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LaGuardia Community College City University of New York Practical Nursing Program SCL 117 Medical-Surgical II Nursing CASE STUDY: GOUT by Marie Jimenez, SPN Client’s Initials: C.M. Age: 68 y/o Date of Admission: 1/06/08 Primary Diagnosis: Acute Renal Failure Secondary Diagnosis: Gout Body System Involved: Musculoskeletal Objectives for the week: To facilitate the client in alleviating discomfort of pain and utilize pain management measures CASE STUDY: SCL 117 GOUT Definition of Acute Renal Failure Acute renal failure (ARF) occurs when the kidneys are unable to rid the body of toxic substances which results in the build up of fluids, electrolytes, and waste products in the blood. The accumulation of fluids, waste and electrolytes causes fluid retention and therefore, results in a decrease of urine production. According to Sommers & Johnson, acute renal failure is “usually accompanied by a marked decrease in urinary output” (Sommers & Johnson, 2002, p. 848). Definition of Gout According to Burke & LeMone, gout is “a metabolic disorder that leads to accumulation of urate crystals in joints and surrounding tissues”(Burke & LeMone, 2007, p.1068). Therefore, it is important to recognize that pain would be an expectant result from the accumulation of urate crystals in the joints. There are two different types of gout: primary gout and secondary gout. According to Burke & LeMone, “primary gout…involves elevated serum uric acid levels [while] secondary gout [involves] uric acid levels [to] increase due to another disorder or treatment with certain drugs”(Burke & LeMone, 2007, p.1068). Therefore, it is important to take a look at lab values to determine whether the patient has primary or secondary gout. Etiology of Gout The Merck Manual Online Medical Library discusses the etiology of gout to occur when “urate levels can be elevated because of decreased excretion, increased production, or increased purine intake…Increased intake of purine-rich foods (e.g. liver, kidney, anchovies) can contribute to hyperuricemia”(Merck Manual Online Medical Library, 2005). Therefore, it is important to note several factors such as renal dysfunction and diet of the patient because of its contributing role in causing gout, and it is also important to use preventative measures to reduce the incidence of gout. Signs & Symptoms of Gout Common signs and symptoms of gout include: intense joint pain, inflammation, and redness (Mayoclinic, 2007). Joint pain is most frequently experienced in the big toe but can occur within the synovial joints such as the wrists, ankles, and knees. Prevention The prevention of gout is usually regulated through medications and modifying diet. According to Burke & LeMone, “NSAIDS are used to treat an acute attack of gout. Indocin is the most frequently used NSAID for gout. Aspirin is avoided because it may interfere with uric acid excretion”(Burke & LeMone, 2007, p.1068). Therefore, it is important that the patient is not taking aspirin while taking non steroidal antiinflammatory drugs such as Indocin because of its contraindication. According to Mayoclinic, the following recommendations are suggested in order to reduce the risk of gout in which patients should reduce or avoid “the amount of red meat and seafood, alcoholic beverages…[and encourage eating] more low-fat dairy products and complex carbohydrates such as whole-grain breads”(Mayoclinic, 2007). It is important to teach the patient to avoid or eliminate certain foods from their diet. Complications Complications of gout may include the following: recurrent gout, advanced gout, and kidney stones (Mayoclinic, 2007). Of significant important, kidney stones is a complication of gout because the build up of urate crystals can cause calculi or stones to form within the kidneys. This is a serious complication because kidney stones require prompt interventions. DIAGNOSTIC LABORATORY TESTS Serum Laboratory Test 1. Uric Acid 217 Purpose of Lab Test Is used to measure serum levels of uric acid, the major end metabolite of purine. It confirms the diagnosis of gout and help detect renal dyfunction Normal Values Actual Client Results Men: 3.4 to 7 mg/dl Women: 2.3 to 6 mg/dl 8.2 mg/dl MEDICATIONS Medication Name Medication Dosage 1. Heparin Sodium 2. Magnesium Oxide 3. Calcium Gluconate 5000 Units 400 mg 1gm Medication Route Subcutaneous Time of Administration q8h (every eight hours) p.o. (by mouth) IVPB (Intravenous Piggy Back) Purpose of Drug Prevention of thrombus formation Nursing Implication: Assess patient for signs of bleeding and hemorrhage (bleeding gums; nosebleed; fall in hematocrit or blood pressure) qd (every day) Treatment/prevention of hypomagnesemia Nursing Implication: Advise pt. not to take this medication within 2 hr of taking other medications like fluoroquinolones and tetracyclines qd (every day) Prevention of hypocalcemia. Nursing Implicattion: Monitor BP, pulse and ECG throughout therapy. DIAGNOSTIC LABORATORY TESTS Laboratory Test 1. Uric Acid (Serum) 2. Uric Acid (Urine) 3. Synovial membrane biopsy Purpose of Lab Test Is used to measure serum levels of uric acid, the major end metabolite of purine. It confirms the diagnosis of gout and help detect renal dyfunction To detect enzyme deficiencies and metabolic disturbances that affect uric acide production such as gout To diagnosis gout, pseudogout, bacterial infections and lesions, and granulomastous infections and to monitor joint pathology Normal Values Nursing Implication Men: 3.4 to 7 mg/dl Women: 2.3 to 6 mg/dl Explain to patient that the uric acid test is used to detect gout and kidney dysfunction 250 to 750 mg/24 hours (SI, 1.48 to 4.43 mmol/d) Instruct patient that he may resume his usual diet and medications, as ordered The membrane surface is smooth, except for villi, folds, and fat pads that project into the joint cavity Explain to the patient that this test provides a tissue specimen from the membrane that lines the affected joint LAGUARDIA COMMUNITY COLLEGE DEPARTMENT OF NATURAL & APPLIED SCIENCE PRACTICAL NURSING PROGRAM DOCUMENTATION OF THE NURSING PROCESS FORM INSTRUCTOR’S NAME: Professor Bridegman STUDENT’S NAME: Marie Jimenez GROUP: B4 DATE: 1/13/08 CLIENT’S INITIALS: C.M. PATIENT CARE OBJECTIVE (S) To facilitate the client in alleviating discomfort of pain and utilize pain management measures. ASSESSMENT SUBJECTIVE Pt. was received sitting upright in chair. Pt. complained of dizziness when standing up. Pt. also complained of pain, particularly in both legs. Pt. stated that he “worked for the MTA for 25 years”. OBEJECTIVE C.M. is a 68-year-old male who was admitted on 1/06/08 for acute renal failure and hypocalcemia secondary to hypertension and gout. Pt. is A/O x 3. Vital Signs: T – 97.2 P – 80 R – 18 BP – 105/72 Medications: Heparin Sodium: 5000 Units inj subcut q8h, Magnesium Oxide: 400mg tab po bid, Calcium Gluconate: 1g inj IVPB q12h infuse over 30 min CLIENT’S PROBLEM(S) NEED(S) (Using the Nursing Diagnostic language) CLIENT’S SHORT TERM GOAL/OUTCOME (PLANNING) NURSING INTERVENTIONS (APPROACH) (ACTION) SCIENTIFIC RATIONALE FOR NURSING INTERVENTION Problem: Pain, acute Client will verbalize adequate relief of pain or ability to cope with incompletely relieved pain 1. Assess pain characteristics: quality, severity, location, onset, duration, precipitating or relieving factors 1. Other methods such as visual analog scale or descriptive scales can be used to identify extent of pain 2. Observe or monitor signs and symptoms associated with pain, such as BP, heart rate, temperature, color and moisture of skin, restlessness, and ability to focus 2. Some people deny the experience of pain when it is present. Attention to associated signs may help the nurse in evaluating pain 3. Different etiological factors respond better to different therapies 4. Some patients may be unaware of the effectiveness of nonpharmacologica l methods and may be willing to try them R/T Etiology: inflammation of the joints and muscles AEB Signs & Symptoms: Dizziness, facial grimacing, weakness, fatigue 3. 4. Assess probable cause of pain Assess patient’s knowledge or preference for the array of pain-relief strategies available Reference: Nursing Care Plans: Nursing Diagnosis & Interventions (5 th ed) 2003 by Gulanick, Myers et. al. St Louis, MO: Mosby, 122 REFERENCES Book Sources Burke, M. K., & LeMone, P. (2007). Medical-Surgical Nursing Care. (2nd ed.). Upper Saddle River: Pearson Education, Inc., 1068 Deglin, H. J., & Vallerand, H. A. (2007). Davis’s Drug Guide for Nurses. (10th ed.). Philadelphia: F.A. Davis Company, 232, 585, 639, 737, 837. Professional Guide to Diagnostic Tests (2005). Ambler: Lippincott Williams & Wilkins, 217, 400, 470 Sommers, S.M., & Johnson, A.S. (2002) Diseases and Disorders: A Nursing Therapeutic Manual. (2nd ed.) Philadelphia: F.A. Davis Company, 848 White, L. (2005). Foundations of Adult Health Nursing. (2nd ed.). Clifton Park: Thomson Delmar Learning 271