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Client with gout

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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 ... – PowerPoint PPT presentation

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Title: 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 gt 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. Herberdens nodes terminal, interphalangeal
    joints
  • 2. Bouchards 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 clients function and mobility
  • Diagnostic Tests
  • a. Based on clients 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 clients
    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
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