LICEO DE CAGAYAN UNIVERSITY RODOLFO N. PELAEZ Blvd.

, KAUSWAGAN CAGAYAN DE ORO CITY COLLEGE OF NURSING NCM501107

Introduction Health History Medical Management Pathophysiology Nursing Assessment Chart SOAPIE

Referrals and Follow - up

Recommendation

December 1, 2012

Gout is a medical condition that shows a strong correlation with hyperuricemia and is characterized by deposition 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 occurs about 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, nearly doubling 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).

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 (8090%) 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 is reabsorbed 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 that have been shown to decrease excretion of UA include loop and thiazide diuretics, ethanol, salicylates, nicotinic acid, levodopa, and cyclosporine.

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.

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 the patients 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 best in 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.

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 patient according 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.

The completion of this case study enables the proponent to do the following: 1. To organize our patients data for the establishment 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 patients illness 3. To review Patients Chart and carry out Medical Orders; thus, relate these interventions to the alleviation of the Patients health condition 4. To present the different results of the patients diagnostic exams together with the comparison of normal values for the understanding of what changes during the disease

6. To discuss the Anatomy, Physiology and Pathophysiology of the Patients health condition 7. To present the data from the nursing assessment performed on the patient using the cephalocaudal approach for the good overview of her over-all health 8. To identify Patients 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 and appropriate discharge plan 10.To have an over-all conclusion and recommendation about the care study

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 intervened to its progress as the weeks 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.

Patients Profile
Clients Name: Age: Address: Civil Status: Spouse: Sex: Job: Nationality: Religion: Birthday: Height: Weight: Educational Attainment: Patient Castillo H. 61 years old Area 4, Lot 11, Blk20, Cagayan de Oro City Married Mrs. R. Castillo Male Sales Agent Filipino Roman Catholic September 12, 1951 164.59 cm (55) 195.8 lbs (89 kgs) College Level

Admitting Physician: Date of Admission: Time of Admission: Chief Complaint: Admitting Diagnosis:

Dr. Victor Angelo Lozano, M.D. November 21, 2012 10:15 in the morning swollen leg foot-ankle Acute Gouty Arthritis; Hyperuricemia

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 de Oro 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 lechon baboy 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.

According to the patient, he noted changes in his left ankle and experienced mild pain. However, he ignored those and dwelt in selftreatment 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 by taking 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 check his 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.

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.

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.

CBC

U/A HGT

Blood Chemistry

Blood Chemistry

Drug Study

Drug Study Drug Study

Drug Study

Drug Study Drug Study

Drug Study

Drug Study

CBC
Result HCT HGB WBC PLATELET 43.3 12.1 8,200 310,000 Normal values 37-47vol % 12-16gms % 5,000-10,000/mm3 150,000-400,000/mm3 Implication 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

Urinalysis
Result Color Normal Values Rationale Normal Light Yellow Pale Yellow- Amber

Glucose
Transparency Protein Specific Gravity Microscopic Exam: Pus Cells RBC

Negative
Clear Negative 1.020 1-3/hpf 0-2/hpf Few

Negative

Normal

Clear to Slightly hazy Normal Negative 1.002-1.030 0-4/hpf 0-3/hpf Negative Normal Normal Normal Normal Indicates Infection

Amourphous Urates / Few Phosphates Epithelial Squamous Cells Bacteria Occasional

HGT
Result 113 mg/dL Normal Value 80-120 mg/dL Significant of the Result Normal

Blood Chemistry

Test Urea

Result 23.62 mg/dL

Normal Value 4.70-23 mg/dL

Significant of the Result May indicate kidney dysfunction/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 Test Creatinine Uric Acid Result 1.3 mg/dL 7.31 mg/dL Normal Value 0.60-1.10 mg/dL 3.50-7.20 mg/dL Significant of the Result Normal

Triglyceride 141.2 mg/dL s Total 216.9 mg/dL Cholesterol HDLC 52.2 mg/dL

excess of uric acid in the blood: uric acid formation-gout 40-160 mg/dL Normal 0-200 mg/dL 0-34 mg/dL Risk for heart disease Increase level of good cholesterol; guards against heart disease

Generic /brand name

Classification

Dose/ route Freque ncy

Mechanism of Action

Specific indication

Contraindication

Adverse reaction

Nursing Precaution

Celecoxib (Celebrex)

Analgesic; NSAID

400mg 1 cap BID PO

Analgesic and Management Contraindicated antiof acute pain with allergies to inflammatory sulfonamides, activities celecoxib, related to NSAIDs, or inhibition of aspirin, the COX-2 significant renal enzyme, impairment. which is activated in inflammation 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.

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 with food or after meals if gI upset occurs. -Establish safety measures if CNS or visual disturbances occur. -Provide further comfort measures to reduce pain.

Generic /brand name

Classification

Dose/ Mechanism of route Action Freque ncy 500 mg 1 tab BID P.O.

Specific indication

Contraindication

Adverse reaction

Nursing Precaution

Colchicine

Antigout

Exact Pain relief of mechanism of acute gout action attack unknown; decreases deposition of uric acid; inhibits kinin formation and phagocytosis, and decreases inflammatory reaction to urate crystal deposition.

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 drugs effectiveness in alleviating symptoms of gout. -Patient should have regular medical followups and blood tests.

Generic /brand name

Classification

Dose/ route Freque ncy

Mechanism of Action

Specific indication

Contraindication

Adverse reaction

Nursing Precaution

Allopurinol (Allurase)

Antigout

300 mg tab OD PO

Inhibits the enzyme responsible for the conversion of purines to uric acid, thus reducing 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 alkalinityurates crystallize in acid urine, sodium bicarbonate or potassium citrate may be ordered to alkalinize urine. -Arrange for regular medical follow-up and blood tests. -Discontinue drug at first sign of skin rash; severe to fatal skin reactions.

Generic /brand name

Classification

Dose/ route Freque ncy

Mechanism of Action

Specific indication

Contraindication

Adverse reaction

Nursing Precaution

Omeprazole Antisecreto ry Proton pump inhibitor

40mg IVTT OD

Gastric acidpump inhibitor: Suppresses gastric acid secretion by specific inhibition of the hydrogenpotassium ATPase enzyme system at the secretory surface of the gastric parietal cells; blocks the final step of acid production.

Reduction of risk of upper GI bleeding

Contraindicate d 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.

Generic /brand name

Classification

Dose/ Mechanism of route Action Freque ncy

Specific indication

Contraindication

Adverse reaction

Nursing Precaution

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 12hours of other oral drugs to reduce risk of drug interactions. -Have periodic blood tests and medical evaluations.

Generic /brand name

Classification

Dose/ route Frequ ency

Mechanism of Action

Specific indication

Contraindication

Adverse reaction

Nursing Precaution

Meloxicam

NSAID

15mg 1 tab OD PO

Antiinflammatory , analgesic, and antipyretic activities related to inhibition of the enzyme cyclooxygen ase (COX), which is required for the synthesis of prostaglandi ns and thromboxan es.

Relief from the signs and symptoms of arthritis

Contraidicate d 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 with food 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.

Generic name/Brand name

Classification

Dose/ Mechanism of route Action Freque ncy

Specific indication

Contraindication

Adverse reaction

Nursing Precaution

PREDNISONE Corticosteroid

30 mg 1tab BID x 7 days

Enters target cells and binds to intracellular corticosteroid receptors, initiating many complex reactions that are responsible for its antiinflammatory effect.

To prevent Contraindicate inflammation 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.

Sakit gihapun gamay ako tiil ilihok. as verbalized by the patient > 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 Acute Pain r/t distention of tissues and inflammatory process 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:

A P

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

S O

Maglisud kog lihok-lihok kay tungod sa kasakit sa akong tiil. as verbalized by the patient

A P

> reluctance to attempt movement > edema on the left leg >swollen left ankle > pain scale=6/10 > body malaise > limited ROM >limitation in performing a few activities of daily living Activity intolerance r/t inflammation process as evidenced by swollen foot Long Term: At the end of 8 hours of nursing interventions, the patient will be able to maintain or increase muscle strength and function. Short Term: At the end of 1 hour of nursing interventions, patient will be able to participate and demonstrate behaviors that enable resumption of activities. 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. 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 O

No verbal complaints made > reluctance to attempt movement > edema on the left leg >swollen left ankle > pain scale=6/10 > body malaise > limited ROM >limitation in performing a few activities of daily living Risk for Injury r/t limited joint movement Long Term: At the end of 8 hours of nursing interventions, the patient will be free from possible causes of injury. Short Term: At the end of 1 hour of nursing interventions, patient will be able to demonstrate behaviors that can prevent injury. 1. Assisted in ambulation and provided safety needs. -Prevents injury and falls. 2. Encouraged patient to maintain upright and erect posture when sitting, standing and walking. -Maximizes joint function and maintains mobility. 3. Encouraged progressive activity/ self -care when tolerated. -Enhances the patients 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. 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.

A P

HEALTH TEACHINGS
The patient is instructed strict compliance of home medications: 1. Allopurinol (Allurase) 300mg 1 tab OD treatment of gouty arthritis 2. Prednisone 30mg 1tab BID- for inflammation 3. Meloxicam 15 mg 1 tab OD- for pain and inflammation 4. Sodium Bicarbonate 100mg 1 tab TID- to minimize uric acid crystalluria 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. Instructed the patient to perform active ROM exercises and encouraged to perform ADL independently as per limitation. -This is to improve circulation and mobility of the affected area. The patient is encouraged to elevate the affected area and support it such as pillows. Ice packs can be applied to the affected joint. -This is to minimize increased pain and decreasing inflammation. The patient is encouraged to visit attending physician as prescribed for follow- up check- up upon discharge. It is critically important to follow up with the doctor. Gouty arthritis is treated in two stages. The first stage is to treat the acute arthritis. The second stage is to prevent gouty arthritis attacks from happening again. Low doses of colchicine may be started during an acute attack, but medications to lower the blood uric acid levels are avoided because this could intensify 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 to lower the blood uric acid level. The patient is instructed to follow the prescribed diet, the low purine diet and to limit intake of foods rich in sodium. Seafoods and meat may be avoided. -Prescribed diet is necessary to eliminate or precipitate the disease.

MEDICATION

EXERCISES

TREATMENT

OUT-PATIENT

DIET

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. Hes advised to drink plenty of water and other fluids. If symptoms re- occur he should not hesitate to ask for consultation.