Med-Surg: Chapter 20: Gout

Question 1

Risk Factors

Answer 1

• obesity
• hypertension
• eating large amounts of meat and seafood
• thiazide diuretics
• large quantities of alcohol

> when metabolized, purine-rich foods such as seafood, meat, and alcohol increased uric acid production
thiazide diuretics (hydrochlorothiazide) increase the net urate reabsorption in the renal tubules, therefore increasing the serum uric acid level

Question 2

Gout

Answer 2

disease in which monosodium urate crystals are deposited into joints, bone, and soft tissues, accompanied by inflammation

• hyperuricemia, an elevated uric acid level in the blood, must be present prior to the evolution of gout
• gout attacks resolve after several days or weeks even if left untreated
• gout can become a chronic inflammatory destructive arthritis

Question 3

Hyperuricemia

Answer 3

elevated uric acid level in blood

• results from overproduction of or diminished renal excretion of uric acid
• urate crystals are the result of an oversaturation of uric acid in the blood; the uric acid settles out of solution into soft tissues and joints; the body’s attempt to rid itself of the crystal deposits results in an inflammatory response process causing swelling, warmth, and intense pain in the affected joint

Question 4

Three Phases of Gout

Answer 4

> Acute:

• involves one joint
• acute onset of pain, redness, and swelling

> Intercritical:

• asymptomatic period between gout attacks
• if gout left untreated, attacks may come more often, with a shortened intercritical period

> Chronic:

• repeated attacks of many years
• leads to production of tophi (uric acid deposits or nodules in the joint) and joint destruction

Question 5

Podagra

Answer 5

term used to identify gout in the first MTP (metatarsophalangeal) joint

Question 6

Typical Presentation of Gout Patients

Answer 6

> Subjective

• i have severe joint pain (great toe or knee)
• i think my joint is swollen
• i cannot move my joint
• my joint feels hot when i touch it

> Objective

• tenderness on palpation
• soft tissue swelling on examination accompanied by warmth and redness
• presence of tophi in the chronic gout patient

> Laboratory

• elevated serum uric acid level
• visualization of urate crystals found in synovial fluid on microscopic examination

> Radiographical

• plain radiographic findings usually normal in early gout
• erosions and soft tissue nodules may be present in chronic gout

Question 7

Diagnosis

Answer 7

-definitive diagnosis made by observing crystals in synovial fluid or tophaceous material

Question 8

Nonpharmacological Therapy

Answer 8

• weight management b/c obesity is a modifiable risk factor
• avoid alcoholic beverages b/c they increased uric acid production
• splinting of the affected joint useful in protecting the joint and alleviating pain

Question 9

Presentation of Gout Patients: Subjective Data

Answer 9

• i have severe joint pain (great toe or knee)
• i think my joint is swollen
• i cannot move my joint
• my joint feels hot when i touch it

Question 10

Presentation of Gout Patients: Objective

Answer 10

• tenderness of palpation
• soft tissue swelling on examination accompanied by warmth and redness
• presence of tophi in the chronic gout patient

Question 11

Tophi

Answer 11

uric acid deposits or nodules in the joint

Question 12

Presentation of Gout Patients: Laboratory

Answer 12

• elevated serum uric acid level

- visualization of urate crystals found in synovial fluid on microscopic examination

Question 13

Presentation of Gout Patients: Radiographical

Answer 13

• plain radiograph usually normal in early gout

- erosions and soft tissue nodules may be present in chronic gout

Question 14

Pharmacological Treatment

Answer 14

> Acute gout:

• focused on pain relief and reduction of inflammation; NSAIDs (indomethacin (Indocin)
• Colchicine (Colcrys) which decrease the buildup of uric acid crystals in the joint
• Glucocorticoids to reduce inflammation and provide pain relief

> Intercritical gout
-NSAIDs and colchicine

> chronic
-use of uric acid lowering agents (allopurinol (Zyloprim) or febuxostat (Uloric)) reduce serum uric acid by inhibiting the production or uric acid

Question 15

Indomethacin (Indocin)

Answer 15

• NSAID
• used for acute gout
• reduction of inflammation

Question 16

Colchicine (Colcrys)

Answer 16

decreased the buildup of uric acid crystals in the joint

-used in acute and intercritical gout

Question 17

Uric Acid Lowering Agents

Answer 17

-allopurinol (Zyloprim)
-febuxostat (Uloric)
>reduce serum uric acid by inhibiting the production of uric acid
-for chronic gout; never use for acute gout

Question 18

Why cant you use uric acid lowering agents in acute gout?

Answer 18

it may provoke or worsen a gout attack

Question 19

What should be avoided in the treatment of gout?

Answer 19

Aspirin

it can increase uric acid levels by causing retention of uric acid

Question 20

Complications

Answer 20

urate crystals can aggregate for form a stone, making patients more likely to develop kidney stones

Question 21

Nursing Management: Assessment and Analysis

Answer 21

clinical manifestations of gout are r/t pain and decreased function due to accumulation of the urate crystals and tophi nodules in the affected joints

• intense joint pain
• tenderness on palpation of affected joint
• swelling of affected joint
• redness of affected joint
• warmth over affected joint
• decreased range of motion
• presence of tophi

Question 22

Nursing Assessments

Answer 22

> Uric acid level
-hyperuricemia promotes crystal formation

> Assess for presence of tophi–lumps or hard nodules under the skin around joints
-presence of tophi= advanced gout

> Assess for red, swollen, and painful joints
-indicated acute gout flare

> Assess pain level
-helps determine the occurrence of a flare and evaluates efficacy of tx

Question 23

Nursing Actions

Answer 23

> Administer uric acid-lowering agents as directed
-necessary to decrease serum uric acid and decrease the incidence of gout flares in chronic gout

> Administer Analgesics and Anti-inflammatory medications as ordered
-used to help control pain and decrease inflammation in acute or intercritical gout

> Administer glucocorticoid therapy as directed
-systemic glucocorticoid therapy may be used in conjunction with or as an alternative to NSAID therapy to reduce inflammation in acute gout

Question 24

Teaching

Answer 24

> Avoid Alcoholic beverages, especially beer
-alcohol is high in purines, which metabolize into uric acid, increasing serum uric acid levels

> Take uric acid-lowering agents as directed
-necessary to decrease serum uric acid levels and help prevent future attacks

> Report gout flares

> proper nutrition
-avoid high-purine foods such as red meat, liver, and fish

Question 25

Evaluating Care Outcomes

Answer 25

goal of treating gout patients is to eliminate gout flares and prevent joint destruction

• done by controlling the uric acid level
• a well-managed patient takes gout-lowering agents appropriately; avoid foods containing purines, such as seafood and red meat; limits alcohol consumption