Nursing Care Plan (NCP) for Gout / Gouty Arthritis
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Outline
Lesson Objective for Gout/Gouty Arthritis Nursing Care Plan
- Understanding Gout Pathophysiology:
- Gain knowledge of the underlying pathophysiological mechanisms of gout, focusing on the formation and deposition of urate crystals in joints and tissues.
- Identifying Etiological Factors:
- Recognize and comprehend the various factors contributing to the development of gout, such as genetics, diet, lifestyle, and comorbid conditions, to inform targeted interventions.
- Developing Holistic Care Strategies:
- Formulate a comprehensive care plan that addresses acute gout attacks, chronic management, and preventive measures. Understand the importance of lifestyle modifications and pharmacological interventions.
- Nursing Assessment Skills:
- Enhance assessment skills to accurately identify signs and symptoms of gout, assess joint inflammation, and recognize potential triggers. Develop competence in differentiating gout from other arthritic conditions.
- Patient Education and Empowerment:
- Acquire communication skills to educate patients about gout, its triggers, and the importance of medication adherence, lifestyle modifications, and dietary changes. Foster patient empowerment for self-management.
Pathophysiology of Gout/Gouty Arthritis
- Uric Acid Accumulation:
- Gout is characterized by an elevated level of uric acid in the blood, a condition known as hyperuricemia. This can result from either overproduction or insufficient excretion of uric acid.
- Formation of Urate Crystals:
- Excess uric acid can crystallize in joints, tendons, and surrounding tissues, forming needle-like crystals known as monosodium urate crystals.
- Inflammatory Response:
- When urate crystals deposit in joints, they trigger an inflammatory response, activating immune cells and causing acute inflammation. This inflammatory process is responsible for the sudden and severe pain characteristic of gout attacks.
- Joint Involvement:
- The first metatarsophalangeal joint of the big toe is often the initial site of gouty arthritis. However, gout can affect other joints such as ankles, knees, wrists, and fingers.
- Chronic Gout and Tophi Formation:
- If left untreated, recurrent gout attacks can lead to chronic gouty arthritis. Prolonged inflammation may result in the formation of tophi, which are deposits of urate crystals in joints, soft tissues, and organs.
Etiology of Gout/Gouty Arthritis
- Hyperuricemia:
- Gout is primarily caused by elevated levels of uric acid in the blood, a condition known as hyperuricemia. This can result from increased production of uric acid or impaired excretion by the kidneys.
- Dietary Factors:
- Certain dietary choices, particularly the consumption of purine-rich foods (such as red meat, seafood, and organ meats), can contribute to elevated uric acid levels and increase the risk of gout.
- Genetic Predisposition:
- Genetic factors play a role in the development of gout. Some individuals may have a genetic predisposition to hyperuricemia and gout, making them more susceptible to the condition.
- Impaired Renal Function:
- Reduced excretion of uric acid by the kidneys can lead to its accumulation in the bloodstream. Conditions that impair renal function, such as chronic kidney disease, may contribute to the development of gout.
- Lifestyle Factors:
- Certain lifestyle factors, including obesity, excessive alcohol consumption (especially beer and spirits), and dehydration, can increase the risk of developing gout. These factors may exacerbate hyperuricemia and trigger gout attacks.
Desired Outcome for Gout/Gouty Arthritis
- Pain Management:
- Alleviate acute pain associated with gout attacks, aiming for a significant reduction in pain intensity and improved overall comfort.
- Inflammation Control:
- Reduce inflammation in affected joints to enhance mobility and function, promoting a better quality of life for the individual.
- Prevention of Recurrent Attacks:
- Implement measures to prevent the recurrence of gout attacks, including lifestyle modifications, dietary changes, and pharmacological interventions.
- Normalization of Uric Acid Levels:
- Achieve and maintain optimal serum uric acid levels to prevent the formation of urate crystals, which are responsible for gout symptoms and joint damage.
- Improved Joint Functionality:
- Enhance joint functionality and minimize long-term joint damage, aiming for increased range of motion and improved joint health over time.
Gout / Gouty Arthritis Nursing Care Plan
Subjective Data:
- Sudden pain in joints, often the big toe
- Stiffness in joint
- Tenderness of the joint
- Limited range of motion
- Itching
Objective Data:
- Tophi (nodules in the skin)
- Renal calculi
- Joint inflammation
- Joint edema
- Erythema
Nursing Assessment for Gout/Gouty Arthritis
- Pain Assessment:
- Evaluate the location, intensity, and characteristics of pain during gout attacks, using a pain scale for accurate measurement.
- Joint Examination:
- Perform a thorough examination of affected joints, assessing for swelling, redness, warmth, and limited range of motion.
- Patient History:
- Obtain a detailed medical history, with a focus on previous gout attacks, family history of gout, and any existing comorbidities.
- Dietary Assessment:
- Assess the patient’s dietary habits, particularly the intake of purine-rich foods and alcohol, to identify potential triggers for gout attacks.
- Uric Acid Levels:
- Monitor serum uric acid levels through blood tests to determine the extent of hyperuricemia and guide treatment strategies.
- Lifestyle Factors:
- Evaluate lifestyle factors such as physical activity, stress levels, and hydration, as they can influence the frequency and severity of gout attacks.
- Medication History:
- Review the patient’s current medications, including any prescribed medications, over-the-counter drugs, and herbal supplements, as some may exacerbate or contribute to gout.
- Patient Education Needs:
- Assess the patient’s knowledge about gout, its triggers, and self-management strategies, identifying areas where education and support are required.
Implementation for Gout/Gouty Arthritis
- Medication Administration:
- Administer prescribed medications such as nonsteroidal anti-inflammatory drugs (NSAIDs), colchicine, or corticosteroids as directed to manage pain and inflammation during acute gout attacks.
- Pain Management Strategies:
- Implement non-pharmacological pain management strategies, including the application of ice packs, elevation of the affected joint, and encouraging rest during acute episodes.
- Fluid Intake Promotion:
- Emphasize the importance of maintaining adequate hydration to help prevent the formation of urate crystals. Encourage the patient to consume plenty of water throughout the day.
- Dietary Modification:
- Collaborate with a dietitian to help the patient modify their diet, reducing the intake of purine-rich foods and alcohol. Provide educational resources on gout-friendly dietary choices.
- Lifestyle Counseling:
- Offer counseling on lifestyle modifications, including weight management and regular exercise, to address contributing factors to gout and improve overall joint health.
Nursing Interventions and Rationales
- Assess and manage pain
- Administer medications
- Apply cool cloths as tolerable
- Assist with positioning to avoid pressure on the affected joint
- Assist with mobility
- Monitor signs of joint inflammation
- Administer medications
- NSAIDs / Corticosteroids
- Colchicine
- Xanthine Oxidase Inhibitors (XOIs)
- Uricosurics
Medications can help relieve the immediate symptoms while others are for long term management and prevention of flare-up recurrence.
- NSAIDs and corticosteroids help reduce swelling and can relieve immediate pain
- Colchicine can be given for acute pain specific to gout attacks
- XOI (allopurinol)- medications that block the production of uric acid and help prevent future attacks
- Uricosurics (probenecid)- help the kidneys more effectively excrete uric acid
- Promote hydration and increase fluid intake
- Assist with AROM or PROM
- Nutrition Education
- Limit or avoid animal proteins (liver, kidney, beef, lamb, and pork)
- Limit intake of seafood, especially those high in purine such as shellfish, sardines, and tuna
- Avoid alcohol as it greatly increases the risk of gout attacks
- Encourage foods that reduce the risk of attacks including coffee, cherries, and foods high in vitamin C
- Limit or avoid foods/drinks sweetened with fructose
Evaluation for Gout/Gouty Arthritis
- Pain Assessment:
- Evaluate the effectiveness of pain management interventions by assessing the patient’s reported pain levels and the frequency of acute gout attacks.
- Joint Functionality:
- Monitor improvements in joint functionality, assessing the patient’s ability to perform daily activities and mobility without significant limitations.
- Medication Adherence:
- Assess the patient’s adherence to prescribed medications and their understanding of the importance of continued therapy in preventing and managing gout attacks.
- Dietary and Lifestyle Changes:
- Evaluate the patient’s adherence to dietary modifications and lifestyle changes recommended to manage gout, such as reduced purine intake, increased hydration, and weight management.
- Uric Acid Levels:
- Regularly monitor serum uric acid levels to determine the success of interventions in maintaining uric acid within the target range and preventing the formation of urate crystals.
References
- https://www.mayoclinic.org/healthy-lifestyle/nutrition-and-healthy-eating/in-depth/gout-diet/art-20048524?p=1
- https://www.webmd.com/arthritis/understanding-gout-symptoms
- https://www.mayoclinic.org/diseases-conditions/gout/diagnosis-treatment/drc-20372903
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Transcript
This is the nursing care plan for gout. Let’s work on it. So the pathophysiology behind gout is that it’s a common and painful form of arthritis that causes swollen, hot, stiff joints. What happens is uric acid crystallizes and settles into the joints and body tissues most frequently affecting the big toe. And if not treated progressive to the ankles, heels, wrist, and hands. This is also severe pain, stiffness and retinas at the joint. Gout attacks often occur in the middle of the night when the joint is a immobile. Once the initial pain subsides, the general discomfort of the area can last for several weeks. The nursing considerations, some things that we want to just be mindful of is this is painful. So we want to promote comfort. Okay. We want to optimize mobility. We want to educate the patient on exacerbating factors, and we want to make sure that we control their pain.
The desired outcome of this is to relieve the acute attack, prevent future attacks and promote optimal excretion of the urines. So subjective, the patient is coming in. They have gout, this inflammation of the joints. What are they going to complain of? Well, the first thing is when it’s acute, they are going to complain of pain, sudden pain and joints. Okay. Now let’s go down a little deeper. There’s going to be limited range of motion because that pain, if you’re thinking of the joints, is going to be very tender and it is so great that you don’t want to move much. And there also may be some complaining of itching.
Well, we’re going to observe as nurses, is we are going to notice, this is what is called tophi. And that is just pretty much nodules in the skin. There’s going to be some renal calculi or renal stones. There’s going to be some joint inflammation, some redness, some edema, those joints are going to be swollen, red and hot. So what are some things that we can do as nurses? We want to assess and manage their pain. Again, they are in a lot of pain. So we want to assess and manage pain. We want to administer any medications. So we want to administer medications And we want to apply cool cloth And assist with positioning to avoid pressure on the affected joint. And the acute attack can cause intense pain for the first 36 hours. Imagine being in pain for 36 hours, it’s not good. We want to offer options to help manage pain. Next thing we want to do is we want to look at some of the medications that we’re going to give. So, what can help? Well, let’s start with the swelling
Steroids help with swelling. We have colchicine. So let’s write that here. And that is a prescription gout medication. And that helps with gout pain. We have allopurinol that blocks your acid production and acute attack again, lasting for 36 hours. So any medications that we can give to help them either with a pain, with NSAIDS or corticosteroids, or to block that we can really help that patient along. We want to promote hydration and increased fluid intake, increased fluid intake. Remember it is all about the uric acid buildup in the body that settles into the joints. It prevents dehydration with the increased fluid intake, but it also is going to help flush out those uric acid crystals via the kidneys. So we want to flush your acid. Okay. The next thing we’re going to do is we’re going to give them some nutrition education. Remember a lot of this can be managed with diet. We want to tell our patients to avoid alcohol. We want to decrease animal proteins. We want to increase their vitamin C. So, we want to increase vitamin c, decrease alcohol , and decrease animal protein. And we want to limit high purine food as purine puree converts to acid in the body. So we want to decrease high pure rain foods. Hyperion foods include shellfish, tuna sardines. And finally, we want to assess and assist with range of motion exercises. This is going to prevent joint stiffness.
And pain. Let’s take a look at the key points. The pathophysiology of gout, it’s a painful form of arthritis. It comes because of the increased uric acid in the blood. Some subjective data that we’re going to have. These patients are going to complain of joint pain, redness, usually in the big toe tenderness and stiffness. Some things that we’re going to see, is we’re going to see those nodules on the skin called tophi. We’re going to also see joint swelling and redness. The diet considerations are number one for this patient, because we want to make sure that these patients know what causes gout because of the uric acid. We want these patients to avoid alcohol. We want them to decrease animal protein, increase vitamin C and limit high purine. Remember those come to form a lot of foods like shellfish preserved foods, such as sardines. We want to have some medication management again, they’re in pain. So NSAIDS and steroids are important. We also have allopurinol, which is going to block the production of uric acid. We love you guys; go out and be your best self today. And, as always, happy nursing.
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