A 56-year-old man presented to the medical surgical floor with complaints of chest pain and shortness of breath. he was transfered from emergency room to medical surgical floor.The patient reported a sudden experience of tightness in his chest while doing yard work 4 hours prior to the ER visit. He has subsequently been experiencing episodes of nausea and periods of coughing. His past medical history is significant for hypertension, type 2 diabetes mellitus, and hypercholesterolemia. His current home medications are metoprolol, metformin, and simvastatin; his wife pointed out that he does not take his medications regularly. He has no known allergies. He smoked 30 packs of cigarettes per year for the past 30 years, and consumes 2 to 3 glasses of wine per day in addition to 2 cups of coffee. The patient denies any history of recreational drug use. The patient does not exercise regularly. currently he is on 4 liter oxgen via nasal canula; and recieved nitroglycerine for his chest pain. beside this, he is currently talking phenergan to control nausea and trodol to control pain.Daily Hours: Cumulative hours: 100

Date: July 11, 2012 

Daily learning Objective

Recognize major risk factors for developing gouty arthritis.

To become familiar with signs, symptoms and nursing interventions of gouty arthritis

To familiarize myself with pharmacologic and non-pharmacologic treatment options of gouty arthritis

To educate client about lifestyle modification to help prevent acute gout attacks.

Learning strategies: preceptor instruction

Medication given

Clinical symptoms

Literature review obtained from:

Gouty arthritis (2008) .Current treatment and new developments. Retrieved July 11, 2012, from http://www.stueckpharmacy.com/downloads/2008_gout.pdf

The information I utilized from the this reference is was to enhance my knowledge of gouty arthritis. Gout is a medical condition that shows a strong correlation with hyperuricemia and is characterized by deposition of monosodium urate crystals in the synovial fluid and tissues (tophi) in and around joints. Hyperuricemia is defined as a serum uric acid level of >7.0 mg/dL in men or >6.0 mg/dL in women. The classical 

 

clinical symptoms of acute gouty arthritis result from inflammation of involved joints, usually the first metatarsophalangeal joint (but may involve lower extremities and arms), and include severe pain, erythema, warmth, and swelling. However, atypical gout can also occur, and it may present with less dramatic onset, especially in the elderly. Atypical gout can often be confused with rheumatoid arthritis or osteoarthritis. Even though an acute gout attack can occur at any time, some conditions precipitating an attack are stress, infection, alcohol consumption, and rapid changes in serum uric acid levels.

Nonsteroidal anti-inflammatory drugs (NSAIDs) are the first line of drug therapy for acute gouty arthritis; especially for patients without complications or contraindications. Although ketoprofen and ibuprofen are often used, the FDA currently has approved only three NSAIDs for treatment of acute gouty arthritis: indomethacin, naproxen, and sulindac. 

Non pharmacological therapy of Gout is influenced by numerous factors, including overeating, obesity, alcohol abuse, hyperlipidemia, and insulin resistance syndrome. A low purine and protein diet along with alcohol restriction, weight loss through caloric restriction, and management of associated disease, may be extremely beneficial. Also, since patients with gout are at an increased risk for developing nephrolithiasis, health care provider should emphasize the importance of increasing fluid intake and decreasing salt consumption. In addition, joint rest and local application of ice may be beneficial.

 

Evidence of accomplishment:

I reported to medical surgical unit 15 minute prior to the start of the shift that starts at 1845 of every day shift. Then, I was received all of my patient’s information from the day shift nurse and assumed care of my patient. One of the patients I take care of today was a 44 year old white male presented with severe pain in his big toe, which was accompanied by inflammation, swelling and erythema of the joints. The patient has previously been diagnosed with acute gouty arthritis 8 years ago and he had experienced another acute attack 4 years ago. He had been taking simvastatin 40 mg daily for hyperlipidemia and 20mg of lisinopril daily for hypertension. He is also taking 25mg of hydrochlorothiazide for hypertension which was recently added 3 month ago. The client states he had been gaining weight over the last few years and states that he drinks about 5 back of beer every day. His doctor suggested discontinuing hydrochlorothiazide and starting taking naproxen 750mg initially followed by 250 mg every 8 hours until the symptom of his gouty subsided. On the top of that his doctor recommended to exercise and to stop or cut down his alcoholic intake and low purine diet

I was able to perform comprehensive assessment of pain including location, characteristics, onset/duration, frequency and quality to provide a base line data and monitor effectiveness of interventions. I also maintained immobilization of affected part by means of bed rest to relieve pain and performed passive ROM exercise to maintain strength/ mobility of unaffected muscle and to help prevent deep vein thrombosis. 

 

Beside this, I was able to administer medication (NSAID) as ordered to control pain and informed the client to report sudden pain unrelieved by analgesics. I pre-medicated the client before changing the dressing around his big toe to assist body’s natural process of healing and kept the bed linen dry and free wrinkles to reduce further skin breakdown. As Primary care provider suggested I was advised the client to modify his lifestyle in order for him to lose weight and encouraged him to avoid food rich in purine.

Evaluation:

My objective of recognizing major risk factors for developing gouty arthritis was fully satisfied. Overweight and obesity is an important factor to determine if a person may develop symptoms of gout (gouty arthritis). Obesity and eating purine rich food may lead to excess uric acid production.  Excessive use of alcohol and hypertension is other risk factors for gout (gouty arthritis) and it may leads to hyperuricemia. Abnormal kidney function is also other risk factors for gout (gouty arthritis) and this happens due to excessive usage of drugs like thiazide diuretics, aspirin, and niacin and tuberculosis medications. In addition, abnormal uric acid level in the blood is also responsible for development of gout (gouty arthritis). Moreover, certain diseases lead to excessive production of uric acid in the body like leukemia, hemoglobin and lymphomas. Low thyroid hormone is other risk factors for gout (gouty arthritis). Therefore, it becomes essential to know risk factors for gout (gouty arthritis) like excessive dining, recent surgery and changes in the body fluid.

 

My objective of familiarizing myself with signs, symptoms and nursing interventions of gouty arthritis were fully complete.  Symptoms of Gout or sometimes called Gouty Arthritis can be the most painful chronic type of inflammatory arthritis. Patients with Gouty Arthritis complain of tenderness, redness, and warmth around swelling joints. The most common joint affected by gout is the big toe but it can also affect the heels, ankles, knees, wrists, elbows, and fingers. The symptoms of Gout develop quickly and usually occur at night. Gouty arthritis has been around for centuries and was once known as a rich man's disease, since it was believed to be a result of gluttony.

 

My objective of familiarizing myself with pharmacologic and non-pharmacologic treatment options of gouty arthritis was partially satisfied. Even though I am familiar with pharmacologic treatment options like NSAID; I wasn’t familiar with some of the non- pharmacologic treatment options for gouty arthritis. This include low purine and protein diet along with alcohol restriction, weight loss through caloric restriction, and management of associated disease, may be extremely beneficial.14 Also, since patients with gout are at an increased risk for developing nephrolithiasis, client should consider the importance of increasing fluid intake and decreasing salt consumption. In addition, joint rest and local application of ice is part of non-pharmacological therapy. 

 

 

 

My objective of educating a client about lifestyle modification to help prevent acute gouty attacks was partially satisfied. Even though I was familiar with modifiable risk factors like obesity and excessive consumption of alcoholic

beverages, I wasn’t familiar with modifiable risk factors like purine rich diet and specific medications. Overall, I was able to teach the client about the importance of increasing fluid intake, decreasing salt consumption and weight loss though caloric restriction.

Personal Reflection:

 After completion of this work I felt that I had learned something that will definitely help me in near future. I am enjoying working in the department like this. Moreover I will gain knowledge through this type of work done by me.