McKenna's Pharmacology for Nursing, 2e

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P A R T 3  Drugs acting on the immune system

CRITICAL THINKING SCENARIO Aspirin and rheumatoid arthritis

THE SITUATION G.T. is an 82-year-old man on a fixed income with a 14-year history of rheumatoid arthritis. He is seen in the clinic for evaluation of his arthritis and to address his complaint that his medicines are not helping him. On examination, it is found that G.T.’s range of motion, physical examination of joints and overall presentation have not changed since his last visit. G.T. states that he had been taking aspirin, as prescribed, for his arthritis. But the aspirin prescribed by his doctor is more expensive than he could handle on his income, so he started taking it only once every 3 days. CRITICAL THINKING Think about the pathophysiology of rheumatoid arthritis and how the drugs ordered act on the inflammatory process. How can the nurse best explain the disease and the drug regimen to G.T.? What could be contributing to G.T.’s perception that his condition has worsened? What interventions would be appropriate to help G.T. cope with his disease and his need for medication? DISCUSSION G.T. should be offered encouragement and support to deal with his progressive disease and the drug regimen required. The fact that his physical status has not changed but he perceives that the disease is worse may reflect other underlying problems that are making it more difficult for him to cope with chronic pain and limitations. The nurse should explore his social situation, any changes in his living situation, and support services. An examination should be done to determine whether other physical problems have emerged that could be adding to his sense that things are getting worse. The actions of aspirin on the arthritic process should be reviewed in basic terms, with emphasis on the importance of preventing further damage and maintaining high enough levels of aspirin to control the arthritis signs and symptoms. Pictures of the process involved in rheumatoid arthritis may help—the simpler the better in most cases. G.T. should also be taught that all aspirin is the same, so it is acceptable to buy the cheapest generic aspirin. He can check the expiration date to make sure that the drug is fresh and still therapeutic and check that it does not smell like vinegar. Tell G.T. that the expensive combination product that G.T. has been using has not been proven to be any more effective at helping arthritis or at decreasing adverse effects than generic aspirin.

If G.T. has been having GI complaints with the aspirin, he can be encouraged to take the drug with food and to have small, frequent meals to keep stomach acid levels at a more steady state. If G.T. has not been having any GI complaints, he should be asked to report any immediately. The importance of the placebo effect cannot be overlooked with this person. Many people actually state that they feel better when they are using well-recognised, brand-name products. With support and encouragement, G.T. can be helped to follow his prescribed drug regimen and delay further damage from his arthritis. CARE GUIDE FOR G.T.: ASPIRIN AND RHEUMATOID ARTHRITIS Assessment: History and examination Allergies to aspirin; renal or hepatic impairment; ulcerative GI disease; peptic ulcer; hearing impairment; blood dyscrasias Concurrent use of anticoagulants, steroids, ascorbic acid, alcohol, frusemide, acetazolamide, antacids, methotrexate, sodium valproate, sulfonylureas, insulin, captopril, beta-adrenergic blockers, probenecid, spironolactone, glyceryl trinitrate Neurological: orientation, reflexes, affect Musculoskeletal system: ROM, joint assessment Skin: colour, lesions CV: pulse, cardiac auscultation, blood pressure, perfusion GI: liver evaluation, bowel sounds Lab tests: FBC, liver and renal function tests Implementation Ensure proper administration of the drug. Administer with food if GI upset occurs. Provide support and comfort measures to deal with adverse effects: small, frequent meals; safety measures if CNS effects occur; measures for headache; bowel training as needed. Provide teaching regarding drug name, dosage, side effects, precautions and warnings to report; supplementary measures to help decrease arthritis pain. Evaluation Evaluate drug effects: decrease in signs and symptoms of inflammation. Monitor for adverse effects: CNS changes, rash, GI upset, GI bleeding. Monitor for drug–drug interactions as listed. Evaluate effectiveness of teaching program. Evaluate effectiveness of comfort/safety measures.