Reference no: EM132401193 , Length: word count:250

Assignment -

Review the Kari Reichart Post and create a response to that post.

To ensure that your responses are substantive, use at least two of these prompts:

Do you agree with your peers' assessment?

Take an opposing view to a peer and present a logical argument supporting an alternate opinion.

Share your thoughts on how you support their opinion and explain why.

Present new references that support your opinions.

Discussion post By Kari Reichart

I would ask about her symptoms, onset and duration of symptoms, location of affected joints, characteristics of the pain. I would ask what she thinks has exacerbated her condition and how it is affecting her daily life. I would ask when she was diagnosed with RA and what she currently does to manage her condition. I would ask her to tell me about when she was diagnosed and how often her flares occur. I would also want to know what medications she currently takes and her past and current medical history. I would also ask about neuropathic pain in her extremities, eye pain and chest pain on deep inhalation. I would also ask about morning joint pain and stiffness and any joint swelling that may improve throughout the day (Dunphy, Winland-Brown, Porter & Thomas, 2019).

As far as diagnostic testing, Dunphy et al. (2019) suggests testing for anti-CCP antibodies, a sed rate, CRP and CBC. If the patient was already undergoing treatment, then a CRP and sed rate can be use to monitor the effectiveness of the therapy (Dunphy et al.). A rheumatoid factor to correlate with severity of the disease. A positive titer >1:150 indicates severe disease, possibly with rheumatoid nodules (Dunphy et al,). If this was a new patient without documentation of having RA, then a quantitative ANA lab test or comprehensive autoantibody panel could be done to differentiate RA from other autoimmune diseases (Dunphy et al.). If the patient said that she has had RA for at least 6 months, then x-rays could be ordered of affected joints to look for bone erosions (Dunphy et al.). Hopefully, this is an established patient so records are available and not all of this testing would need to be repeated.

Management of exacerbated RA depends on what the patient tells me in her history and how bad the flare is. I want to know how she normally manages her flares. I would likely start her on oral steroids or steroid injections into the affected joints. However, this would not be indicated if the patient was also diabetic or had osteoporosis (Dunphy et al, 2019). It is also suggested by Dunphy et al that the first line therapy is aspirin and NSAIDs, but before I could recommend this to a patient, I would want to know about their kidney function and if there is a history of ulcers, since NSAIDs can be hard on the GI mucosa. Also, if the patient had already moved past the point of NSAIDs, then I probably wouldn't recommend her to step backwards in the treatment continuum. Dunphy et al recommends triple therapy of methotrexate, sulfasalazine and hydroxychloroquine for active disease and consideration of adding a TNF-alpha factor blocking agent for patients with moderate to severe RA. If I put this patient on a DMARD, I would also want to check and CMP to evaluate liver and kidney function as a baseline. However, it is suggested to refer the patient to rheumatology for management of RA, especially if DMARDs are needed (Dunphy et al.).

As far as patient education, the patient probably has heard a lot already, especially if this is not a new diagnosis. I would ask the patient what her goals for therapy are and then have a discussion about how I can help her achieve those goals. Dunphy et al (2019) states that patient education should be focused on reduction of pain, control of inflammation, and preservation of function. If a new medication, such as a DMARD were initiated, then I would educate on the safety and side effects and use of that medication. It would be important to ascertain if the patient had gone through menopause or not since DMARDs are contraindicated in pregnancy. For that that matter, NSAIDs are contraindicated in pregnancy too. I would also ask about how the patient was doing emotionally and make any necessary referrals to support groups or other community resources. If the patient was having difficulty with daily tasks, then I could offer some tips on accomplishing her ADLs or make a referral to OT if needed. I could also ask if the patient needed any information that could be shared with her family/children about RA.

Reference - Dunphy, L.M., Winland-Brown, J.E., Porter, B.O., & Thomas, D.J. (2019). Primary care: The art and science of advanced practice nursing- an integrative approach (5th ed.). Philadelphia, PA: F.A. Davis.

Instructions: Need 250 Words.