University of Saint Louis

Tuguegarao City, Cagayan 3500

SCHOOL OF HEALTH AND ALLIED SCIENCES

BACHELOR OF SCIENCE IN NURSING

CASE STUDY 1

Andrea Fuentes is a 58-year-old female went to the community health clinic for routine annual evaluation, Ms. Fuentes is
5'5’” and weighs 150 lbs. The RN is assigned to take her vital signs which are: BP 140/84 , Pulse 84 Resp 18 and temp. is
98.6 degrees.

On initial interview by an RN, Ms. Fuentes reports an increase in dull, aching pain around joints of the digits of the both
hands. Observation of the hands finds the evidence of early manifestations of Heberden’s and Bouchard’s nodes. On
further assessment, she reports the use of aspirin to help relieve pain, and antacids to decrease the discomfort in her
stomach, which she believes is due to the constant use of aspirin. continued gathering of data reveals lack of exercise and
years of "vegan" diet, but the use of herbs and nuts as supplements. After the RN completes the history and physical, she
is then seen by the NP who corroborates data gathered by the nurse, discuss findings with Ms. Fuentes, then orders
serum labs to help confirm the presenting symptoms and subjective data. Serum labs are ordered and reveal WBC count:
10,000 mm3, RBC count: 4.5 million/mm3, Hgb:38%, PLT: 250,000 cells/mm3, Calcium: 8.4 mg/dl, Na : 135 mEq/ L, K+4.4
mEq/L, Rheumatoid factor, antinuclear antibody, and erythrocyte sedimentation rate (ESR) are elevated.

The labs are reviewed and the client is referred to the community hospital for a magnetic resonance imaging (MRI) of the
hands and spine, Ms. Fuentes undergoes MRI of the hands and spine which reveals degenerative changes, especially of
the spine.

Aims and Purpose of the Presentation

 To analyze a 56 year old female patient’s case showing signs and symptoms of Rheumatoid Osteoarthritis. This
includes the identification of possible Pharmacologic and nonpharmacologic interventions as necessary for the
situation

Introduction to the Patient

Name: Patient A.F.
Gender: Female
Age: 56 year old

SUBJECTIVE
 Chief Complaint: Increase in Dull, aching pain around joints of the digits of the both hands and early
manifestations of Heberden’s and Bouchard’s nodes.
 History of Present Illness: The patient states that she uses aspirin to help relieve the pain and antacid to
decrease the discomfort in her stomach, which she beliefs due to the constant use of aspirin.
 Review of systems: Muskuloskeletal Systems
 Past medical and Surgical History:
 Past medical history: Patient A. F. reports that she is taking aspirin and antacids, which may indicate a
history of gastric discomfort , possibly related to aspirin use.
 Surgical History: The provided information does not specify any surgical history of the patient. It’s
possible that she may not have had any significant surgeries.
 Allergies/ Medication: Patient A.F. is taking aspirin to relieve pain and antacids to decrease the discomfort
in her stomach
 Social/Work History: NA
 Family History: NA
OBJECTIVE
The objective data obtained from the physical examination will be utilized to identify and elucidate the pertinent
clinical findings and to develop an accurate understanding of the patient’s current medical condition.
 Physical examination
 Height: 5’5”
 Weight: 150lbs
 Blood Pressure: 140/80
 Pulse rate : 84
 Respiration Rate: 18
 Temperature: 98.6 F(37 C)

 Laboratory and Other tests:

 Serum labs were ordered and results revealed that the WBC, HGB, RBC, HCT, PLT count are all in
normal range
 The results also showed an elevated Rheumatoid factor which is an indicator of rheumatoid arthritis
because it is an auto-antibody that attack healthy joint tissue.
 Elevated antinuclear antibody level suggests the presence of auto-antibodies that can target the cell
nucleus, although not specific to rheumatoid arthritis, a positive antinuclear can be seen in
autoimmune diseases that includes Rheumatoid arthritis
 Elevated Erythrocyte Sedimentation rate. Increased ESR is observed in rheumatoid arthritis due to the
chronic inflammatory process affecting the joints
 Magnetic resonance imaging (MRI) on the hands and spine revealed degenerated changes, especially
in the spine

ASSESSMENT
 Working Diagnosis/ Differential diagnosis: Rheumatoid Arthritis
 Differential Diagnoses:
 Rheumatoid Arthritis (RA): the presence of joint pain and the early manifestations of Heberden’s and
Bouchard’s nodes are indicative of Rheumatoid arthritis. Elevated Rheumatoid factor, antinuclear
antibody, and ESR further support this diagnosis
 Osteoarthritis: while the patient present in joint pain, osteoarthritis can also be considered due to her
age and degenerative changes noted in the MRI. However, the elevation of specific laboratory markers
like rheumatoid factor and antinuclear antibody suggests an autoimmune condition more closely
aligned with RA
 Gastrointestinal distress: the use of aspirin and antacids for stomach discomfort may indicate
gastrointestinal issues related to long-term aspirin used. However, it’s important to rule out other
causes, and RA could be contributing to the use of aspirin as pain reliever
 Nutritional deficiencies and Dietary Choices: The patient’s dietary history, including years of vegan
diet with lack of exercise, suggests that nutritional deficiencies might be contributing to her health
issues, including bone and joint health
 Secondary Conditions due to RA: degenerative changes revealed in the MRI of the spine could be a
secondary effect of RA, potentially leading to conditions like osteoporosis or degenerative spine
changes

PLAN
 Pharmacologic management
A. Ibuprofen
 Used to treat mild to moderate pain, and helps relieve symptoms of arthritis such as inflammation,
swelling, stiffness and joint pain
B. Methylprednisolone
 These drugs help by reducing immune responses that can lead to swelling, pain, and joint damage
C. Methotrexate
  A disease modifying antirheumatic drug (DMARDs) that helps ease symptoms like joint pain, fatigue,
redness, and swelling

 Non-Pharmacologic management
A. Exercise
 Flexibility stretching
 Muscle conditioning
 Cardiovascular/ aerobic exercises
B. Diet
 Incorporating minerals and vitamins in diet. Calcium and Protein is essential as it maintain healthy
bones and muscle strength
C. Physical and Occupational Therapy
 Splinting and adaptive aids to reduce deforming stresses on the joints of the hands and maintain
mobility
 Follow up Plan
A. X-rays
 Help track the progression of rheumatoid arthritis joints over time
B. Follow-up check-up every 3 months
 Due to monitoring of ibuprofen, Methylprednisolone, or Methotrexate, routine follow up is advised

Overview of the illness or Condition

NURSING PROLEMS
 Joint Pain and Inflammation: Andrea reports dull, aching pain around the joints of her fingers. She exhibits
early manifestations of Heberden’s and Bouchard’s nodes. This suggests a potential musculoskeletal issue,
likely osteoarthritis
 Medication Use and Gastrointestinal Discomfort: Andrea is using aspirin to alleviate pain, but it is causing
discomfort in her stomach, leading her to use antacids. This indicates a need for pain management and
addressing gastrointestinal issues
 Dietary and Lifestyle Factors: Andrea follows a "vegan" diet and uses herbs and nuts as supplements. Her lack
of exercise and dietary choices may be contributing to her health issues, including the joint pain.
 Elevated Laboratory Markers: The elevated white blood cell count (WBC), rheumatoid factor, antinuclear
antibody, and erythrocyte sedimentation rate (ESR) suggest a potential autoimmune or inflammatory
component to her condition.
 Degenerative Changes in the Spine: The MRI reveals degenerative changes, especially in the spine, indicating
a need for further evaluation and management of spinal health.

DIAGNOSIS

 Chronic Pain related to joint inflammation and damage secondary to rheumatoid arthritis as evidenced by the
patient's report of increasing pain in the hands and the presence of Heberden's and Bouchard's nodes.
 Impaired Physical Mobility related to pain and joint stiffness as evidenced by increased dull, aching pain around the
joints of the digits of both hands and early manifestations of Heberden's and Bouchard's nodes.
 Risk for Acute Pain related to potential gastrointestinal irritation secondary to the use of aspirin as.
 Imbalanced Nutrition: Less Than Body Requirements related to dietary choices and inadequate intake of essential
nutrients, as evidenced by a vegan diet for several years
·

PATHOPHYSIOLOGY
Outcome of Care
After six hours of nursing care, the disease activity would be under control, the rate of joint destruction would be
slowed, and problems, particularly in the Heberden's and Bouchard's nodes, would be minimized. There wouldn't be any
signs that her stomach was in any discomfort.

Therapeutic alternatives

MEDICATIONS
 Non-steroidal Anti inflammatory drugs (NSAIDs) like naproxen can help reduce pain and inflammation.
 Disease- modifying anti- rheumatic drugs (DMARDs) like hydroxychloroquine can help slow the progression of
rheumatoid arthritis and reduce joint damage.
 Corticosteroids like prednisone are used for short-term relief of symptoms and to reduce inflammation.

LIFESTYLE AND DIETARY CHANGES

 Exercise : encourage patient A.F to start a gentle exercise routine, such as yoga, low impact aerobic exercise
like swimming, stationary cycling or walking or even a simple range of motion exercises to improve joint
mobility and overall health.
 Diet : while she follows a “vegan” diet, it’s important to ensure she’s getting adequate nutrients,
including calcium and protein.

Patient Education (Nursing Considerations)

 Pain Management:
 Patient A. F is using aspirin to relieve joint pain. It's important to assess the effectiveness of this pain relief
and inquire about any allergies or sensitivities she may have to aspirin. The nurse should also educate her
on alternative pain management strategies and the importance of discussing them with her healthcare
provider.

 Stomach Discomfort:
 Patient A. F is experiencing stomach discomfort due to aspirin use. The nurse should inquire about any
history of gastrointestinal issues and recommend discussing these concerns with the NP. It may be
necessary to switch to a different pain management approach that is less likely to irritate the stomach.

 Diet and Supplements:

 Patient A. F has been on a vegan diet but uses herbs and nuts as supplements. The nurse should assess her
diet in more detail to ensure she is getting all necessary nutrients. Referral to a registered dietitian may be
beneficial to provide guidance on maintaining a balanced diet, especially since she is experiencing
symptoms of joint pain.

 Exercise:
 Lack of exercise is a potential concern. The nurse should encourage Patient A. F to engage in regular
physical activity, as appropriate for her condition. Gentle exercises and stretching routines can help
improve joint mobility and reduce pain.