Help me brainstorm, swollen hands on pt.

[lovesmarissa]

Hello! I have a home care patient who has the following dx: rheumatoid arthritis, crohn's, macular degen,history of strokes. She is in hospice. About a month ago she was in the hospital. Upon her return home, she started complaining of pain and soreness to her R hand, which had the IV. She was treated w/10 days of antibiotics. Several days after that, she became swollen again, and we started another round of abt. She has one more day on the Keflex, and when I saw her today she had swelling in BOTH hands, nonpitting, warmth and some erythema to the hands. The forearms were more gelatinous in firmness, but were not really edematous per se. She had swelling in between each knuckle also. No other places with swelling, such as the lower extremities. I thought it may have initially been a case of cellulitis, but now that it's present in both hands I'm throwing it out the window. Another Nurse I work with thinks it's more of a circulation problem, aeb some discoloration to the area that is intermittent-some visits the area looks cyanotic and other times it isn't. Pulses are good and strong....

What to you think? I know I'm missing something here....

Thanks for any suggestions and Ideas!!

-Bea

[RamaMama]

I'm not even in nursing school yet so this may be way off... could the swelling of hands be due to an RA flare? Let us know if you find the answer!

[adria37]

Hmmm does she have any cough, facial edema, or jvd? I am thinking about superior vena cava syndrome. Looking for those zebras :)

[leslie :-D]

it's against the terms of service to be providing medical advice.

leslie

[CRNI-ICU20]

This is classic Rheumatoidal disease....it is an immune system response....did she have co=comittent pain with this in her hands as well? I work for a Rheumatologist at my other job, and I see these types of symptoms all the time....the enlarged joints....sometimes only unilateral swelling....sometimes both....sometimes other parts of the body....it can travel....it usually follows a stress response, ie emotional or physical...ie infection, recent hospitalization, or another illness...

The swelling can sometimes be relieved with steroidal medications....ie, prednisone, solumedrol....ibuprofen...

You mentioned the patient was in hospice....so aggressive treatment may not be the goal....but comfort should be....usually this is very painful. Tylenol is good for this kind of pain, because it does have anti-inflmmatory effects....

Sometimes some pulse doses of Remicade may really benefit, if the patient is needing the palliation....just a thought....

crni

[Super Nurf]

".......About a month ago she was in the hospital. Upon her return home, she started complaining of pain and soreness to her R hand, which had the IV. She was treated w/10 days of antibiotics.........."

Why would someone get 2 runs of antibiotics for complaint of pain and soreness in a hand? Was there a visible cellulitis going on there? This makes no sense to me at all. It sounds like there is more going on and if you want definitive answers, I think you should be talking to the MD. Go to the top to find out instead of trying to guess if you're not sure, that's the best way to learn.

[lovesmarissa]

thanks for the ideas....there was a call out to the MD (who is on vacation of course) so he will see her when she gets back. I too think it's more of an RA flare up. She did have cellulitis visualized on the R hand, hence the abt...