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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.
