GOUTY GCP

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Introduction

Health History

Medical Management

Pathophysiology

Nursing Assessment Chart

SOAPIE

Referrals and Follow - up

December 1, 2012

LICEO DE CAGAYAN UNIVERSITY

RODOLFO N. PELAEZ Blvd., KAUSWAGAN

CAGAYAN DE ORO CITY

COLLEGE OF NURSINGNCM501107

Recommendation

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Gout is a medical condition that shows a strong

correlation with hyperuricemia and is characterized bydeposition of monosodium urate crystals in the synovial

fluid and tissues (tophi) in and around joints.

Hyperuricemia is defined as a serum uric acid level of

>7.0 mg/dL in men or >6.0 mg/dL in women. Gout occursabout 7 to 9 times more frequently in men than in

women and has an increased prevalence in industrialized

Western countries, where diet is considered the primary

culprit. The incidence of gout increases with age, nearlydoubling for men between the ages of 55 and 64 years

compared with those between the ages of 40 and 44

(1.8/1000 vs 1/1000, respectively).

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Uric acid (UA) is the end product of purine metabolism in

humans. Because no known physiologic functions exist for

UA, it is considered a waste product. Excess UA can

accumulate as a result of underexcretion and/or overproduction. The majority of patients with gout (80-

90%) are under-excreters; excretion of UA is mainly

through the kidneys and to a lesser extent by the

gastrointestinal tract. About 90% of filtered UA isreabsorbed by the proximal tubule. Because of the close

correlation between sodium proximal tubule reabsorption

and UA reabsorption, an increase in sodium reabsorption

can cause an increase in UA reabsorption. Drugs thathave been shown to decrease excretion of UA include

loop and thiazide diuretics, ethanol, salicylates, nicotinic

acid, levodopa, and cyclosporine.

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Since UA is the end product of purine metabolism,

reduction of purine intake or production is also an area of

focus. Production of purines occurs via two pathways: 1)

conversion of tissue nucleic acid to purine nucleotides; or 2) de novo synthesis of purine bases. It is important to note

that, since the last two steps in the conversion of purines to

UA are both catalyzed by xanthine oxidase, inhibition of

this enzyme can limit UA production.The classical clinical symptoms of acute gouty arthritis

result from inflammation of involved joints, usually the first

metatarsophalangeal joint (but may involve lower

extremities and arms), and include severe pain, erythema,warmth, and swelling.7,8 However, atypical gout can also

occur, and it may present with less dramatic onset,

especially in the elderly. Atypical gout can often be

confused with rheumatoid arthritis or osteoarthritis.

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Even though an acute gout attack can occur at any

time, some conditions precipitating an attack are

stress, infection, alcohol consumption, and rapid

changes in serum UA levels.

The reason why we chose this patient was that

his case was the most interesting among all thepatients in the ward. There were a lot of problems

that we could identify that caught our interest and

where we can give a lot of health teachings and

interventions to our client. In short, his case fits bestin the criteria for choosing a case study because his

diagnosis was something that we have not

encountered yet. We also want to go deeper with

this kind of case and learn more from it.

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As fourth year (N107B) nursing students of

Liceo de Cagayan University, within three (2) days of

nursing intervention on a client with Acute Gouty

Arthritis at Polymedic General Hospital, Velez., the

group will be able to conduct a thorough and

comprehensive study of the assigned patientaccording to the data that was gathered through a

series of interviews. The condition of the

aforementioned will augment and free of possible

complications from the disorder.

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The completion of this case study enables the

proponent to do the following:

1. To organize our patient’s data for theestablishment of good background information

2. To show the family history as well as the history

of past and present illness for the knowledge of

what could be the predisposing factors that might

contribute to the patient’s illness

3. To review Patient’s Chart and carry out Medical

Orders; thus, relate these interventions to the

alleviation of the Patient’s health condition

4. To present the different results of the patient’s diagnostic exams together with the comparison of

normal values for the understanding of what

changes during the disease

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6. To discuss the Anatomy, Physiology and

Pathophysiology of the Patient’s health condition

7. To present the data from the nursing assessment

performed on the patient using the cephalocaudalapproach for the good overview of her over-all

health

8. To identify Patient’s Clinical Manifestations as

basis for a specific, measurable, attainable,realistic and time-bounded Actual and Ideal

Nursing Care Plans.

9. To impart appropriate health teachings specifically

for the patient to promote wellness andappropriate discharge plan

10.To have an over-all conclusion and

recommendation about the care study

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The case study merely covers data that

have been gathered through interview per assessment tool and chart referral on the day

of the assessment phase in loading assigned

patients and in the succeeding days of the

rotation, in the care formulated and intervenedto its progress as the week’s rotation ended.

Thus, it is limited to the days in the rotation the

student nurse interacted with the client in the

hope to gather the necessary data to support

the presentation which is not enough to acquire

a bulk of specific details.

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Patient’s Profile

Client’s Name: Patient Castillo H.

Age: 61 years old

Address: Area 4, Lot 11, Blk20, Cagayan de Oro City

Civil Status: Married

Spouse: Mrs. R. Castillo

Sex: Male

Job: Sales Agent

Nationality: FilipinoReligion: Roman Catholic

Birthday: September 12, 1951

Height: 164.59 cm (5’5’’)

Weight: 195.8 lbs (89 kgs)

Educational Attainment: College Level

Admitting Physician: Dr. Victor Angelo Lozano, M.D.

Date of Admission: November 21, 2012

Time of Admission: 10:15 in the morning

Chief Complaint: swollen leg foot-ankle

Admitting Diagnosis: Acute Gouty Arthritis; Hyperuricemia

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Personal Health History

Patient Castillo H. is married to Mrs. R. with eight children, a

sales agent of Philippine Real Estates at Pueblo de Oro, Cagayan deOro City. He started smoking at the age of 18 years old and stopped at

the age of 42. He was also an occasional drinker of liquor and

consumed moderately. He was aware that he had a high blood pressure

and astigmatism.

According to patient Castillo H., he stopped his vices when he

was diagnosed to have pneumonia way back on the year 2003.

He had taken MX3 Mangosteen for the past months and

stopped taking the supplement because of financial crisis. He loves to

eat foods that are prohibited at his age now. He liked to eat lechonbaboy especially the its crispy skin and fatty parts, “sampayna”,

“adobong atay”, “batikulon” and “paklay”. He sometimes cannot resist

eating those foods. Two days before the day of admission, he ate

humba, lechon baboy, and peanuts.

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According to the patient, he noted changes in his left ankle and

experienced mild pain. However, he ignored those and dwelt in self-

treatment only. The wife advised him to have a medical check-up of his

condition but he refused. He said that he could still manage the pain bytaking pain reliever and can still perform his activities of daily living. Until

such time when patient Castillo H. can no longer manage the pain and

the changes he experienced. He complained of chronic pain upon

walking, limited movement, joint pain, and swelling of his left foot-ankle.

Because of that, Patient Castillo H. decided to consult a doctor to checkhis condition and sought medical admission at Polymedic General

Hospital, Velez, and then the doctor finally diagnosed Patient Castillo H.

of Acute Gouty Arthritis and Hyperuricemia.

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Family History

During the interview, there were no traced of underlying condition in

their family. His father died having an untreated arthritis only.

Past Medical History

In the year 2003, Patient Castillo H. was admitted and diagnosed with

pneumonia.

History of Present Illness

Five days prior to admission, patient noted to have swelling of his left

foot-ankle associated with positive joint pain, limitation of movement,

pain and tenderness on walking.

Then a day prior to admission, patient complained of swollen leg foot

and sought for medical attention. Therefore, patient sought medical

admission at Polymedic General Hospital, Velez.

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Family History

During the interview, there were no traced of underlying

condition in their family. His father died having an untreated arthritis

only.

Past Medical History

In the year 2003, Patient Castillo H. was admitted and

diagnosed with pneumonia.

History of Present Illness

Five days prior to admission, patient noted to have swelling of his left foot-ankle associated with positive joint pain, limitation of

movement, pain and tenderness on walking.

Then a day prior to admission, patient complained of swollen leg foot

and sought for medical attention. Therefore, patient sought medical

admission at Polymedic General Hospital, Velez.

Chief Complaints

One day prior to admission, patient complained of swollen leg

foot. Therefore, patient sought medical admission at Polymedic General

Hospital, Velez.

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CBC

U/A

HGT

Blood Chemistry

B l o o d C h emi s t r y

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Drug Study

Drug Study

Drug Study

Drug Study

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Result Normal values Implication

HCT

HGB

WBC

PLATELET

43.3

12.1

8,200

310,000

37-47vol %

12-16gms %

5,000-10,000/mm3

150,000-400,000/mm3

Normal

Normal

Normal

Normal

Diff. Count

Neutrophils

Granulocyte

Lymphocytes

Monocytes

69

50

43

7

50-62 %

43.4-76.2 %

17.4-48.2 %

4.5-10.5 %

Respond to any

inflammation

Normal

Normal

Normal

CBC

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Result Normal Values Rationale Color Glucose Transparency Protein Specific Gravity Microscopic Exam: Pus Cells RBC Amourphous Urates /

Phosphates Epithelial Squamous

Cells Bacteria

Light Yellow Negative Clear Negative 1.020 1-3/hpf 0-2/hpf Few Few Occasional

Pale Yellow- Amber Negative Clear to Slightly hazy Negative 1.002-1.030 0-4/hpf 0-3/hpf Negative

Normal Normal Normal Normal Normal Normal Normal

Indicates Infection

Urinalysis

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HGT

Result Normal Value Significant of the

Result 113 mg/dL 80-120 mg/dL Normal

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Test Result Normal Value Significant of the

Result Urea

23.62 mg/dL

4.70-23 mg/dL

May indicate kidneydysfunction/failure

Sodium 134.10

mEq/L 135-155 mEq/L Slightly below normal

range; may result

from excess body

water diluting the

serum sodium

Blood Chemistry

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Test Result Normal Value Significant of the

Result Creatinine 1.3 mg/dL 0.60-1.10

mg/dL Normal

Uric Acid 7.31 mg/dL 3.50-7.20

mg/dL excess of uric acid

in the blood: uric

acid formation-gout

Triglyceride

s 141.2 mg/dL 40-160 mg/dL Normal

Total

Cholesterol 216.9 mg/dL 0-200 mg/dL Risk for heart

disease HDLC 52.2 mg/dL 0-34 mg/dL Increase level of

good cholesterol;

guards against heart

disease

Blood Chemistry

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Generic

/brand name Classifi-

cation Dose/

route

Freque

ncy

Mechanism of

Action Specific

indication Contra-

indication Adverse reaction Nursing Precaution

Celecoxib(Celebrex) Analgesic;

NSAID 400mg

1 cap

BID PO

Analgesic andanti-

inflammatory

activities

related to

inhibition of

the COX-2

enzyme,

which is

activated ininflammation

to cause the

signs and

symptoms

associated

with

inflammation;

does not

affect the

COX-1

enzyme,

which protects

the lining of

the GI tract

and has blood

clotting and

renal

functions.

Managementof acute pain Contraindicated

with allergies to

sulfonamides,

celecoxib,

NSAIDs, or

aspirin,

significant renal

impairment.

Headache, dizziness,somnolence, insomnia,

fatigue, tiredness,

dizziness, rash,

pruritus, sweating, dry

mucous membranes,

stomatitis, nausea,

abdominal pain,

dyspepsia, flatulence,

GI bleed, neutropenia,eosinophilia,

leucopenia,

pancytopenia,

thrombocytopenia,

agranulocytosis,

decreased Hgb or Hct,

peripheral edema

-Administer drug withfood or after meals if gI

upset occurs. -Establish safety

measures if CNS or

visual disturbances

occur. -Provide further comfort

measures to reduce pain.

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Generic


cation Dose/

route

Freque

ncy

Mechanism of

Action Specific

indication Contra-


Colchicine Antigout 500 mg

1 tab

BID P.O.

Exact

mechanism of

action

unknown;

decreases

deposition of

uric acid;

inhibits kininformation and

phagocytosis,

and

decreases

inflammatory

reaction to

urate crystal

deposition.

Pain relief of

acute gout

attack Contraindicated

with allergy to

colchicines,

blood

dyscrasia;

serious GI

disorders,

hepatic, renal,or cardiac

disorders.

Diarrhea, vomiting,

peripheral neuritis,

myopathy,

dermatoses, alopecia,

abdominal pain, bone

marrow depression

-Monitor for relief of pain,

signs and symptoms of

gout attack; usually

abate within 12hour and

are gone within 24-48

hours. -Discuss the dosage

regimen with patient. -Administration should

begin at the first sign of

an acute attack; delay

can decrease drug’s

effectiveness in

alleviating symptoms of

gout. -Patient should haveregular medical follow-

ups and blood tests.

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Generic


cation Dose/

route

Freque

ncy

Mechanism

of Action Specific

indication Contra-


Allopurinol (Allurase)

Antigout 300

mg tab

OD PO

Inhibits the

enzyme

responsible

for the

conversion of

purines to

uric acid,

thusreducing the

production of

uric acid with

a decrease

in serum and

sometimes in

urinary acid

levels,relieving the

signs and

symptoms of

gout.

Manageme

nt of the

signs and

symptoms

of gout

Contraindicate

d with allergy

to Allopurinol,

blood

dyscrasias. -Use

cautiously with

liver disease,renal failure.

Headache,

drowsiness,

peripheral

neuropathy, neuritis,

paresthesias, rashes,

nausea, vomiting,

diarrhea, abdominal

pain, gastritis,hepatomegaly,

hyperbilirubinemia,

exacerbation of gout

and renal calculi,

renal failure. Anemia,

leucopenia,

agranulocytosis,

thrombocytopenia,aplastic anemia,

bone marrow

depression

-Administer drug

following meals. -Encourage patient to

drink 2.5-3L/day to

decrease the risk of

renal stone

development. -Check urine alkalinity-urates crystallize in

acid urine, sodium

bicarbonate or

potassium citrate may

be ordered to alkalinize

urine. -Arrange for regular

medical follow-up andblood tests. -Discontinue drug at

first sign of skin rash;

severe to fatal skin

reactions.

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Generic

/brand

name Classifi-

cation Dose/

route

Freque

ncy

Mechanism

of Action Specific

indication Contra-


Omeprazole Antisecretory

Proton

pump

inhibitor

40mgIVTT

OD Gastric acid-pump

inhibitor:

Suppresses

gastric acid

secretion by

specific

inhibition of

the

hydrogen-

potassium

ATPase

enzyme

system at

the secretory

surface of the gastric

parietal cells;

blocks the

final step of

acid

production.

Reductionof risk of

upper GI

bleeding

Contraindicated with

hypersensitivit

y to

Omeprazole

or its

components.

Headache,dizziness, asthenia,

vertigo, insomnia,

apthy, anxiety,

paresthesias, dream abnormalities,

rash, inflammation,

urticaria, pruritus,

alopecia, dry skin,

diarrhea, abdominal

pain, nausea,

vomiting,

constipation, dry

mouth

-Arrange regular medical check-ups. -Advise pt to report

immediately for side

effects.

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Generic


cation Dose/

route

Freque

ncy

Mechanism of

Action Specific

indication Contra-


Sodium

Bicarbonate Antacid; Electrolyte; Systemic

alkalinizer; Urinary

alkalinizer

100mg

1tab

TID ;

PO

Increases

plasma

bicarbonate;

buffers

excess

hydrogen ion

concentration;

raises blood

pH; reverses

the clinical

manifestation

of acidosis;

increases the

excretion of

free base in

the urine,

effectively

raising the

urinary pH;neutralizes or

reduces

gastric acidity,

resulting in an

increase in

the gastric

pH.

Minimization

of uric acid

crystalluria

in gout, with

uricosuric

agents.

Contraindicated

with allergy to

components of

preparations;

low serum

chloride;

metabolic and

respiratory

alkalosis;

hypocalcemia.

Gastric rupture

following

ingestion,headache,

nausea, irritability,

weakness, chemical

cellulitis, tissue

necrosis

-Have patient chew oral

tablets thoroughly before

swallowing, and follow

them with a full glass of

water. -Do not give oral sodium

bicarbonate within 1-

2hours of other oral

drugs to reduce risk of

drug interactions. -Have periodic blood

tests and medical

evaluations.

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Generic


cation Dose/

route

Frequ

ency

Mechanism

of Action Specific

indication Contra-


Meloxicam NSAID 15mg1 tab

OD PO

Anti-inflammatory

, analgesic,

and

antipyretic

activities

related to

inhibition of

the enzyme

cyclooxygen

ase (COX),

which is

required for

the

synthesis of

prostaglandins and

thromboxan

es.

Relief fromthe signs

and

symptoms

of arthritis

Contraidicated with allergy

to aspirin or

meloxicam.

Headache,dizziness,

somnolence,

insomnia, fatigue,

rash, pruritus,

sweating, dry

mucous

membranes,

nausea, dyspepsia,

GI pain, diarrhea,

vomiting, dysuria,

renal impairment,

bleeding, dyspnea,

hemoptysis,

peripheral edema

-Administer drug withfood or milk if GI upset

occurs. -Establish safety

measures if CNS

disturbances occur. -Monitor patient on

prolonged therapy for

signs of GI bleeding or

hepatic toxicity.

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Generic

name/Brand

name Classifi-

cation Dose/

route

Freque

ncy

Mechanism of

Action Specific

indication Contra-


PREDNISONE Corticosteroid 30 mg

1tab

BID x 7

days

Enters target

cells and

binds to

intracellular

corticosteroid

receptors,

initiating

many

complexreactions that

are

responsible

for its anti-

inflammatory

effect.

To prevent

inflammation

. Contraindicate

d with

infections and

allergy to

Prednisone.

Vertigo, headache,

hypertension, Na and

fluid retention, muscle

weakness, nausea

and vomiting,

increase appetite and

weight gain.

>Administer once a day

dose before 9am.

>Increase dosage when

patient is subject to

stress.

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S “Sakit gihapun gamay ako tiil ilihok ” as verbalized by the patient

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S Sakit gihapun gamay ako tiil ilihok. as verbalized by the patient

O

- > reports of pain > pain scale=6/10

- > facial grimace > reluctance to attempt movement

- >swollen left ankle > pain scale=6/10

- > body malaise > limited ROM

- >limitation in performing a few activities of daily living

- >edema on left leg

A Acute Pain r/t distention of tissues and inflammatory process

P Long Term:

At the end of 8 hours of nursing interventions, the patient will be able to incorporate relaxation

skills in controlling the pain.

Short Term:

At the end of 1 hour, patient will be able to report in comfort and relieved pain.

I 1. Encouraged to maintain bedrest and suggested to assume position in comfort. - In acute exacerbation bedrest is necessary and to limit pain and injury to joint.

2. Encouraged to ambulate sometimes. -Helps the client to enhance physical mobility and condition. -Prevents joint stiffness.

3. Applied warm, moist compresses to affected joints. -Heat promotes muscle relaxation and decreases pain.

4. Provided or involved in diversional activities. - Refocuses attention. 5. Provided gentle massage. -Promotes relaxation and reduces muscle tension.

6. Administered Celecoxib 400mg 1 cap BID PO for pain, and Colchicine 500mg 1tab BID PO astreatment of gouty arthritis.

E Long term: At the end of 8 hours of nursing interventions, the patient was able to incorporate

relaxation skills in controlling the pain.

Short term: At the end of 1 hour, patient reported in comfort and relieved pain, with a pain scale

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S “Maglisud ko’g lihok-lihok kay tungod sa kasakit sa akong tiil. ” as verbalized by the patient

O

- > reluctance to attempt movement > edema on the left leg

- >swollen left ankle

- > pain scale=6/10

- > body malaise - > limited ROM


A Activity intolerance r/t inflammation process as evidenced by swollen foot

P Long Term: At the end of 8 hours of nursing interventions, the patient will be able to maintain or increasemuscle strength and function. Short Term:

At the end of 1 hour of nursing interventions, patient will be able to participate and demonstratebehaviors that enable resumption of activities.

I 1. Provided calm, restful surroundings, and bed rest. -To reduce fatigue and improve strength.

2. Assisted with active or passive ROM exercises. -Maintains or improves joint function and muscle strength.

3. Encouraged patient to maintain upright and erect posture when sitting, standing and walking. -Maximizes joint function and maintains mobility.

4. Assisted and provided safety needs.

-Prevents injury and falls. 5. Repositioned frequently while observing proper measures. -Relieves pressure on tissues and promotes circulation.

E Long Term: At the end of 8 hours of nursing interventions, patient maintained increase in muscle

strength and function.

Short term: At the end of 1 hour of nursing interventions, patient participated and demonstrated

behaviors that enable resumption of activities.

S N b l l i d

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S No verbal complaints made

O

- > reluctance to attempt movement > edema on the left leg

- >swollen left ankle

- > pain scale=6/10

- > body malaise

- > limited ROM


A Risk for Injury r/t limited joint movement

P Long Term:

At the end of 8 hours of nursing interventions, the patient will be free from possible causes ofinjury. Short Term:

At the end of 1 hour of nursing interventions, patient will be able to demonstrate behaviorsthat can prevent injury.

I 1. Assisted in ambulation and provided safety needs. -Prevents injury and falls.

2. Encouraged patient to maintain upright and erect posture when sitting, standing andwalking. -Maximizes joint function and maintains mobility.

3. Encouraged progressive activity/ self -care when tolerated. -Enhances the patient’s sense of well-being or confidence.

4. Maintained or promoted safety environment.

- Promote safety and prevent possible harm to the patient. 5. Repositioned frequently while observing safety measures. -Relieves pressure on tissues and promotes circulation and safety.

E Long Term: At the end of 8 hours of nursing interventions, the patient was freed from possible

causes of injury.

Short term: At the end of 1 hour of nursing interventions, patient demonstrated behaviors to

prevent injury.

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MEDICATION

The patient is instructed strict compliance of home medications:1. Allopurinol (Allurase) 300mg 1 tab OD – treatment of goutyarthritis2. Prednisone 30mg 1tab BID- for inflammation3. Meloxicam 15 mg 1 tab OD- for pain and inflammation

4. Sodium Bicarbonate 100mg 1 tab TID- to minimize uric acidcrystalluria in gouty arthritis -To achieve the desired goal of the affected area by the use of dependent interventions such as the use of medications prescribed.

EXERCISES Instructed the patient to perform active ROM exercises andencouraged to perform ADL independently as per limitation. -This is to improve circulation and mobility of the affected area.

TREATMENT The patient is encouraged to elevate the affected area and supportit such as pillows. Ice packs can be applied to the affected joint. -This is to minimize increased pain and decreasing inflammation.

OUT-PATIENT The patient is encouraged to visit attending physician as prescribedfor follow- up check- up upon discharge. It is critically important tofollow up with the doctor. Gouty arthritis is treated in two stages.The first stage is to treat the acute arthritis. The second stage is toprevent gouty arthritis attacks from happening again. Low doses of

colchicine may be started during an acute attack, but medicationsto lower the blood uric acid levels are avoided because this couldintensify or prolong your attack. -You will need to follow up with your doctor after the acute attack has resolved to determine if it is necessary to start medications tolower the blood uric acid level.

DIET The patient is instructed to follow the prescribed diet, the lowpurine diet and to limit intake of foods rich in sodium. Seafoods andmeat may be avoided. -Prescribed diet is necessary to eliminate or precipitate the disease.

HEALTH TEACHINGS

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We recommend to Mr.Castillo H, to follow

all the imparted health teachings to prevent future

attacks. He must consult his doctor even if his pain from

gout is gone. The build - up of uric acid that led to gout

attack can still harm the joints. Some medicines may

need to be taken for the rest of his life. Control of weight,and avoidance of too much alcohol intake and too much

meat and fish high in purine must be observed. He’s

advised to drink plenty of water and other fluids. If

symptoms re- occur he should not hesitate to ask for consultation.

GOUTY GCP

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