Nursing Care and Considerations with Granulomatosis in the Emergency Department

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Within REACH Nursing Care and Considerations with Granulomatosis in the Emergency Department

Ann Jimenez, BSN, RN, CCRN, CEN - Carilion Giles Community Hospital Emergency Department Mrs.G presents to the emergency department with complaints of shortness of breath and worsening voice hoarseness. She was quickly assisted into her wheelchair while her spouse, who accompanied her, was questioned about her health history. He explained that she has Wegener’s Granulomatosis.

Granulomatosis with polyangiitis (GPA, formerly known as Wegener’s Granulomatosis) is an autoimmune small-vessel vasculitis causing inflammation. It is a rare multisystem disease, often affecting the sinuses, lungs, and kidneys. It has no known etiology and requires several studies to confirm the diagnosis. Many factors play a role in diagnosing GPA. Symptoms that support a diagnosis include a runny nose, hemoptysis, dyspnea, and fatigue, all of which conspicuously do not improve (Lutalo, D’Cruz, 2014).

Early diagnosis is essential in beginning treatment because GPA can worsen rapidly. A patient can be diagnosed by a common blood test called anti-neutrophil cytoplasmic antibody (ANCA), which identifies a specific antibody in serum. A positive ANCA test alone cannot confirm the diagnosis, so a tissue biopsy may still be needed. Once a GPA diagnosis is confirmed, treatment regimens will be dictated by the particular organ systems involved, as well as by medications that treat systemic inflammation (Falk, Merkel, King, 2019).

Treatment regimens will include glucocorticoids and immunosuppressive medications. Nurses will be familiar with most of the medications that are used in the treatment of GPA because these medications are frequently seen on medication lists of patients with organ transplants, rheumatoid arthritis, lupus, and irritable bowel disease, in addition to other autoimmune diseases.

Once GPA symptoms are controlled, patients may be required to take medications to prevent a relapse, like methotrexate and rituximab. The hallmark medication combination is prednisone and Cytoxan, which provide insight into whether remission can be achieved. However, there are side effects that must be considered, including hair loss, nausea, and diarrhea. In particular, severe immunosuppression will need to be taken seriously. Regular monitoring of complete blood count, renal function, liver function, urine studies, and clinical symptoms is recommended. Plasma exchange, known as plasmapheresis, may be considered in those patients where medication treatment has failed. Plasmapheresis works by eliminating ANCA from the body circulation in those patients with life-threatening renal vasculitis (Lutalo, D’Cruz, 2014).

Initially, nursing care of a patient with GPA will always focus on airway, breathing, and circulation. This may sound elementary but should guide an emergency department nurse’s care. The nurse should place the patient on the heart monitor, blood pressure, and oxygen saturation monitors and establish IV access. Anticipated care includes oxygen, nebulization treatments, IV corticosteroids, and possibly anxiolytics since anxiety can potentiate symptoms. The physician and respiratory therapist should be called to the bedside promptly.

Mrs. G was quite anxious and breathless with audible stridor, caused by GPA-induced subglottic stenosis and supraglottic inflammation. Joining the team at the bedside, the ED physician guided her care. While the nurses connected her to heart and vital sign monitors and started a saline lock, the respiratory therapist treated her with a racemic epinephrine nebulizer.

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Practical Applications of Nursing Inquiry

The patient was injected with dexamethasone and a small dose of lorazepam. Fortunately, Mrs. G’s worrisome symptoms reversed quickly, with her dyspnea subsiding and hoarseness lessening. She was monitored closely for return of symptoms and transferred expeditiously to a tertiary care center.

Nursing implications include caring for those life-threatening airway symptoms that prompt quick intervention. Another consideration is monitoring for acute kidney injury requiring emergent hemodialysis. Emergency nurses should recognize that immunosuppressed patients can develop overwhelming infections with serious implications. Nurses must also be aware of the psychological and emotional impact this illness carries when patients fail outpatient treatment, or outpatient treatment renders complications. The need for tracheostomy placement, hemodialysis, and critical care treatment for sepsis can be devastating news for the GPA patient. The need to adapt to breathing through a tracheostomy tube, the limitation it imposes on communication, and the tube's appearance can all have an immensely negative impact on such patients.

However, nursing care for patients while in the emergency environment can positively affect psychological well-being. Facilitating communication between the healthcare team, patients, and their families, when appropriate, is a vital role for nursing. Explaining care and interventions, reassuring patients about the transfer, and providing patients with information about inpatient care before admission all serve to reduce anxiety that can exacerbate their condition. Working towards providing optimal psychological care will positively influence patients' psychological recovery and may also help physical rehabilitation after inpatient care (Pattison, 2005).

Mrs. G arrived at a small critical access hospital in extremis but was transferred with an improvement of her acute symptoms. Though her journey for recovery is uncertain, there is one comforting prospect worth noting. Seriously ill patients arrive at the emergency department daily, requiring critical thinking skills and collaboration from team members. Nursing gratification occurs when patient acuity improves, and goals of delivering quality care and enhancing patients’ condition is accomplished.