JUVENILE IDIOPATHIC ARTHRITIS

•BY: PAIGE NESTOR

•YOUNGSTOWN STATE UNIVERSITY

•NURS 7047

•FAMILY NURSE PRACTITIONER 3

•DR. BALLONE & DR. HOYSON

•SEPTEMBER 18, 2021

 WHAT IS JUVENILE IDIOPATHIC ARTHRITIS?

• Juvenile idiopathic arthritis (JIA) is the most common type

of arthritis in kids and teens. It typically causes joint pain
and inflammation in the hands, knees, ankles, elbows
and/or wrists. But, it may affect other body parts too. JIA
types are autoimmune or autoinflammatory diseases. That
means the immune system, which is supposed to fight
invaders like germs and viruses, gets confused and attacks
the body’s cells and tissues. This causes the body to release
inflammatory chemicals that attack the synovium (tissue
lining around a joint). Synovium fluid is a fluid that lays in
your joints that cushions joints and helps them move
smoothly. An inflamed synovium may make a joint feel
painful or tender, look red or swollen or difficult to move.  
PATHOPHYSIOLOGY

• Juvenile idiopathic arthritis is the result of an

autoinflammatory response from the innate
immune system. The humoral response is
responsible for the release of autoantibodies, an
increase in serum immunoglobulins, and the
formation of circulating immune complexes and
complement activation. The cell-mediated reaction
is associated with a T-lymphocyte response that
plays a key role in cytokine production, resulting in
the release of tumor necrosis factor-α, IL-1, and IL-
6. Activation of B lymphocytes by T-helper cells
produces autoantibodies that link to self-antigens.
B lymphocytes infiltrate the synovium producing
nonsuppurative chronic inflammation of the
synovium that can lead to articular cartilage and
joint structure erosion.
 CASE STUDY

• A 12-year-old girl presents to her pediatrician's office with her

mother. She complains of feeling awful and fatigued lately and
states that she has been missing a lot of school in the past three
months. She states that it is very hard for her to get out of bed, and
she can barley move in the morning. She verbalizes feeling stiff,
achy, and pain. She states over the past three months, her stiffness
has been progressively getting worse in the mornings and has missed
a total of 2 weeks of school. She states that with how much school
she has been missing, it is becoming hard to catch up. She states that
the stiffness is located in both of her ankles, knees, and her right
wrist. She states that she has noticed swelling in those areas, but it is
not all the time. Patient’s mom did state that she has noticed a limp
in her gait once in awhile, in the mornings.
HISTORY AND PHYSICAL

• History of Present Illness: This patient has had a new onset in the past three months of fatigue,
aching, and stiffness in both ankles, knees, and right wrist. This patient struggles getting out of bed
in the morning, due to the stiffness and pain in her joints. Mom states a noticeable limp in her gait
in the mornings.
• Chief Complaint: Pain/stiffness in knees, ankles, and right wrist; fatigue; trouble getting out of bed
in the morning; limping; fatigue
• Past Medical History: This patient was diagnosed 3 years ago with psoriasis. Otherwise, this
patient has no pertinent medical history.
• Medications: Daily multivitamin

• Allergies: No Known Allergies

HISTORY AND PHYSICAL CONTINUED

• Social History: Patient attends Mineral Ridge Middle School

and is involved in many school sports and school programs.
She plays basketball and softball Patient states he has many
friends and a good support system surrounding her, including
her family. She is an only child. She lives at home with her
mother and father who are married. She states he feels safe at
home. She states that within the past three months she has
missed a total of two weeks at school and is falling behind in
her classes. She claims that she is right-handed and finds it
hard to take notes and do her homework. She has also been
missing many basketball practices and is nervous she is going
to be kicked off the team.
• Family History: Mom diagnosed with Rheumatoid Arthritis at
the age of 30.
REVIEW OF SYMPTOMS

• Neurological: No reports of seizures, headaches, syncope, tremors, trauma to the head, swallowing, or speaking.
No reports of problems with memory or thought processes. Reported difficulty walking, due to ankle and knee pain
and stiffness. Patient reports no history of diagnosed mental health problems. No history of meningitis, congenital
disorders, encephalitis, stroke, or injury to the spinal cord or head.
• EENT: Patient denies blurred vision, swelling, or discharge of the eyes. Patient did state that she has occasional
redness and pain in her eyes. Patient denies a history of injury to the eyes or surgery. Patient denies hearing
difficulty, earaches, discharge, tinnitus, or vertigo. Patient also denies history of sinus infections, trauma to the nose,
epistaxis, altered smell, or nasal discharge. Denies toothaches, hoarseness or altered taste.
• Cardiovascular: Patient denies history of heart murmur, hypertension, elevated cholesterol, heart attacks, anemia,
or rheumatic fever. Patient denies chest pain, cough, shortness of breath or dyspnea. Patient does state that she has
had an increase in fatigue over the past three months and edema in her ankles, knees, and right wrist.
• Pulmonary: Patient states no current shortness of breath, dyspnea, or allergies to anything environmental. Denies
history of bronchitis, pneumonia, asthma, reoccurring respiratory infections, exposure to mold, chest Xray’s, or
smoking/exposure to secondary smoke.
REVIEW OF SYMPTOMS CONTINUED

• Gastrointestinal: Patient has had no complaints nausea, vomiting, abdominal pain, diarrhea, heartburn, abdominal
distention, bloating, blood in urine or stool, or intolerance to heat or cold. Patient states no recent change in appetite or
unintentional weight loss. Patient denies history of diabetes, thyroid disorders, liver or gallbladder disease, colon
cancer.
• Integumentary: Patient denies any hair loss, bruising, or mole changes. Denies history of skin cancer, eczema, hives,
or yellowing of the skin. Patient does state that she was diagnosed with psoriasis 3 years ago and does present with an
itchy rash. She states that she is typically treated with hydrocortisone when her psoriasis flairs up.
• Renal/Urinary: Denies history of kidney or liver disease, kidney stones, urinary frequency, or hydronephrosis.
• Musculoskeletal: Patient states she has current fatigue, pain and stiffness in both ankles, knees, and right wrist. Patient
states that she cannot get out of bed in the morning due to this and does note some swelling in those areas on occasion.
Patient denies history of bone cancer, broken or fractured bones, scoliosis, or trauma.
 OBJECTIVE FINDINGS

• Patient is alert and oriented x4. Patient presents with

swelling and decreased range of motion in both
ankles, knees, and right wrist. A noticeable flexion
contractor was seen with her right wrist. Patient's gait
was slow and had decreased range of motion at the
hip. Patient’s vitals were as follows: heart rate of 80,
SPO2 level of 98% on room air, blood pressure
114/60, respirations 24, and temperature of 98.3F.
Labs were drawn and knee, ankle, and wrist x-rays
were done. X-rays showed no fractures or erosions.
CBC: Normal; ANA: Positive at 1:320; ESR: 66;
Rheumatoid factor: negative; CRP: 2.8; Lyme’s Titer:
Negative; Blood Cultures: Negative; BMP: Normal.
PHYSICAL ASSESSMENT

• Vital Signs: HR: 80; SPO2: 98% RA; BP: 114/60; RR: 24, Temp: of 98.3F.

• Pain: Patient stated that she currently has ankle, knee, and right wrist pain 5 out of 10 on the numeric pain scale.

• Skin/Hair/Nails: Patient appeared to be well groomed. Less than 3 second capillary refill, no clubbing.

• Head: Her head had good symmetry, with no lesions or unusual bumps, no pain or tenderness. Palpated sinuses with no pain or tenderness, no
swelling. Assessed patient’s lymph nodes, anterior and posterior triangle with no pain or tenderness, no swelling or enlarged lymph nodes. Temporal
and carotid arteries were +2. No bruits were heard when listening to the temporal, carotid, thyroid, or eyes.

• Eyes: Patient’s eyes were symmetrical with no bulging, lesions, or trauma. When palpated, no swelling, but patient did complain of pain and
tenderness. Conjunctiva was pink and moist, but bilateral sclera’s were red. Patient stated that she does not wear glasses/contacts. PEERLA was found
in both eyes when a light was brought in.

• Nose: Patient’s nose was symmetrical with no drainage, redness, or lesions. Inside of nose showed no redness or any unusual bumps.

• Ears: Palpated patient’s ears bilaterally, no pain or tenderness at the tragus or pina. While looking inside of her ears, no redness, swelling, scarring,
foreign bodies, or bulging was noted. The patients inner ear structures and tympanic membrane were intact bilaterally.

• Mouth: While assessing the patient’s mouth, patient’s tonsils were pink with no swelling. While assessing the patient’s gums and tongue, mucus
membranes were pink and moist.
PHYSICAL ASSESSMENT CONTINUED

• Cardiovascular: Patient currently states that she does have fatigue. No current cyanosis, pallor, or shortness of breath. Edema is noted in
her ankles, knees, and right wrist. Carotid pulse: 2+, Temporal pulse 2+. No bruits heard in carotid. No heaves, lifts, or thrills felt with
palpation of the heart or point of maximum impulse. Normal S1 and S2 heard. No extra heart sounds heard such as S3, S4, or murmurs.
Heart Rate: 80.
• Pulmonary: Patient is currently having fatigue. No allergies to anything environmental noted. No tripoding, nasal flaring, retractions,
shortness of breath, audible stridor or wheezing, cyanosis, pallor, or clubbing of the fingers visualized. No adventitious breath sounds heard.
Felt no areas of pulsations, crepitus, areas of tenderness, bulges, depressions, masses, or unusual movement with palpation. Good,
symmetrical thoracic expansion observed. Respiratory rate: 24; SPO2: 98%.
• Peripheral Vascular: No bruits were heard in aorta, renal, iliac, or femoral arteries. No heaves, lifts, or thrills felt with palpation of the
aorta, renal, iliac, or femoral arteries. No current pallor, cyanosis, but patient does have current edema in her ankles, knees, and right wrist,
but no pitting edema. Patient’s upper and lower extremities are warm to touch, with no bruising or bleeding. Capillary refill less than 3
seconds bilaterally on both upper and lower extremities. Pulses bilaterally: Carotid pulses: 2+, Aortic: 2+, Renal pulses: 2+, Iliac pulses: 2+,
Femoral: 2+ Radial pulses: 2+, Brachial pulses: 2+, Popliteal pulses: 2+, Dorsalis Pedis pulses: 2+, Posterior Tibial pulse: 2+.
PHYSICAL ASSESSMENT CONTINUED

• Abdominal: Patient has no nausea, vomiting or abdominal pain. Upon inspection, abdomen flat, symmetrical, skin pink and warm, no distention,
hernias, bulges, masses. Smooth even movements occur with respirations. Upon auscultation, patient had active bowel sounds in all four quadrants of
the abdomen, no friction rubs were heard over liver or spleen, no bruits were heard in the aortic, renal, iliac, or femoral arteries. With light and deep
palpation, no pain or rebound tenderness was noted by patient and no masses were palpated. No bulges or masses felt with palpation of umbilical ring.
No thrills or heaves felt with palpations of aortic, renal, iliac or femoral arteries. With percussion, tympany was heard in all four abdominal quadrants
and gastric bubble, dullness was heard with palpation of the liver and spleen. When assessing kidneys for tenderness, no tenderness was noted.

• Neurological: Patient was Alert and Oriented x4. No reports of seizures, headaches, syncope, tremors, trauma to the head, difficulty balancing,
swallowing, or speaking. No reports of problems with memory or thought processes. Positive results were found when testing cranial nerves, I through
XII. Patient had good coordination and fine motor skills with rapid rhythmic movements, and accuracy of upper and lower extremity movements.
Patient had an abnormally slow gait and posture, due to decreased range of motion at the hip. Patient was able to feel all sensory pain and soft touch.
Superficial and deep tendon reflexes were seen in abdominal, plantar, biceps, brachioradialis, triceps, patellar, and Achilles.

• Musculoskeletal: Patient states current stiffness in her ankles, knees, and right wrist. No deformity’s seen, no crepitus felt, no nodules or masses
palpated. With palpation of muscles, all had good size, good strength, symmetry, no spasms. All skin and subcutaneous tissues were pink and warm to
touch, no skin folds. With range of motion, all joints listed (hands, left wrist, elbows, shoulders, temporomandibular, cervical spine, thoracic and
lumbar, legs, and feet) had good passive and active range of motion bilaterally. Patient had a decreased ROM in both ankles, knees, hips bilaterally,
and her right wrist. A noticeable flexion contractor was seen with her right wrist. Patient had an abnormally slow gait and posture, due to decreased
range of motion at the hip.
• Diagnostic Tests and Lab Results: Labs were drawn, and knee, ankle, and wrist x-rays
were done. X-rays showed no fractures or erosions. CBC: Normal; ANA: Positive at
1:320; ESR: 66; Rheumatoid factor: negative; CRP: 2.8; Lyme’s Titer: Negative; Blood
Cultures: Negative; BMP: Normal

• Problem List: Pain/stiffness in knees, ankles, and right wrist; fatigue; trouble getting out
of bed in the morning; limping; fatigue

• Differential Diagnosis List:

• Juvenile Idiopathic Arthritis*
• Lyme’s Disease
• Fracture or trauma
• Osteomyelitis
• Acute Rheumatic Fever

• Assessment (Primary Diagnosis): Polyarticular Juvenile Idiopathic Arthritis

RECOMMENDATIONS/TREATMENTS

• Referral to Rheumatology
• Get baseline labs drawn before starting on Methotrexate: CBC, Liver Function Tests, BMP and creatinine.
• Start her on Methotrexate: 10mg once a week
• Prescribe Naproxen: 250mg PO every 6-8 hours PRN for pain and swelling
• Prescribe Folic Acid to take the day after taking Methotrexate, to minimize the side effects if Methotrexate.
• Patient education supplements on diagnosis and information on the medication prescribed.
• Referral to ophthalmologist.
• Referral to physical and occupational therapy, due to physical limitations noted on exam.
FOLLOW UP AND COMMUNITY RESOURCES

• Follow up in 1 months to the Rheumatologist.

• Follow up with PCP in 2 months.

• Have maintenance labs drawn in 2 months to assess for drug

toxicity to Methotrexate (CBC, Liver Function Tests, BMP and
creatinine) and repeat ESR and CRP to assess treatment and
inflammation.
• More information and community resources can be found at:
• Patient and Family Education:
https://www.arthritis.org/juvenile-arthritis
• Community Resources and JIA groups:
https://connectgroups.arthritis.org/groups/northeast
• Family Support Groups:
https://www.arthritis.org/juvenile-arthritis/a-welcoming-h
ome-for-ja-families
REFERENCES

• Juvenile idiopathic arthritis (jia): Arthritis Foundation. Juvenile Idiopathic Arthritis (JIA) | Arthritis
Foundation. (n.d.). Retrieved September 19, 2021, from https://www.arthritis.org/diseases/juvenile-
idiopathic-arthritis. 
• Maaks, Dawn Lee Garzon ,Starr, Nancy Barber,Brady, Margaret A.,Gaylord, Nan M.,Driessnack,
Martha,Duderstadt, Karen. Burns' Pediatric Primary Care E-Book (p. 549). Elsevier Health Sciences.
Kindle Edition.
• Mayo Foundation for Medical Education and Research. (2020, November 18). Juvenile idiopathic arthritis.
Mayo Clinic. Retrieved September 19, 2021, from https://www.mayoclinic.org/diseases-
conditions/juvenile-idiopathic-arthritis/symptoms-causes/syc-20374082.