In nursing school, we are taught to use care plans to help manage our patients’ health problems. First, we assess the patient; next, we develop a plan of care; and finally, we implement the plan of care. At the end of this process, the patient response hopefully matches what we were expecting. If not, we go back to step one and start over.
While there is nothing wrong with this systematic approach, taking care of patients in real life rarely adheres to nice, orderly care plans. In fact, it sometimes feels like the more we plan, the more complicated things become.
Such is the case with J.S.
J.S. is a 78-year-old man with a very complicated medical history. He has diverticulitis, benign prostatic hyperplasia, and diabetes mellitus. Add to that unstable angina, hypertension, hyperlipidemia, peripheral artery disease, and coronary artery disease. And a myocardial infarction suffered almost 20 years ago resulting in a coronary artery bypass graft. (Wait, there’s more!)
J.S. is a smoker. Finally, he has seropositive rheumatoid arthritis (RA).
J.S. has been coming to our clinic for about 10 years. His RA has proven to be refractory to most of the treatments we have tried. This is no doubt at least partly due to the fact that he refuses to quit smoking despite multiple referrals to smoking cessation clinics and offers of pharmacologic and nonpharmacologic interventions. Since we can’t change his behavior, we have to work with what we have. J.S. is currently on methotrexate and folic acid and had, until recently, also been receiving intravenous infliximab every 8 weeks.
At J.S.’ most recent visit, we went through all the usual questions as part of our review of symptoms (ie, any signs of infection, recent changes in health, medication updates). J.S. vaguely answered that he had nothing new to report, although it was clear that he was avoiding directly answering our inquiries. When we finally got to the question about recent hospitalizations, the magic lightbulb went on, and J.S. informed us that he had just been discharged from a local hospital after a new case of congestive heart failure (CHF).
At this point, I may have literally banged my head against the wall. Infliximab, as we know, is contraindicated at high doses in patients with moderate-to-severe CHF.1 While J.S. was unclear about his stage of CHF, we certainly couldn’t infuse infliximab without knowing.
So much for our nice, tidy, completely worthless plan of care. And we still had a patient who needed treatment for his RA.
So what did we do? The only thing we could do, really. We sent J.S. home without his infliximab. But we also made sure he had a follow-up appointment scheduled with his cardiologist, started the paperwork to get his outside records faxed to us, and counseled him (again) about the need to quit smoking.
On paper, J.S. looks like a train wreck. But in person, he is really a delightful (if somewhat ornery) gentleman who is managing very well on his own despite issues that would overwhelm the majority of my patients. When I meet someone like J.S., I am reminded that RA is almost never just RA. It brings with it risk factors for so many other conditions, and it is only with constant vigilance and care that we can hope for good outcomes for our patients.
Elizabeth Kirchner, CNP, is a nurse practitioner at the Cleveland Clinic in Cleveland, Ohio, and the Education and Curriculum Chair of the Rheumatology Nurses Society.
- Remicade (infliximab) prescribing information. Janssen Biotech, Inc. October, 2015.