Case Scenario Nursing Process

CASE SCENARIO:
FOR THE APPLICATION OF NURSING PROCESS (Nursing Care Plan)
A 55 year-old male presented for an evaluation of rapid onset of pain and swelling in
his right toe. The patient reported that he had two similar previous episodes with the
same symptoms lasting four to five days and was treated by emergency physicians.
The patient past medical history is significant for hypertension and treated with
Hydrochlorothiazide.
The review of systems was negative for headache, fever, chills, rash, earache, sore
throat, cough, rhinorrhea, vision changes, weight loss, or change in appetite or
disposition. The patient was afebrile, and this blood pressure was slightly elevated.
PHYSICAL EXAMINATION: General: The patient is a pleasant male who appears

to be in no apparent distress. Vital Signs: blood pressure 123/48, heart rate 76,
Temperature 38.3 and 98% on room air. HEENT: Extraocular muscles are intact.
Pupils are equal, round, and reactive to light and accommodation. Neck: Supple. No
jugular vein distention noted. No carotid bruits noted. Lungs: Clear to auscultation
bilaterally. No wheezes, rubs or rhonchi. Heart: Regular rate and rhythm. Normal S1,
S2. A 2/6 to 3/6 systolic ejection murmur at the right upper sternal border. PMI is
nondisplaced. Abdomen: Notable for laparoscopy surgical wound. Positive bowel
sounds. Extremities: MTP is red, hot and swollen. Neurologic: The patient is alert and
oriented x3. No focal neurologic deficits noted.
Pathophysiology
Gout is an inflammatory disease characterized by the deposition of uric acid crystals

in and around joints, subcutaneous tissues, and kidneys. Although men and women
are equally affected by gout, men are six times more likely to have serum
concentrations above 7 mg per dL. Gout typically occurs during middle age and is
uncommon before the age 30 years old. Women rarely have gouty arthritis attacks
before menopause 1.
Clinical Presentation
Gout attacks are usually associated with precipitated events. Patients usually present
with rapid onset of severe pain, swelling, redness, and warmth in one or tow joints.
This pain and inflammation are caused by inflammatory response. Acute attack
untreated attacks usually last two to 21 days depending on cases. There are four
clinical stages of gout according to the National Institute of Arthritis and
Musculoskeletal and Skin Diseases (NIAMS). The first stage is known as
asymptomatic hyperurecemia. During this stage, the patients can have an elevation of
uric acid in the blood but they do not have any symptoms yet. After more and more
urate deposits around a joint and if any trauma triggers the release of crystal into the
joint space, patients will suffer acute attacks of gout. This second stage is known as
acute gouty arthritis. The third stage, known as interval or intercritical gout, involves
the interval between acute flare gout attacks with persist crystals in the joints. When
crystals deposits continue to accumulate, patients are likely to develop chronically
stiff and swollen joints. This stage is called chronic tophceous gout. Some permanent
damage to affected joints and sometimes to kidneys can be seen. This advanced stage
is relatively uncommon if patients receive proper treatment.
CASE SCENARIO:
Differential Diagnosis
Gout in the elderly is often polyarticular and involves upper extremity joints
(especially proximal interphalangeal joints and distal interphalangeal joints). Women
present 70% of the time with polyarticular disease rather than the classic
monoarticular arthritis seen in men. Gout can be mistaken for rheumatoid arthritis
because tophi may resemble rheumatoid nodules and rheumatoid factors often become
weakly positive as people age. It may be difficult to differentiate cellulitis or septic
arthritis from gout, particularly when a fever, leukocytosis, redness, or desquamation
is present. The term pseudogout, for calcium pyrophosphate deposition disease, belies
the difficulty in clinically differentiating it from gout. For definitive diagnosis, joint
fluid must be aspirated for culture and a search for urate crystals.
Diagnostic Test
The gold standard diagnostic test for gout is an arthrocentesis. The American College
of Rheumatology has established 12 clinical criteria, 6 of which a patient must have
for diagnosis.
* Maximum joint inflammation within 1 day
* More than one attack over time
* Monoarticular arthritis (although gout can be polyarticular)
* Redness of joint
* Great metatarsophalangeal pain or swelling
* Unilateral great metatarsophalangeal involvement
* Unilateral tarsal involvement
* Suspected tophus
* Hyperuricemia
* Asymmetrical swelling within the joint on x-ray
* Subcortical cysts without erosion on x-ray
* Joint fluid culture negative for organisms during attack
Treatment and Management
The gold of treating gout is to minimize or eliminate the urate crystals from the joints
and other structures associated with them. Several aspects must be taken into
consideration and each treatment regiment is varied from patients to patients. The
three main objectives that FNP take into consideration are treatment for the acute
attacks, prophylaxis against recurrent attacks, and management of hyperurecemia.
CASE SCENARIO:
Asymptomatic hyperurecemia: urate-lowering drugs is not recommended to treat

patients with asymptomatic hyperurecemia. If hyperurecemia is identified, underlying
causes such as obesity, hypercholesterolemia, alcohol consumption, and hypertension
should be addressed.
Acute gout: NSAIDs are being used as first-line therapy. Indomethacin (Indocin),
ibuprofen (Motrin), naproxen (Naprosyn), sulindac (Clinoril), piroxicam (Feldene) are
also effective against gout.
Corticosteroids:
intra-articular, intravenous, intramuscular or oral corticosteroids are effective in acute

gout. When one or two joints are involved, intra-articular injection of corticosteroid
can be used.
Intramuscular triamcinolone acetonide is as effective as indomethacin in relieving

acute gouty arthritis. Triamcinolone acetonide is especially useful in patients with
contraindication to NSAIDs.
Oral prednisone: is an option when repeat dosing is anticipate. Prenisone, 0.5 mg per
kg on day 1 and tapered by 5 mg each day is effective.
Cochicine is also effective treatment for acute gout. However, majority of patients
experience gastrointestinal side effects, including nausea, vomiting, and diarrhea.
Patient Education
If they are obese, they should be advised to begin a concerted program of supervised
weight reduction (see Chapter 233), but to avoid starvation or very low calorie diets
that may only exacerbate the risk of gout. Drinkers should be warned against binges.
Maintenance of good hydration needs to be stressed to those at risk for
nephrolithiasis. On the other hand, patients will find it comforting to know that severe
dietary restrictions are unnecessary. Fasting should be avoided because it may
precipitate an attack. The importance of treating an acute attack at the first sign of
illness also needs to be stressed. For the patient with interval gout, a discussion of the
risks and benefits of prophylactic therapy and the importance of compliance is
indicated. Those taking allopurinol should be warned of the risk of a hypersensitivity
reaction and advised to cease intake immediately and call the physician at the first
sign of a rash, fever, or other manifestation. Pain management is the primary concern
during acute phase of and attack. The patient should be advised to take analgesic
medications as schedule. The joint should be rested as much as possible in a position
of comfort. Ice, not heat, may help with reducing discomfort.
Conclusion
Gout is one of the most causes of acute monoarticular arthritis. Primary gout runs in
families and follows multifactorial inheritance. The expanded use of agents that
decrease uric acid excretion has significantly increased the incidence of secondary
gout. The Fremingham Study suggested that almost half of new cases were associated
with thiazide use.
CASE SCENARIO:
The FNP should be able to properly diagnose acute gout, treat it, prevent recurrence,
and minimize the chances for the development of chronic gouty arthritis. Patients who
present with asymptomatic hyperuricemia should be further investigated to prevent
complications from this disorder.

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CASE SCENARIO:

FOR THE APPLICATION OF NURSING PROCESS (Nursing Care Plan)

PHYSICAL EXAMINATION: General: The patient is a pleasant male who appears

Gout is an inflammatory disease characterized by the deposition of uric acid crystals

* Maximum joint inflammation within 1 day

* More than one attack over time

* Monoarticular arthritis (although gout can be polyarticular)

* Great metatarsophalangeal pain or swelling

* Unilateral great metatarsophalangeal involvement

* Unilateral tarsal involvement

* Asymmetrical swelling within the joint on x-ray

* Subcortical cysts without erosion on x-ray

* Joint fluid culture negative for organisms during attack

Treatment and Management

Asymptomatic hyperurecemia: urate-lowering drugs is not recommended to treat

intra-articular, intravenous, intramuscular or oral corticosteroids are effective in acute

Intramuscular triamcinolone acetonide is as effective as indomethacin in relieving

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