NURSING CARE PLAN
ASSESSMENT
Subjective:
“Masakit ang paa
ko, hindi ako
makalakad” (My
feet hurts, I can’t
walk) as
verbalized by the
patient.
Objective:
•
Reluctance to
attempt
movement.
•
Limited range
of motion.
•
Decreased
muscle
strength.
•
V/S taken as
follows:
T: 37.5
P: 76
R: 20
BP: 120/80
DIAGNOSIS
Impaired
physical
mobility
related to pain.
INFERENCE
•
Gout is a
disorder of
purine
metabolism
characterized
by elevated uric
acid levels with
deposition of
urate crystals in
joints and other
tissues. High
uric acid levels
result from
decreased
excretion of uric
acid ( 90% of
cases) due to a
wide variety of
causes. The
disorder may
progress from
an
asymptomatic
stage through
acute gouty
arthritis, to
chronic
tophaceous
gout.
Complications
include erosive
deforming
PLANNING
•
INTERVENTION
RATIONALE
Independent:
After 3 days • Evaluate or
•
continuously
of nursing
monitor degree of
intervention
joint inflammation
s, the
or pain.
patient will
maintain or
increase
strength and • Maintain bed rest •
function of
or chair rest when
affected or
indicated.
compensato
Schedule
ry body part.
activities
providing frequent
rest periods and
uninterrupted
night time sleep.
•
Encourage
adequate fluid
intake.
•
•
Assist with active
or passive range
of motion.
•
•
Encourage
patient to
maintain upright
and erect posture
when sitting,
standing, or
walking.
•
Level of activity •
or exercise
depends on
progression and
resolution of
inflammatory
process.
Systemic rest
during acute
attacks and
important
throughout all
phases of
disease to
reduce fatigue
and improve
strength.
To assist with
excretion of uric
acid and
decrease
likelihood of
stone formation.
Maintains or
improves joint
function,
muscle
strength, and
general
stamina.
Maximizes joint
function,
maintains
mobility.
EVALUATION
After 3 days of
nursing
interventions,
the patient was
able to maintain
or increase
strength and
function of
affected or
compensatory
body part.
arthritis, uric
acid kidney
stones, and
urate
nephropathy
caused by
hyperuricemia.
•
•
•
Encourage the
patient to avoid
alcohol.
Review foods that
are rich in purines
like sardines,
anchovies, shell
fish and organ
meats.
Provide safety
needs.
Collaborative:
• Administer antiinflammatory
drugs and also
colchicines as
prescribed.
•
•
That can
precipitate
acute attack.
To avoid foods
that precipitate
acute attacks.
•
Help prevent
accidental
injuries or falls.
•
To relieve pain
and swelling
during acute
attacks.