Client%20with%20gout

1
Client with gout

• Definition
• a. Syndrome occurs from inflammatory response to
  production or excretion of uric acid resulting in
  high levels of uric acid in blood and other body
  fluids such as synovial fluid
• b. Metabolic disorder characterized by deposits
  of urates in connective tissues of body
• c. Primary gout
• d. Secondary gout
• 1. Malignancies (leukemia)
• 2. Chronic renal failure
• 3. Certain medications, such as some diuretics

2
Client with gout

• Pathophysiology
• a. Uric acid is a breakdown product of purine
  metabolism and is normally excreted through urine
  and feces
• b. Levels gt 7.0 mg/dL (normal 3.4 7.0 mg/dL in
  males 2.4 6.0 mg/dL in females) lead to
  formation of urate crystals in peripheral tissues
  (synovial membranes, cartilage, heart, earlobe,
  kidneys) and perpetuate inflammation

3
Client with gout

• Manifestations 3 stages in untreated gout
• a. Hyperuricemia
• 1. Uric acid levels average 9 10 mg/dL
• 2. Recurrent attacks of inflammation of single
  joint
• 3. Tophi in and around the joint
• 4. Renal disease and renal stones
• 5. Many persons do not progress beyond this level
• b. Acute gouty arthritis
• 1. Acute attack usually affecting a single joint
• 2. May be triggered by trauma, alcohol ingestion,
  dietary excess, stressor, such as surgery or
  hospitalization
• 3. Affected joint is red, hot, swollen, very
  painful and tender often first
  metatarsophalangeal joint (great toe)
• 4. Accompanied by fever, elevated WBC and ESR
• 5. Episode last hours to weeks followed by
  asymptomatic period

4
Client with gout

• Tophaceous (chronic) gout
• 1. Occurs when hyperuricemia not treated
• 2. Tophi develop in cartilage, synovial
  membranes, tendons, soft tissues
• 3. Skin over tophi may ulcerate exude chalky
  material and urate crystals
• 4. Leads to joint deformities and nerve
  compression
• 5. May lead to kidney disease (uric acid stones
  and can lead to ARF)
• Collaborative Care
• a. Treatment directed towards ending acute attack
• b. Treatment directed towards preventing
  recurrent attacks and complications

5
Client with gout

• Diagnostic Tests
• a. Diagnosis with classic presentation by
  history and physical examination
• b. Uric acid
• c. WBC
• d. Erythrocyte sedimentation rate (ESR) elevated
  from acute inflammation process
• e. 24-hour urine collection to determine uric
  acid production and excretion
• f. Fluid aspirated from acutely inflamed joints
  shows urate crystals

6
Client with gout

• Medications
• a. Used to terminate acute attack and prevent
  future ones
• b. Reduce serum uric acid levels
• c. Treatment of acute gout attack
• 1. NSAIDs, specifically indomethacin (Indocin)
• 2. Colchicine interrupts cycle of urate crystal
  deposits and inflammation
• a. Anti-inflammatory use limited to gout
• b .Use limited by significant side effects with
  oral administration abdominal cramping,
  diarrhea, nausea, vomiting
• 3. Corticosteroids, including intra-articular
  route
• 4. Analgesia, including narcotics

7
Client with gout

• Prophylactic therapy
• 1. Clients who do not eliminate uric acid
  adequately are treated with colchicines and
  uricosuric drugs, such as probenecid (Benemid)
  and sulfinpyrazone (Aprazone, Anturane, Zynol)
• 2. Clients who produce excessive amounts of uric
  acid are treated with allopurinol (Zyloprim),
  which lowers serum uric acid levels

8
Client with gout

• Dietary Management
• a. Dietary purines contribute only slightly to
  uric acid levels if low-purine diet recommended,
  client must avoid all meats, seafood, yeast,
  beans, oatmeal, spinach, mushrooms
• b. Client may be advised to lose weight, but
  fasting not advised
• c. Avoid alcohol, foods known to precipitate gout
  attack
• Other Treatments
• a. During acute attack of gouty arthritis, bed
  rest until 24 hours post attack, elevate joint
  with hot or cold compresses
• b. Liberal fluid intake (2000 mL) to increase
  urate excretion urinary alkalinizing agents
  (sodium bicarbonate and potassium citrate) to
  minimize risk of uric acid stones

9
Client with gout

• Nursing Diagnoses
• a. Acute Pain
• b. Impaired Physical Mobility
• Home Care
• a. Education regarding prescribed medications
• b. Education on maintaining high fluid intake of
  fluid and avoiding alcohol

10
Client with osteoarthritis (OA)

• Description
• a. Most common of all forms of arthritis
• b. Characterized by loss of articular cartilage
  in articulating joints and hypertrophy of bones
  at articular margins
• c. Causes are idiopathic or secondary (post
  injury)
• d. Affects more than 60 million adult Americans
• e. Males more often than females, until age 55
  when incidence twice as high in females
• f. Men more likely to have OA in the hips, women
  in the hands

11
Client with osteoarthritis (OA)

• Risk Factors
• a. Age, but may be inherited as autosomal
  recessive trait
• b. Excessive weight especially in hip and knee
• c. Inactivity
• d. Strenuous, repetitive exercise as with sports
  participants increased risk for secondary OA
• e. Hormonal factors such as decreased estrogen in
  menopausal women

12
Client with osteoarthritis (OA)

• Pathophysiology
• a. Cartilage lining joints degenerates and loses
  tensile strength loss of articular cartilage
  results in bone thickening, reducing the ability
  to absorb energy in joint loading
• b. Osteophytes (bony outgrowths) form, change
  anatomy of joint these spurs enlarge, break off
  and lead to mild synovitis

13
Joint changes in degenerative joint disease
14
Client with osteoarthritis (OA)

• Manifestations
• a. Onset is gradual, insidious, slowly
  progressive
• b. Pain and stiffness in one or more joints pain
  is a deep ache aggravated by use of motion and
  relieved by rest but may be persistent with time
• c. Pain may be referred to other places
• d. Periods of immobility are followed by
  stiffness
• e. Decreased range of motion of joint and grating
  or crepitus during movement
• f. Bony overgrowth causes joint enlargement
• 1. Herberdens nodes terminal, interphalangeal
  joints
• 2. Bouchards nodes proximal, interphalangeal
  joints
• g. Flexion contractures occur with joint
  instability

15
Client with osteoarthritis (OA)

• Complications Spondylosis, a degenerative disk
  disease, which may lead to herniated disk
• Collaborative Care
• a. Relieve pain
• b. Maintain clients function and mobility
• Diagnostic Tests
• a. Based on clients history and physical
  examination
• b. Characteristic changes seen on xray

16
Client with osteoarthritis (OA)

• Medications
• a. Pain management with aspirin, acetaminophen,
  NSAIDs
• b. Capsaicin cream topically to reduce joint pain
  and tenderness
• c. NSAID COX-2 inhibitors
• 1. Results similar to conventional NSAIDs with
  fewer GI and renal systems side effects
• 2. Meloxicam (Mobic), celecoxib (Celebrex),
  rofecoxib (Vioxx)
• d. Corticosteroid injection of joints, but this
  may hasten rate of cartilage breakdown

17
Client with osteoarthritis (OA)

• Conservative Treatment
• a. Physical therapy
• b. Rest of involved joint
• c. Using ambulation devices
• d. Weight loss
• e. Analgesic and anti-inflammatory medications

18
Client with osteoarthritis (OA)

• Surgery
• a. Arthroscopy
• 1. Arthroscopic debridement and lavage of
  involved joints
• 2. Unclear about effectiveness long term
• b. Osteotomy
• 1. Incision into or transection of bone to
  realign affected joint
• 2. Shifts joint load toward areas of less
  cartilage damage
• 3. Delays joint replacement for several years
• c. Joint arthroplasty
• 1. Reconstruction or replacement of joint
  indicated when client has severely restricted
  joint mobility and pain at rest
• 2. Total joint replacement is procedure done for
  most OA clients, which involves replacing both
  surfaces of affected joint with prosthetic parts

19
Client with osteoarthritis (OA)

• Complementary Therapies
• a. Bioelectromagnetic therapy
• b. Elimination of nightshade foods
• c. Nutritional supplements, herbal therapies,
  vitamins
• d. Osteopathic manipulation
• e. Yoga
• Nursing Care
• a. Promote comfort
• b. Maintain mobility
• c. Assist with adaptation of life style

20
Client with osteoarthritis (OA)

• Health Promotion
• a. Maintenance of normal weight
• b. Program of regular, moderate exercise
• c. Use of glucosamine and chrondroitin
• Nursing Diagnoses
• a. Chronic Pain
• b. Impaired Physical Mobility
• c. Self-care Deficit
• Home Care
• a. Education regarding avoiding overuse or stress
  on affected joints
• b. Education regarding pharmacological and other
  forms of pain-relief
• c. Clients post TJR activity restrictions and
  assistive devices

21
Rheumatoid arthritis (RA)

• Definition
• a. Chronic systemic autoimmune disease causing
  inflammation of connective tissue primarily in
  joints
• 1. Three times more likely to affect females than
  males
• 2. Onset is between 20 40 years
• b. Course and severity are variable clients
  exhibit pattern of symmetrical multiple
  peripheral joints involvement with periods of
  remission and exacerbation
• c. Cause is unknown combination of genetic,
  environmental, hormonal, reproductive factors
  infectious agents, especially Epstein-Barr,
  thought to play role

22
Rheumatoid arthritis (RA)

• Pathophysiology
• a. Normal antibodies become autoantibodies
  (rheumatoid factors -RF) and attack host tissues,
  which bind with target antigens in blood and with
  synovial membranes forming immune complexes
• b. Synovial membrane damaged from inflammatory
  and immune processes leads to erosion of
  articular cartilage and inflammation of ligaments
  and tendons
• c. Granulation tissue (pannus) forms over denuded
  areas of synovial membrane and scar tissue forms
  immobilizing joint

23
Rheumatoid arthritis (RA)

• Joint manifestations
• a. Onset is usually insidious but may be acute
  after stressor, such as infection
• b. Systemic manifestations fatigue, anorexia,
  weight loss and non-specific aching and stiffness
  precedes joint involvement
• c. Joint swelling with stiffness, warmth,
  tenderness and pain usually multiple joints and
  symmetric involvement
• d. Proximal interphalangeal and
  metacarpophalangeal joints of fingers, wrists,
  knees, ankles, and toes are frequently involved
• e. Joint deformity of fingers include swan-neck
  deformity and boutonniere deformity wrist
  deformity leads to carpel tunnel syndrome knee
  deformity leads to disability and feet and toes
  develop typical deformities

24
Joint destruction in rheumatoid arthritis
25
Rheumatoid arthritis (RA)

• Extra-articular manifestations
• a. While disease is active fatigue, weakness,
  anorexia, weight loss, low-grade fever
• b. Anemia develops as does skeletal muscle
  atrophy
• c. Rheumatoid nodules develop in subcutaneous
  tissue in areas subject to pressure on forearm,
  olecranon bursa, over metacarpophalangeal joints
• d. Pleural effusion, pericarditis, splenomegaly
  may occur

26
Rheumatoid arthritis (RA)

• Collaborative Care
• a. Relief of pain and reduction of inflammation
• b. Slow or stop joint damage
• c. Improve well-being and ability to function
• d. Relief of manifestations

27
Rheumatoid arthritis (RA)

• Diagnostic Tests
• a. Client history and physical assessment
• b. Rheumatoid factors (RF), autoantibodies to IgG
  present in 75 of persons with RA
• c. Elevation of ESR indicator of disease and
  inflammatory activity used to evaluate
  effectiveness of treatment
• d. Examination of synovial fluid signs
  associated with inflammation
• e. Xrays of affected joints show diagnostic
  changes
• f. CBC shows moderate anemia with elevated
  platelet count

28
Rheumatoid arthritis (RA)

• Medications
• a. Aspirin and NSAIDs, mild analgesics to relieve
  manifestations, but have little effect on disease
  progression
• 1. Aspirin
• a. Often first prescribed in high doses just
  under toxic dose, which produces tinnitus and
  hearing loss
• b. GI side effects and interference with platelet
  function are hazards associated with aspirin
  therapy
• c. May use enteric-coated forms of aspirin or
  nonacetylated salicylate compounds

29
Rheumatoid arthritis (RA)

• NSAIDs
• a. Different, specific NSAIDs are tried to
  determine the most effective drug for individual
  clients
• b. Have GI side effects and can be toxic to
  kidneys
• b. Low dose oral corticosteroids
• 1. To reduce pain and inflammation
• 2. To slow development and progression of disease
• 3. Often have dramatic effects, but long-term use
  results in multiple side effects

30
Rheumatoid arthritis (RA)

• Treatments
• a. Balanced program of rest and exercise
• 1. Rest with exacerbation and may utilize
  splinting
• 2. Exercise to maintain ROM, muscle strength
• 3. Low impact exercise such as swimming or
  walking
• b. Physical and occupational therapy
• c. Heat and cold analgesia and muscle-relaxation
• d. Assistive devices and splints which help rest
  joints and prevent contractures
• e. Diet well-balanced some benefit from omega-3
  fatty acids found in fish oils
• f. Surgery variety of procedures may be done
  synovectomy, arthrodesis, joint fusion,
  arthroplasty or total joint replacement

31
Rheumatoid arthritis (RA)

• Nursing Care assist client to deal effectively
  with physical manifestations and psychosocial
  effects
• Health Promotion
• a. Support client in becoming arthritis
  self-managers prevent deformities and effects of
  arthritis by balance of exercise and rest, weight
  management, posture, and positioning
• b. Referral Arthritis Foundation
• Nursing Diagnoses
• a. Chronic Pain increasing pain requires need to
  decrease activity level
• b. Fatigue
• c. Ineffective Role Performance
• d. Disturbed Body Image
• Home Care support for client and family to
  become active in disease management

32
Systemic Lupus Erythematosus (SLE)

• Definition
• a. SLE is chronic inflammatory immune complex
  connective tissue disease affecting multiple body
  systems can range from mild episodic disorder to
  rapidly fatal disease process
• b. Affects mostly females in childbearing age
  more common in African Americans, Hispanics,
  Asians
• c. Cause is unknown causative factors are
  genetic, environmental, and hormonal
• d. Most clients have mild chronic case with
  periods of remissions and exacerbations those
  with virulent disease often develop renal and CNS
  involvement and death is related to infection

33
Systemic Lupus Erythematosus (SLE)

• Definition
• a. SLE is chronic inflammatory immune complex
  connective tissue disease affecting multiple body
  systems can range from mild episodic disorder to
  rapidly fatal disease process
• b. Affects mostly females in childbearing age
  more common in African Americans, Hispanics,
  Asians
• c. Cause is unknown causative factors are
  genetic, environmental, and hormonal
• d. Most clients have mild chronic case with
  periods of remissions and exacerbations those
  with virulent disease often develop renal and CNS
  involvement and death is related to infection

34
Systemic Lupus Erythematosus (SLE)

• Pathophysiology
• a. Production of large variety of autoantibodies
  against the normal components of body especially
  the nucleic acids leads to development of immune
  complexes which leads to tissue damage in
  multiple organs
• b. Reaction to some medications (procainamide,
  hydralazine) causes a syndrome similar to lupus,
  which usually resolves when medication is
  discontinued

35
Systemic Lupus Erythematosus (SLE)

• Manifestations
• a. Early manifestations fever, anorexia,
  malaise, weight loss, multiple arthralgias and
  symmetric non-deforming polyarthritis
• b. Skin manifestations usually occur red
  butterfly rash across the cheeks and bridge of
  the nose accompanied by photosensitivity
  (maculopapular rash upon sun exposure) alopecia
  is common
• c. 50 of persons have renal involvement
  including proteinuria, cellular casts, and
  nephrotic syndrome 10 develop renal failure
• d. Hematologic manifestations
• e. Cardiovascular system
• f. Pulmonary system
• g. Neurologic involvement
• h. Ocular system
• i. GI symptoms

36
Systemic Lupus Erythematosus (SLE)

• Collaborative Care
• a. Diagnosis is often difficult due to the
  diversity of manifestations in individual clients
• b. Effective management has improved survival rate

37
Systemic Lupus Erythematosus (SLE)

• Diagnostic Tests
• a. Clinical history, physical examination
• b. Anti-DNA of various antibodies, this antibody
  is more specific for SLE rarely found in any
  other disorder
• c. ESR typically elevated, especially during
  exacerbations
• d. Serum complement levels levels are low (used
  in development of antigen-antibody complexes)
• e. CBC severe anemia, leucopenia with
  lymphcytopenia, thrombocytopenia
• f. Urinalysis mild proteinuria, hematuria, blood
  cell casts
• g. BUN and creatinine determine renal function
• h. Kidney biopsy obtain accurate diagnosis of
  kidney lesion and plan definitive treatment with
  renal insufficiency

38
Systemic Lupus Erythematosus (SLE)

• Medications
• a. Mild cases of SLE may be treated with
  supportive care and possible aspirin and NSAIDs
• b. Skin and arthritic manifestations are treated
  with anti-malarial drugs
• c. Severe cases are often treated with high-dose
  corticosteroid therapy tapered as clients
  disease allows treatment may also include
  immunosuppressive agents (cyclophosphamide or
  azathioprine) alone or with the steroids

39
Systemic Lupus Erythematosus (SLE)

• Other treatments
• a. Avoid sun exposure use of sunscreens
• b. Clients with ESRD require dialysis and kidney
  transplantation
• Nursing Care client with severe disease has
  needs related to system involvement and similar
  to client with RA

40
Systemic Lupus Erythematosus (SLE)

• Nursing Diagnoses
• a. Impaired Skin Integrity
• b. Ineffective Protection
• 1. Teach client to follow aseptic techniques
• 2. Monitor closely for signs of infection, which
  are often suppressed
• c. Impaired Health Maintenance client often has
  involved physical and psychological needs
• Home Care
• a. Teaching regarding skin care, avoiding sun,
  following treatment plan including medications
• b. Wearing medical identification
• c. Family planning
• d. Referral to home nursing care, resources and
  support groups