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: characterized by elevated serum uric
acid levels from inborn error of purine metabolism or
decrease in renal uric acid excretion due to unknown
cause
d. Secondary gout: hyperuricemia occurs as a result of
other disorders or treatments
 1. Malignancies (leukemia)
 2. Chronic renal failure
 3. Certain medications, such as some diuretics
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
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
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
Client with gout
Diagnostic Tests
 a. Diagnosis with classic presentation: by history
and physical examination
 b. Uric acid: usually elevated above 7.5 mg/dL
 c. WBC: elevation as high as 20,000/mm3 during
acute attack
 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
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
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
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
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
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
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
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
Joint changes in degenerative joint disease
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
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
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
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
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
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
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
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
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
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
Joint destruction in rheumatoid
arthritis
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
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
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
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
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
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
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
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
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
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
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: anemia, leukopenia,
thrombocytopenia
 e. Cardiovascular system: pericarditis, vasculitis, Raynaud’s
phenomenon, endocarditis
 f.
Pulmonary system: pleurisy, pleural effusion
 g. Neurologic involvement: organic brain syndrome,
psychosis, seizures
 h. Ocular system: conjunctivitis, photophobia, retinal
vasculitis
 i.
GI symptoms: anorexia, nausea, abdominal pain, diarrhea
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
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
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 highdose corticosteroid therapy tapered as
client’s disease allows; treatment may also
include immunosuppressive agents
(cyclophosphamide or azathioprine) alone or
with the steroids
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
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
Systemic Lupus Erythematosus (SLE)