client with gout definition a.syndrome occurs from inflammatory response to production or excretion...

Client with gout Definitiona. 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: characterized by elevated serum uric acid levels from inborn error of purine metabolism or decrease in renal uric acid excretion due to unknown cause

d. Secondary gout: hyperuricemia occurs as a result of other disorders or treatments

1. Malignancies (leukemia) 2. Chronic renal failure 3. Certain medications, such as some diuretics

Client with gout

Pathophysiology a. Uric acid is a breakdown product of

purine metabolism and is normally excreted through urine and feces

b. Levels > 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

Client with goutManifestations: 3 stages in untreated gouta. 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 levelb. 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

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

Client with gout

Diagnostic Tests a. Diagnosis with classic presentation: by

history and physical examination b. Uric acid: usually elevated above 7.5 mg/dL c. WBC: elevation as high as 20,000/mm3 during

acute attack 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

Client with gout

Medicationsa. Used to terminate acute attack and prevent future

onesb. Reduce serum uric acid levelsc. 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

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

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

Client with gout

Nursing Diagnosesa. Acute Painb. Impaired Physical Mobility

Home Carea. Education regarding prescribed

medicationsb. Education on maintaining high fluid

intake of fluid and avoiding alcohol

Client with osteoarthritis (OA)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


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


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

Joint changes in degenerative joint disease


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. Herberden’s nodes: terminal, interphalangeal

joints 2. Bouchard’s nodes: proximal, interphalangeal

joints g. Flexion contractures occur with joint instability


Complications: Spondylosis, a degenerative disk disease, which may lead to herniated disk

Collaborative Care a. Relieve pain b. Maintain client’s function and mobilityDiagnostic Tests a. Based on client’s history and physical

examination b. Characteristic changes seen on xray


Medicationsa. Pain management with aspirin, acetaminophen,

NSAIDsb. Capsaicin cream topically to reduce joint pain and

tendernessc. 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


Conservative Treatmenta. Physical therapy b. Rest of involved jointc. Using ambulation devicesd. Weight losse. Analgesic and anti-inflammatory

medications

Client with osteoarthritis (OA)Client with osteoarthritis (OA)Surgerya. Arthroscopy 1. Arthroscopic debridement and lavage of involved joints 2. Unclear about effectiveness long termb. 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 yearsc. 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


Complementary Therapies a. Bioelectromagnetic therapy b. Elimination of nightshade foods c. Nutritional supplements, herbal therapies,

vitamins d. Osteopathic manipulation e. YogaNursing Care a. Promote comfort b. Maintain mobility c. Assist with adaptation of life style

Client with osteoarthritis (OA)Client with osteoarthritis (OA)Health Promotion a. Maintenance of normal weight b. Program of regular, moderate exercise c. Use of glucosamine and chrondroitinNursing Diagnoses a. Chronic Pain b. Impaired Physical Mobility c. Self-care DeficitHome 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

Rheumatoid arthritis (RA)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


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


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

Joint destruction in rheumatoid arthritis


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


Collaborative Carea. Relief of pain and reduction of

inflammationb. Slow or stop joint damagec. Improve well-being and ability to

functiond. Relief of manifestations


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


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


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


Treatmentsa. 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 walkingb. Physical and occupational therapyc. Heat and cold: analgesia and muscle-relaxationd. Assistive devices and splints which help rest joints and

prevent contracturese. Diet: well-balanced; some benefit from omega-3 fatty

acids found in fish oilsf. Surgery: variety of procedures may be done:

synovectomy, arthrodesis, joint fusion, arthroplasty or total joint replacement


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 FoundationNursing Diagnoses a. Chronic Pain: increasing pain requires need to

decrease activity level b. Fatigue c. Ineffective Role Performance d. Disturbed Body ImageHome Care: support for client and family to become active in

disease management

Systemic Lupus Erythematosus (SLE)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


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

Systemic Lupus Erythematosus (SLE)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: anemia, leukopenia, thrombocytopenia

e. Cardiovascular system: pericarditis, vasculitis, Raynaud’s phenomenon, endocarditis

f. Pulmonary system: pleurisy, pleural effusion g. Neurologic involvement: organic brain syndrome,

psychosis, seizures h. Ocular system: conjunctivitis, photophobia, retinal

vasculitis i. GI symptoms: anorexia, nausea, abdominal pain,

diarrhea


Collaborative Carea. Diagnosis is often difficult due to

the diversity of manifestations in individual clients

b. Effective management has improved survival rate


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


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 client’s disease allows; treatment may also include immunosuppressive agents (cyclophosphamide or azathioprine) alone or with the steroids


Other treatmentsa. Avoid sun exposure: use of

sunscreensb. 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


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 needsHome 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

client with gout definition a.syndrome occurs from inflammatory response to production or excretion...

Documents

gout b

excretion of uric acid

gout medications

uric acid production

gout tophaceous chronic

treatment of acute gout

primary gout

gout manifestations