Client with gout

1. Client with gout Definition a. 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: d. Secondary gout: • 1. Malignancies (leukemia) • 2. Chronic renal failure • 3. Certain medications, such as some diuretics

2. 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

3. Client with gout Manifestations: 3 stages in untreated gout a. 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 level b. 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

4. 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

5. Client with gout Diagnostic Tests • a. Diagnosis with classic presentation: by history and physical examination • b. Uric acid: • c. WBC: • 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

6. Client with gout Medications a. Used to terminate acute attack and prevent future ones b. Reduce serum uric acid levels c. 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

7. 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

8. 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

9. Client with gout Nursing Diagnoses • a. Acute Pain • b. Impaired Physical Mobility Home Care • a. Education regarding prescribed medications • b. Education on maintaining high fluid intake of fluid and avoiding alcohol

10. 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

11. Client with osteoarthritis (OA) 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

12. Client with osteoarthritis (OA) 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

13. Joint changes in degenerative joint disease

14. Client with osteoarthritis (OA) 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

15. Client with osteoarthritis (OA) Complications: Spondylosis, a degenerative disk disease, which may lead to herniated disk Collaborative Care • a. Relieve pain • b. Maintain client’s function and mobility Diagnostic Tests • a. Based on client’s history and physical examination • b. Characteristic changes seen on xray

16. Client with osteoarthritis (OA) Medications a. Pain management with aspirin, acetaminophen, NSAIDs b. Capsaicin cream topically to reduce joint pain and tenderness c. 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

17. Client with osteoarthritis (OA) Conservative Treatment • a. Physical therapy • b. Rest of involved joint • c. Using ambulation devices • d. Weight loss • e. Analgesic and anti-inflammatory medications

18. Client with osteoarthritis (OA) Surgery a. Arthroscopy • 1. Arthroscopic debridement and lavage of involved joints • 2. Unclear about effectiveness long term b. 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 years c. 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

19. Client with osteoarthritis (OA) Complementary Therapies • a. Bioelectromagnetic therapy • b. Elimination of nightshade foods • c. Nutritional supplements, herbal therapies, vitamins • d. Osteopathic manipulation • e. Yoga Nursing Care • a. Promote comfort • b. Maintain mobility • c. Assist with adaptation of life style

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

21. 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

22. Rheumatoid arthritis (RA) 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

23. Rheumatoid arthritis (RA) 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

24. Joint destruction in rheumatoid arthritis

25. Rheumatoid arthritis (RA) 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

26. Rheumatoid arthritis (RA) Collaborative Care • a. Relief of pain and reduction of inflammation • b. Slow or stop joint damage • c. Improve well-being and ability to function • d. Relief of manifestations

27. Rheumatoid arthritis (RA) 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

28. Rheumatoid arthritis (RA) 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

29. Rheumatoid arthritis (RA) 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

30. Rheumatoid arthritis (RA) Treatments a. 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 walking b. Physical and occupational therapy c. Heat and cold: analgesia and muscle-relaxation d. Assistive devices and splints which help rest joints and prevent contractures e. Diet: well-balanced; some benefit from omega-3 fatty acids found in fish oils f. Surgery: variety of procedures may be done: synovectomy, arthrodesis, joint fusion, arthroplasty or total joint replacement

31. Rheumatoid arthritis (RA) 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 Foundation Nursing Diagnoses • a. Chronic Pain: increasing pain requires need to decrease activity level • b. Fatigue • c. Ineffective Role Performance • d. Disturbed Body Image Home Care: support for client and family to become active in disease management

32. 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

33. 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

34. Systemic Lupus Erythematosus (SLE) 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

35. 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: • e. Cardiovascular system: • f. Pulmonary system: • g. Neurologic involvement: • h. Ocular system: • i. GI symptoms:

36. Systemic Lupus Erythematosus (SLE) Collaborative Care • a. Diagnosis is often difficult due to the diversity of manifestations in individual clients • b. Effective management has improved survival rate

37. Systemic Lupus Erythematosus (SLE) 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

38. Systemic Lupus Erythematosus (SLE) 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

39. Systemic Lupus Erythematosus (SLE) Other treatments • a. Avoid sun exposure: use of sunscreens • b. 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

40. Systemic Lupus Erythematosus (SLE) 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 needs Home 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