceful blowing. Avoid contact on gingival when brushing and flossing teeth. Avoid situations in which trauma may occur, such as shaving with straight-edge razor, ambulating after taking medication that may cause orthostasis, or using sharp utensils.
Avoid purseful sexual intercourse and use adequate lubrication. Avoid rectal thermometers, suppositories, and enemas. Avoid heating pads or hot water bottles. Iron salts are gastric irritants and should always be taken following meals. Iron preparation taken on empty stomach cause dyspepsia, abdominal discomfort, and diarrhea Liquid iron preparations should be well diluted and taken through a straw (undiluted liquid iron stains teeth). Use of stool softeners or laxative to avoid PRN to avoid straining.
Ascorbic acid (Vitamin C) promotes iron absorption, thus iron preparations should be taken with orange juice. Bowel movements will be black from excess iron excretion. Iron supplements usually given for at least 6 months to restore body stores. Keep skin clean and bedclothes dry. Encourage diet high in protein, vitamins, and minerals. Encourage cool, bland foods; flavored ices and ice cream are well tolerated. Monitor Hb/Hct and assess whether other factors (e.g., nutritional deficiencies, fluid and electrolyte disorders, depression, etc.) are contributing to symptomatology. Assess activity schedule and suggest daily activities that allow for rest periods. Transfuse whole blood and packed red blood cells as ordered by physician
Nursing interventions for Constipation:
Observe usual pattern of defecation including time of day, amount and frequency of stool, consistency of stool, history of bowel habits or laxative use; diet including fluid intake; exercise patterns; personal remedies for constipation. Review client's current medications. Many medications affect normal bowel function, including ferrous sulfate Palpate for abdominal distention, percuss for dullness, and auscultate bowel sounds. In clients with constipation the abdomen is often distended with a palpable colon Provide privacy for defecation. Assist the client to the bathroom and close the door if possible. Bowel elimination is a very private act, and a lack of privacy can contribute to constipation.
Encourage fiber intake of 25 g/day for adults. Emphasize foods such as fresh fruits, beans, vegetables, and bran cereals. Add fiber to diet gradually. Fiber helps prevent constipation by giving stool bulk. Add fiber to diet gradually because a sudden increase can cause bloating, gas, and diarrhea. A daily fiber intake of 25 g can increase frequency of stools in clients with constipation. Encourage a fluid intake of 1.5 to 2 L/day (6 to 8 glasses of liquids per day). If oral intake is low, gradually increase fluid intake. Fluid intake must be within the cardiac and renal reserve. Adequate fluid intake is necessary to prevent hard, dry stools. Increasing fluid intake to 1.5 to 2 L/day along with fiber intake of 25 g can significantly increase frequency of stools in clients with constipation.
Initiate a regular schedule for defecation, using the client's normal evacuation time whenever possible. Offer hot coffee, hot lemon water, or prune juice before breakfast, or while sitting on the toilet if necessary. An optimal time for many individuals is 30 minutes after breakfast because of the gastrocolic reflex. A schedule gives the client a sense of control, but more importantly it promotes evacuation before drying of stool and constipation occur. Hot liquids can stimulate peristasis and result in defecation Provide laxatives, suppositories, and enemas as needed and as ordered only; establish a client goal of eliminating their use. Avoid soapsuds enemas, or use a low concentration of castile soap only. Use of laxatives should be avoided. Soapsuds enemas can cause damage to the colonic mucosa. The use of a soapsuds enema was shown to increase stool output as compared with tap water enemas in preoperative liver transplant patients; amount of mucosal irritation was unknown.
