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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