I.

Introduction

According to www.patient.co.uk, research using the UK primary care database reported the incidence of gout per 1,000 person-years to be 2.68 (4.42 in men and 1.32 in women) for the years 2000-2007. The prevalence increased with age. Asian populations and people of the Pacific Islands have a much higher prevalence and more severe disease. The male to female ratio is 9:1. The prevalence increases in women after the menopause although this is partly reduced by hormone replacement therapy. Factors such as the introduction of fructose-high corn sweetener and the rise in obesity have led to a dramatic increase in the incidence of gout in developed countries such as America. Gout is a type of arthritis. It occurs when uric acid builds up in blood and causes inflammation in the joints. Gout is caused by having higher-than-normal levels of uric acid in your body. This may occur if: your body makes too much uric acid or your body has a hard time getting rid of uric acid. If too much uric acid builds up in the fluid around the joints (synovial fluid), uric acid crystals form. These crystals cause the joint to swell and become inflamed. The characteristic symptoms and signs of gout are the sudden onset of pain, swelling, heat, and redness. This usually affects a single joint. The pain is typically severe, reflecting the severity of inflammation in the joint. The affected joint is often exquisitely sensitive to touch to the point that some patients experience pain from something as simple as pulling the bed sheets over the affected area at night. Another sign of gout is the presence of tophi. A tophus is a hard nodule of uric acid that deposits under the skin. When gout is mild, infrequent, and uncomplicated, it can be treated with diet and lifestyle changes. When attacks are frequent, uric acid kidney stones are present, the uric acid level is very high, tophi are present, or there is evidence of joint damage from gout, medications are necessary to treat gout. Medications for the treatment of gout generally fall into one of three categories: uric-acid-lowering medications (e.g. allopurinol (Zyloprim, Aloprim)), prophylactic medications (medications used in conjunction with uric-acid-lowering medications to decrease the risk for a gout flare during the first six months of treatment, such as NSAIDs), and rescue medications to provide immediate relief from gout pain (colchicine (Colcrys), NSAIDs and steroid medications).

II.

Anatomy and Physiology

THE SKELETAL SYSTEM This section presents the skeletal system as presented by Elaine N. Marieb. Essentials of Human Anatomy and Physiology (Ninth Edition). The skeletal system provides an internal framework for the body, protects organs by enclosure, and anchors skeletal muscles so that muscle contraction can cause movement. The skeleton is subdivided into two divisions: the axial skeleton, the bones that form the longitudinal axis of the body, and the appendicular skeleton, the bones of the limbs and girdles. In addition to bones, the skeletal system includes joints, cartilages, and ligaments (fibrous cords that bind the bones together at joints). The joints give the body flexibility and allow movement to occur. The Axial Skeleton The axial skeleton (trunk) is made up of the 80 bones in our upper body. Bones of the axial skeleton include: Skull (facial and cranial bones)
1

Hyoid Vertebrae in the spine (backbones) Ribs Sternum (breastbone) Our arms and shoulders hang from the axial skeleton.

The Appendicular Skeleton There are 126 bones in the arms, shoulders, hips, and legs. The appendicular skeleton is made up of our limbs or appendagestwo arms and two legsour pelvis and right and left shoulders. Our arms hang from our shoulders and legs attached to our hips. Bones of the Upper Appendage (Arm) Shoulder girdlescapula (shoulder blade), clavicle (collar bone) Humeruslong bone of the upper arm Radiuslong bone of the forearm; connects with the humerus to form the elbow Ulnalong bone of the forearm; connects with the humerus to form the elbow Carpals8 small bones of the wrist Metacarpalssmall bones of the hand Phalanges14 bones of the fingers (3 in each finger) and thumb (2 in the thumb) Bones of the Lower Appendage (Leg) Pelvic Girdlemade up of the right and left hip bones which are joined in the back with the sacrum and in the front at the symphysis pubis Hipbonemade of the ilium, pubis and ischium Femurlong bone of the thigh and longest bone in the body; connects with pelvis to form and hip joint and the tibia and fibula to form the knee joint Tibialong bone of the lower leg (shin bone); connects with the femur to form the knee Fibulathinner, long bone of the lower leg Patellakneecap (Learn more about knee anatomy) Tarsalssmall bones of the hand Metatarsalsankle Phalangesbones of the toes (3 in each toe and 2 in the big toe) The Joints Joints, also called articulations, have two functions: they hold the bones together securely but also give the rigid skeleton mobility. Joints are classified into two ways functionally and structurally. The functional classification focuses on the amount of movement the joint allows. On this basis, there are synarthroses, or immovable joints; amphiarthroses, or slightly movable joints; and diarthroses, or freely movable joints. Freely movable joints predominate in the limbs, where mobility is important. Immovable and slightly movable joints are restricted mainly to the axial skeleton, where firm attachments and protection of internal organs are priorities. Structurally, there are fibrous, cartilaginous, and synovial joints. Fibrous: the articular surfaces (point on the bones surface where the two bones meet) are held together by fibrous connective tissue. Very little movement is possible. Examples of fibrous joints are sutures, syndesmoses, and gomphoses.
2

 Cartilaginous (amphiarthroses): the bones in cartilaginous joints are held together by cartilage which allows slight movement. o Synchondroses-these are temporary joints where the cartilage converts to bone by the time we are adults. The growth plates of long bones are examples of this type of joint. o Symphyses-these joints have a pad of fibrocartilage separating the bones; an example is the symphysis pubis Synovial-the bony surfaces on the ends of the bones are covered with articular cartilage and separated by a slippery, lubricating fluid called synovia. They bones are held together in the joint by ligaments lined with synovial membranes which produce the synovial fluid. These freely moving joints are mostly found in our arms and legs. Synovial joints also include: o A joint cavity or joint space: space between the articulating surfaces; articulating surfaces are the bone surfaces that move against each other when the joint moves. The articulating surfaces are covered with a layer of hyaline cartilage that cushions and protects the bones. The synovial membrane defines the boundaries of the joint spaceeverything outside of the synovial membrane is outside the joint space. The synovial membrane is wrapped by layers of connective tissue that form the joint capsule. o An articular capsule: a sac-like structure that surrounds the joint and has an outer layer lined with a synovial membrane (synovium) that makes the synovial fluid. Synovial fluid acts as a lubricant, forms a fluid seal and helps distribute the force placed on the joint. o Reinforcing ligaments: tough, fibrous connective tissues that connect the bones and reinforce the joint capsule. On the outside of the joint capsule are thick strap-like bands, called collateral ligaments. These ligaments direct the force that travels through the joint and keep the joint on track. Outside of these structures are the muscles that travel across the joint. III. TEXTBOOK DISCUSSION

Definition Gout can be defined as arthritis due to deposition of monosodium urate (MSU) monohydrate crystals within joints causing acute inflammation and eventual tissue damage. It has been aptly described as, "... one of the most painful acute conditions that human beings can experience ...". Classification The condition can be classified into primary or secondary gout depending on the cause of hyperuricaemia:

Primary gout occurs mainly in men aged 30-60 years presenting with acute

attacks. Normally, secondary gout is due to chronic diuretic therapy. It occurs in older subjects, both men and women, and is often associated with osteoarthritis.

Causes Gout is caused by the accumulation in the joint of crystals of a byproduct chemical of metabolism known as uric acid. When uric acid crystals accumulate, it causes inflammation in a joint. Joint inflammation causes pain, redness, heat, and swelling of the joint.

Normal sUA levels in men ( 7 mg/dl) and women ( 6 mg/dl) are already close to the limits of urate solubility (6.8 mg/dl at 37C). An elevated uric acid level in the bloodstream leads to uric acid accumulation in the tissues of a joint. Uric acid is normally found in the body and is a normal byproduct of the way the body breaks down
3

certain proteins called purines. Causes of an elevated uric acid level (hyperuricemia) in the bloodstream include genetics, obesity, certain medications such as diuretics (water pills), and chronic decreased kidney function. Risk factors Male sex Age (Middle-aged and elderly) Meat Seafood Alcohol (10 or more grams per day) Diuretics Obesity Hypertension Coronary heart disease Diabetes mellitus Chronic renal failure High triglycerides Purine-rich foods (Meat and fish purines)

Other factors since identified include chemotherapeutic drugs, psoriasis and heart failure. The presence of previous joint morbidity and trauma may influence which joint is affected. Symptoms of Gout All patients with gout should be aware of gout symptoms. These include: Severe pain Acute inflammation High Fever Presence of tophi The affected joint is sensitive to touch Fatigue Manifested by the Patient Rationale

From the Textbook Severe pain

Caused by proteins called interleukins, which are produced by the body to fight off infection

Acute inflammation High Fever Tophi

Indicates an inflammatory process

Sensitive to touch Fatigue

Laboratory and Diagnostic Tests Clinical Chemistry o Uric Acid o Creatinine o Potassium o Sodium Hematology Gram Stain Bacteriology Report Urinalysis Treatments Nursing Management: Dress wound with betadine and OS to prevent further infection and facilitate healing. Drug administration to cure gout by reducing uric acid synthesis and to reduce blood pressure. Vital signs taking and recording in order to monitor for any signs of inflammatory process and hypertension. Positioning of lower extremities in order to relieve pressure and to improve circulation in the left foot. Medical Management: Cardiac glycosides Antigout drug to reduce uric acid synthesis Antihypertensive to reduce blood pressure

IV.

PATHOPHYSIOLOGY Predisposing Factors: *Age: 68 years old *Sex: Male *Hypertension *Heart Problem

Precipitating Factors: *Meat (High Purine) *Alcohol Drinker (since 38 years old)

Overproduction/ underexcretion of uric acid Hyperuricemia Tophi Crystal Formation Microcrystal Release Fever Inflammatory Cascade Gout Flare

Heat Swelling Redness Pain Loss of Function

V.

VITAL INFORMATION ADMITTED: DATE: February 21, 2014 TIME: 2:08 PM

NAME

Mr. L. L. L. S.

AGE NATIONALITY STATUS

68 years old Filipino Married

RELIGION PLACE OF BIRTH

Roman Catholic Burias, Mambusao, Capiz

PROVINCIAL ADDRESS
6

Burias, Mambusao, Capiz

DATE OF BIRTH

August 24, 1946

OCCUPATION SPOUSE RM./WARD CHIEF COMPLAINT

Farmer Mrs. E. L. MSW Non-healing Wound Left Foot

ADMITTING DIAGNOSIS

Infected Non-Healing Wound Left Foot

FINAL DIAGNOSIS ATTENDING PHYSICIAN Dr. C. R.

VI.

ASSESSMENT Clinical Assessment PAST MEDICAL HISTORY

Patient L. has developed a particular heart problem (the term was unknown to him) when he was 52 years old which caused him his first hospitalization. After 3 years, he developed the gouty arthritis in which, according to him, also caused him to goback-and-forth the hospital (SACH) two times. During his admissions, his doctors gave him medications like Arcoxia, Danilon, Voltaren and a lot more. Patient L. was an alcohol drinker since he was 38 years old but according to him, he already stopped 4 years ago since hes already aware that this could worsen his condition. HISTORY OF PRESENT ILLNESS Four days prior to admission (February 21, 3014), Patient L. was brought to Mambusao District Hospital and was advised to self-drain and dress the wound at home. Three days after, the wound did not heal so Pt. L decided to seek medical consultation at St. Anthony College Hospital. The physical findings revealed nonhealing wound at the 2nd digit of left foot. Vital Signs Monitoring DAY 1 FEBRUARY 23, 2014 8 AM T = 36.6 C 12 PM T = 36.2 C

CR = 75 bpm PR = 73 bpm RR = 16 S/U = 1/3

CR = 70 bpm PR: 68 bpm RR = 15 S/U: 0/0

VII.

LABORATORY AND DIAGNOSTIC DATA CLINICAL CHEMISTRY Test Name Result Normal Values Uric Acid (Feb. 22, 2014) 502.8 umol/L (H) 155.0 428.0 Creatinine (Feb. 23, 2014) Potassium (Feb. 22, 2014) Sodium (Feb. 22, 2014) 105.5 umol/L 3.9 mmol/L 53.0 115.0 3.5-5.1

Rationale Indicates overproduction of uric acid

133 mmol/L (L) 136-145 HEMATOLOGY (Feb. 21, 2014) 0.32 vol (fr) (L) 109 gms/L (L) x / (L) x / 69 % (H) 0% 8 % (H) 16 % (L) 7 % (H) 92 fL 31 pg 34 g/dL 0.42 - 0.52 135 180 4.7 6.0 4.0 10.5 50 65 01 14 25 -30 2 -5 78 100 27 31 32 - 36 *Indicates bleeding

*CBC Hematocrit Hemoglobin RBC Count WBC Count *Differential Count Segmenters Basophils Eosinophils Lymphocytes Monocytes *Indices MCV MCH MCHC Platelet: Adequate

*Indicates infection *Indicates infection *Indicates infection *Indicates severe infection

CLINICAL MICROSCOPY (Urinalysis) (Feb. 23, 2014) Macroscopic Color Transparency Reaction Specific Gravity Protein Glucose Microscopic Amorphous Urates RBC WBC Epithelial Cells Bacteria Pstraw Shazy 6.0 pH 1.005 (-) (-) Occasional 0-2 /hpf 0-2 /hpf Occasional Occasional

BLOOD TYPING (Feb. 21, 2014) Blood Type Rh O Pos (+)

MICROBIOLOGY (Feb. 22, 2014) Wound Gram Stain > Squamous Epithelial Cells Occasional >Organism Seen / OIF Occasional (+) cocci in singles; occasional gram (-) bacilli in singles and pairs BACTERIOLOGY REPORT (Feb. 23, 2014) Nature of Specimen: Wound Organism Identified: Final Report: Pseudomonas Aeruginosa Sensitive to: -piperacillin/tazobactam -ceftazidime -cefepime -imipenem -meropenem -amikacin -gentamicin -ciprofloxacin -ampicillin -amoxicillin/clavulanic acid -cefuroxime -cefuroxime axetil -cefoxitin -coustin -trimethoprim -sulfonamides

Resistant to:

VIII.

DRUG STUDY Dosage, Route and Frequency Classification of Drug Action Mechanism of Action Indications Side Effects Contraindications Nursing Responsibilities

Name of Drug

Lanoxin

0.25 mg/tab *Functional tab OD Class: Inotropic antidysrhythmi c, cardiac glycoside *Chemical Class: Digitalis preparation

Antidysrhyt hmic

Inhibits sodiumpotassium ATPase, which makes more calcium available for contractile proteins, resulting in increased cardiac output

1. Rapid digitalization in CHF, 2. Atrial fibrillation, 3. Atrial flutter, 4. Atrial tachycardia; 5. Cardiogenic shock, 6. Paroxysmal atrial tachycardia

*CNS:

drowsiness, apathy, confusion, disorientation, fatigue, depression, hallucinations

*GI: nausea,

vomiting, anorexia, abdominal pain, diarrhea

*CV:

*Hypersensitivity to digitalis *Ventricular fibrillation *Ventricular Tachycardia *Carotid Sinus Syndrome *2nd- or 3rd- degree heart block

1. Assess and document apical pulse for 1min before giving drug; if pulse <60 in adult or is significantly different, take again in 1hr; if <60 in adult, call prescriber; note rate, rhythm, character. 2. Do not give at same time as antacids or other drugs that decrease absorption. 3. Instruct patient to notify prescriber of any loss of appetite, lower stomach pain, diarrhea, weakness, drowsiness, headache, blurred or yellow-green vision, rash, depression; teach toxic symptoms of this drug

Dysrhythmias, hypotension, bradycardia, AV block

*EENT: Blurred

vision, yellowgreen halos, photophobia, diplopia

10

and when to notify prescriber. 4. Advise patient to maintain a sodiumrestricted diet as ordered; to take potassium supplements as ordered to prevent toxicity.

Name of Drug

Dosage, Route and Frequency 300 mg 1 cap OD

Classification of Drug

Action

Mechanism of Action

Indications

Side Effects

Contraindications

Nursing Responsibilities

Allopurinol

*Functional Class: Antigout drug *Chemical Class: Xanthine enzyme inhibitor

Antigout

Inhibits the enzyme xanthine oxidase, reducing uric acid synthesis.

1. Chronic gout, 2. Hyperuricemia associated with malignancies, 3. Recurrent Calcium oxalate calculi, 4 Chagas disease, 5. Cutaneous/ visceral leishmaniasis

*CNS: headache,

drowsiness, neuritis, paresthesia

*Hypersensitivity

*GI: nausea,

vomiting, anorexia, malaise

*EENT:

1. Assess for pain including location, characteristics, onset/ duration, frequency, quality, intensity or severity of pain, precipitating factors. 2. Monitor uric acid levels q2wk; normal uric acid levels are 6 mg/dL or less; check I&O ratio; increase fluids to 2L/day to

Retinopathy, cataracts, epistaxis

11

*HEMA:

Agranulocytes, thrombocytopenia , aplastic anemia, pancytopenia, leucopenia, bone marrow suppression, eosinophilia
*INTEG: Fever,

prevent stone formation, toxicity. 3. Monitor nutritional status: discourage organ meat, sardines, salmon, legumes, gravies (high-purine foods), alcohol.

chills, dermatitis, pruritis, purpura, erythema, ecchymosis, alopecia

Name of Drug Vasalat

Dosage, Route and Frequency 5 mg 1 tab OD

Classification of Drug *Functional Class: Antianginal, calcium channel blocker, antihypertensiv e *Chemical

Action

Mechanism of Action Inhibits calcium ion influx across cell membrane during cardiac depolarization; produces relaxation of coronary vascular smooth

Indications

Side Effects

Contraindications

Nursing Responsibilities 1. Monitor B/P and pulse; if B/P drops, call prescriber. 2. Monitor cardiac status: B/P, pulse, respirations, ECG 3. Advise patient to

Antianginal and antihyperte nsive

1. Chronic stable angina, 2. Hypertension, 3. Vasospastic angina

*CNS: headache,

fatigue, dizziness, anxiety, depression, insomnia, paresthesia, somnolence, asthenia

*Sick sinus syndrome *2nd- or 3rd- degree heart block *Hypotension less than 90 mmHg systolic *Hypersensitivity

12

Class: Dihypyridine

muscle, peripheral vascular smooth muscle dilates coronary vascular arteries; increases myocardial oxygen delivery in patients with vasospastic angina.

*GI: nausea,

vomiting, diarrhea, gastric upset, constipation, abdominal cramps, flatulence, anorexia

*INTEG: Rash,

avoid hazardous activities until stabilized on drug, dizziness is no longer a problem. 4. Teach patient to use as directed even if feeling better; may be taken with other cardiovascular drugs (nitrated, B-blockers).

pruritus, urticaria, hairloss

*GU: Nocturia,

polyuria

13

IX.

Nursing Care Plan

Assessment Subjective Data:

Diagnosis

Planning

Interventions

Evaluation

Impaired Skin Integrity After the nursing related to nonhealing intervention, the Nagbuswang akon bukol sa wound patient will be able to tiil. display timely healing of wound and ability Pain Scale = 5 to manage situation. Objective Data: * Ulcer is noted at the 2nd digital of the left foot *Swelling is noted *Presence of redness

1. Monitor vital signs especially GOAL PARTIALLY MET. temperature to observe for any changes in the patients status. The patient can manage his situation as evidence 2. Administer antigout medication per by frequent ambulation physician orders: Allopurinol 300 mg 1 and fewer complaints capsule once a day in order to treat the about pain. root of present condition. Pain Scale= 3 3. Keep the area clean and dry, carefully dress wounds, prevent infection to assist bodys natural process of repair. 4. Elevate patients left foot to prevent pressure and facilitate circulation and the normal process of repair. 5. Encourage early ambulation or mobilization. Promotes circulation and reduces risks associated with mobility. 6. Keep the patient rested and comfortable.

14

15

X.

Dischare Planning Medications: Lanoxin 0.25 mg/tab tab OD (8 am) Allopurinol 300 mg 1 cap OD Vasalat 5 mg 1 tab OD (12 NN) Exercise: Encourage the patient to exercise regularly, as well as to perform daily activities that could help in the development of the patients fitness. After discharge, the patient can already perform activities that is tolerable to him. Treatment: Encourage the patient to comply with the medications prescribed by his attending physician in order to aid in his complete recovery. Explain to the patient, as well as to the folks, the significance of adhering to the medications prescribed. Health Education: Instruct the patient to refrain from doing activities that can cause so much fatigue such as heavy work. More importantly, advise patient to never go back on alcohol drinking because it is one of the risk factors of gout. Out-Patient Follow-up Diet Encourage the patient to avoid from eating high purine foods such as meat and fish. Vegetable rich in purine is acceptable. The patient was advised to have a low salt, low fat diet. Spirituality The family was encouraged to continue attending masses every Sunday and participating in the Churchs celebrations The family, especially the patient, was advised to pray together regularly in order to strengthen their faith to God.

16

XI. XII.

NURSING CARE PLAN DISCHARGE PLANNING

17