N495 Module 8 assignment: holistic patient assessment, a full sample

Morning Stiffness and a Lunch Line to Run: A Holistic Assessment of a 52-Year-Old Woman Newly Diagnosed With Rheumatoid Arthritis

Student Name

RN to BSN Program, Aspen University

N495: Health Assessment

Instructor Name

Month Day, Year

Morning Stiffness and a Lunch Line to Run: A Holistic Assessment of a 52-Year-Old Woman Newly Diagnosed With Rheumatoid Arthritis

A holistic assessment treats the person, not only the disease. This paper presents a four-part assessment of a composite 52-year-old woman diagnosed with rheumatoid arthritis six months ago: a health history; an assessment of physiological, psychological, social, cultural, developmental, and spiritual dimensions; an interpretation of her findings through the pathophysiology of the disease; and a teaching plan. An outline of the accompanying presentation follows. Mrs. G. and every detail of her story are composites created for this paper.

Part One: Health History

Mrs. G. is a 52-year-old woman who manages the cafeteria at an elementary school. Her chief concern is "my hands are stiff every morning and I'm always tired." Her symptoms began about ten months ago with swelling and pain across the knuckles and toe joints on both sides, worse in the morning and lasting more than an hour. A rheumatologist diagnosed rheumatoid arthritis six months ago based on symmetrical small-joint synovitis, a positive rheumatoid factor and anti-cyclic citrullinated peptide antibody, and an elevated C-reactive protein. She started methotrexate 15 mg weekly with daily folic acid four months ago and reports partial improvement.

Past history includes hypertension treated with amlodipine and a cholecystectomy at 40. She is perimenopausal. Family history includes a mother with hypothyroidism and a father who died of a myocardial infarction at 64. She has never smoked, drinks wine occasionally, and walks little because her feet hurt. She is married with two children, ages 24 and 19, and helps care for a grandson two afternoons a week.

Part Two: Holistic Assessment

Physiological. Vital signs are within normal limits except blood pressure of 136/86 mmHg. The metacarpophalangeal and proximal interphalangeal joints of both hands are warm, swollen, and tender, with reduced grip strength; the metatarsophalangeal joints are tender to squeeze. She reports morning stiffness of about 90 minutes, down from over two hours. She has lost 3 kg since diagnosis and reports mild nausea the day after her methotrexate dose. Most recent laboratory tests show a mild normocytic anemia and normal liver enzymes.

Psychological. She describes frustration and worry that she will "end up in a wheelchair like my aunt." She reports low mood on bad days but denies hopelessness; a depression screen is negative. Social. Her job requires lifting trays and standing for hours, and she fears losing it. Her husband helps where he can, though his shifts run late. She has reduced her time with her grandson because lifting him hurts, which she finds painful.

Cultural. She is a second-generation Mexican American who speaks English and Spanish. When asked about health beliefs, she said her mother recommends a home remedy of warm compresses with herbs, which she uses and finds soothing, and she asked whether it would interfere with her medicine. Developmental. At 52 she is in Erikson's stage of generativity versus stagnation, and her sense of purpose centers on her work feeding children and caring for her grandson; illness threatens both. Spiritual. She is Catholic, attends Mass weekly, and draws strength from prayer and her parish community, which she describes as "where I don't have to explain myself."

Part Three: Pathophysiologic Interpretation

Rheumatoid arthritis is a chronic autoimmune disease in which an immune response, often beginning years before symptoms, targets the synovial lining of joints. In people with anti-citrullinated protein antibodies, as Mrs. G. has, immune tolerance to citrullinated self-proteins is lost. Activated T cells, B cells, and macrophages infiltrate the synovium and release cytokines such as tumor necrosis factor and interleukin 6, which drive synovial inflammation and proliferation. The inflamed synovium forms pannus, which invades cartilage and bone and, if uncontrolled, causes erosions and permanent joint damage (Smolen et al., 2016).

Her findings follow from this process. The symmetrical swelling and tenderness of the small joints reflect synovitis; prolonged morning stiffness reflects the accumulation of inflammatory fluid and mediators during inactivity. Her fatigue, weight loss, and mild anemia are systemic effects of the same cytokines, which suppress red blood cell production and alter metabolism. The elevated C-reactive protein is a marker of this systemic inflammation. Rheumatoid arthritis also increases cardiovascular risk beyond traditional risk factors, which matters for a woman with hypertension and a father who died of a heart attack at 64 (Smolen et al., 2016).

Treatment aims to suppress this process early, before damage occurs. Current guidelines strongly recommend methotrexate as the preferred initial disease-modifying drug for patients with moderate to high disease activity, with treatment adjusted toward a target of low disease activity or remission (Fraenkel et al., 2021). Her partial response after four months means the treat-to-target principle applies: the goal is not "better" but remission, and her rheumatologist may escalate therapy if she has not reached it. Methotrexate's side effects, such as nausea and potential liver toxicity, explain the folic acid and regular laboratory monitoring.

Part Four: Teaching Plan

Priority 1, medication safety. Mrs. G. will state that methotrexate is taken once weekly, never daily, and will name her dose day. Teaching covers taking folic acid daily as prescribed to reduce side effects, limiting alcohol, keeping laboratory appointments for blood counts and liver tests, reporting fever or signs of infection promptly, and discussing vaccines with her provider before receiving any live vaccine. Taking methotrexate in the evening may reduce the next-day nausea she reports; she will discuss this with her rheumatologist. Her question about the herbal compresses is answered respectfully: warm compresses are safe, and she will show the specific herbs to her pharmacist to confirm none interact with her medicines.

Priority 2, joint protection and activity. She will practice joint-protection techniques at work, such as using both hands and forearms to carry trays and using a cart for heavy loads, and will ask her employer about a stool for tasks she can do seated. She will begin low-impact activity, starting with water exercise at a community pool three times a week, and warm morning showers to reduce stiffness. A Cochrane review found that dynamic exercise programs improved aerobic capacity and muscle strength in people with rheumatoid arthritis without harmful effects, with limited evidence that water-based training improves functional ability (Hurkmans et al., 2009), which supports reassuring her that exercise will not damage her joints. A referral to occupational therapy will address hand function and workplace adaptations.

Priority 3, cardiovascular risk and emotional health. She will monitor her blood pressure at home and bring readings to her primary care visit, since rheumatoid arthritis raises cardiovascular risk. She will be given information about an arthritis self-management class and a local support group, and invited to share her fear of disability with her rheumatologist, who can discuss her prognosis with modern treatment. Teaching is evaluated with teach-back at each visit and by her report of morning stiffness, work attendance, and time spent with her grandson.

Presentation Outline

The accompanying presentation summarizes the assessment in nine slides.

Conclusion

Mrs. G.'s rheumatoid arthritis appears in her joints, her laboratory results, and her fatigue, but it also threatens her job, her time with her grandson, and her sense of purpose. A holistic assessment brings those dimensions together with the pathophysiology that explains her symptoms and guides her treatment. The resulting teaching plan addresses medication safety, joint protection, cardiovascular risk, and emotional health, and it measures success by the outcomes that matter most to her.

References

Fraenkel, L., Bathon, J. M., England, B. R., St. Clair, E. W., Arayssi, T., Carandang, K., Deane, K. D., Genovese, M., Huston, K. K., Kerr, G., Kremer, J., Nakamura, M. C., Russell, L. A., Singh, J. A., Smith, B. J., Sparks, J. A., Venkatachalam, S., Weinblatt, M. E., Al-Gibbawi, M., ... Akl, E. A. (2021). 2021 American College of Rheumatology guideline for the treatment of rheumatoid arthritis. Arthritis Care & Research, 73(7), 924-939. https://doi.org/10.1002/acr.24596

Hurkmans, E., van der Giesen, F. J., Vliet Vlieland, T. P. M., Schoones, J., & Van den Ende, E. C. H. M. (2009). Dynamic exercise programs (aerobic capacity and/or muscle strength training) in patients with rheumatoid arthritis. Cochrane Database of Systematic Reviews, (4), Article CD006853. https://doi.org/10.1002/14651858.CD006853.pub2

Smolen, J. S., Aletaha, D., & McInnes, I. B. (2016). Rheumatoid arthritis. The Lancet, 388(10055), 2023-2038. https://doi.org/10.1016/S0140-6736(16)30173-8