Med-Surg: Chapter 20: Gout Flashcards
Risk Factors
- 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
Gout
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
Hyperuricemia
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
Three Phases of Gout
> 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
Podagra
term used to identify gout in the first MTP (metatarsophalangeal) joint
Typical Presentation of Gout Patients
> 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
Diagnosis
-definitive diagnosis made by observing crystals in synovial fluid or tophaceous material
Nonpharmacological Therapy
- 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
Presentation of Gout Patients: Subjective Data
- 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
Presentation of Gout Patients: Objective
- tenderness of palpation
- soft tissue swelling on examination accompanied by warmth and redness
- presence of tophi in the chronic gout patient
Tophi
uric acid deposits or nodules in the joint
Presentation of Gout Patients: Laboratory
- elevated serum uric acid level
- visualization of urate crystals found in synovial fluid on microscopic examination
Presentation of Gout Patients: Radiographical
- plain radiograph usually normal in early gout
- erosions and soft tissue nodules may be present in chronic gout
Pharmacological Treatment
> 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
Indomethacin (Indocin)
- NSAID
- used for acute gout
- reduction of inflammation
Colchicine (Colcrys)
decreased the buildup of uric acid crystals in the joint
-used in acute and intercritical gout
Uric Acid Lowering Agents
-allopurinol (Zyloprim)
-febuxostat (Uloric)
>reduce serum uric acid by inhibiting the production of uric acid
-for chronic gout; never use for acute gout
Why cant you use uric acid lowering agents in acute gout?
it may provoke or worsen a gout attack
What should be avoided in the treatment of gout?
Aspirin
it can increase uric acid levels by causing retention of uric acid
Complications
urate crystals can aggregate for form a stone, making patients more likely to develop kidney stones
Nursing Management: Assessment and Analysis
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
Nursing Assessments
> 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
Nursing Actions
> 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
Teaching
> 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
Evaluating Care Outcomes
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
