GOUTY ARTHR

Grand Case Presentation

Presented by:

Group 1 and 2

LEARNING OBJECTIVES

General Objective
This case presentation aims to impart knowledge to the readers about the disease process, anatomy and physiology and to implement a comprehensive nursing care management for Gouty Arthritis.

Specific Objectives:
To be able to determine the signs and symptoms of gouty arthritis To be able to determine the precipitating, predisposing and aggravating factors of gouty arthritis. To be able to determine the effects of the disease in the human body. To be able to determine the treatment necessary to cure a person afflicted with this kind of disease

To identify the pharmacologic treatment given to the patient including its therapeutic effect, side effects and adverse effects
To identify the nursing problem of the patient to provide a well-suited nursing care plan for the patient; and To provide a well-formulated discharge plan necessary for the patients well being.

INTRODUCTION

GOUTY ARTHRITIS

Also known as: the disease of kings

It refers to a form of arthritis caused by deposits of needle-like crystals of uric acid. It accounts for approximately 5% of all cases of arthritis. It is one of the most painful rheumatic diseases.

SIGNS AND SYMPTOMS

ETIOLOGY
Certain conditions related to diet and body weight Medicines that may increase uric acid concentration

FOUR STAGES OF GOUTY ARTHRITIS

Asymptomatic Hyperurecemia Acute Gout/Acute Gouty Arthritis

Interval/Intercritical Chronic Tophaneous Gout

RISK FACTORS
Overweight or Obesity Eating Purine-Rich Foods Excessive Alcohol Intake High Blood Pressure Lead Poisoning Abnormal Kidney Function Family History - Gender Age Certain Medications Certain Medical Conditions

CASE ABSTRACT

Patient X is a 55-year-old male rushed to the emergency room of Los Baos Doctors Hospital last December 3, 2011 around 1:54 PM because he couldnt move his legs due to severe pain in his both knees. Laboratory tests, Hematology, Urinalysis, Blood Chemistry, and Uric Acid were conducted in order to determine the disease condition of the patient. The results showed that he has Gouty Arthritis. Patient was then advised for admission. He was then transferred to the Pay Ward with an IVF of PNSS 1L x 31-32gtts/min to run for 8hrs. The doctor ordered Colchicine, Arcoxia as some of his curative medications. Following day, December 4, 2011, he has undergone Arthrocentesis for the aspiration of uric acid that has accumulated in his knees. Operation started at 10:00 AM, and the collection of fluid that was aspirated was 94mL on his right leg and 80mL on his left leg. The operation ended at 11:00AM and patient was brought back to his room. Medical and nursing management was continuously given after.

PATIENT

ASSESSMENT
DATA BASE

HEALTH HISTORY
Patient: X Birthday: 09-11-56 Age: 55 years old Address: Bambang, Los Banos, Laguna Religion: Catholic Sex: Male Nationality: Filipino Civil status: Married Rank in the Family: Father Admission Date and Time: 12-03-2011; 1:54 pm Date of Discharge and Time: 12-07-2011; 4:00 pm Attending Physician: Dr. T Initial Diagnosis: Acute Gouty Arthritis Final Diagnosis: Gouty Arthritis Source of History: Patient Reliability of Historian: Reliable Chief Complaint: Painful Knee, both Vital Signs: Temp: 36.5 C R.R: 25bpm C.R: 76cpm BP: 140/90 mmHg

HISTORY OF PRESENT ILLNESS

Four days prior to admission, patient was experiencing joint pain on both knees. As the pain progresses it became severe that he can no longer bear it. He became weak, loses his appetite, and can hardly sleep. He was then brought to the ER of Los Banos Doctors Hospital and Medical Center on December 3, 2011 at 1:54pm. The doctor order to have a laboratory tests of blood chemistry and urinalysis. He was advised for an admission and was immediately hooked with an IVF of PNSS 1Lx31-32gtts/min to run for 8 hours. He was given a standing order medication of arcoxia, 120mg OD and colchicine, 1 tab OD. Parecoxib was also ordered as PRN for pain. He was advised for arthrocentesis the following day. Result of arthrocentesis was 94ml on right knee and 80ml on left knee

PAST HEALTH HISTORY

August 2008 when patient was diagnosed with gouty arthritis. He was given an allopurinol, 200mg TID for maintenance and Arcoxia for pain reliever. When the patient is relieved with pain after 3 or 4 days, he suddenly stops his medication. A year after, he was hospitalized due to recurrence of joint pain. On March 19, 2011, he was confined and treated at Healthserv Medical Center for the same medical diagnosis of gouty arthritis. His tophi on both of his elbows were then removed through excision. He has no known allergies for any drugs and foods.

FAMILY HISTORY OF ILLNESS

Patient X has three siblings and he is the eldest. They have a history of arthritis. His father has arthritis and his mother has a heart disease. His sister is hypertensive but the youngest brother has no known illness. His grandmother on his father side died of a kidney disease and has also a history of arthritis. He has two children but no known illnesses.

Developmental Task

His developmental task according to Erik Erickson is generativity vs. stagnation. In the period of Generativity strength comes through care of others. While stagnation is when the relationships or goal change, maybe forced with major life changes- the mid-life crisis and struggles with finding new meanings and purposes, and if we dont get through this stage successfully, we can become stagnant. Patient X got the moral support and strength from his family and loving children. He has his work in IRRI, where he has good friends around him and hang out with him.

FUNCTIONAL HEALTH PATTERN

Health Perception and Health Management Pattern

According to the patient, he drinks alcohol often especially during Friday night out to unwind himself from his work together with his officemates. He also smoked 5 sticks of cigars a day or can be increased if he is under stress. When given a medication, he usually follows the doctors order but when he feels better after a few days, he stops the medications. He does not usually finish his medication regimen. He then realized how important it is to finish the course of treatment.

Nutritional and Metabolic Pattern

According to the patient, his typical foods to eat are monggo and string beans. He sometimes make the monggo bean as his rice and rice as his viand. He also loves to eat dinuguan, boiled camote, tuna, grilled liempo, and innards. He is a drinker, he drinks four times weekly.He loses weight after he experiences the recurrence of joint pain. He has a diet restriction of low purine, low salt, and low fat.

Elimination Pattern
According to the patient, he defecates at least once a day and urinates several times. He has no difficulty in urination and defecation. His stool color is dark brown and soft formed.

Activity-Exercise Pattern
The patient works as a research technician at IRRI. He has a sedentary lifestyle; he does not have any routine exercise. On weekends, he usually spend his time with his family, sometimes they go to the mall. During confinement, the patient has no physical activity. He cant do whatever he wants, and has seen very limited range of motion especially in his lower extremities.
Feeding Bathing Toileting Bed Mobility Dressing = = = = = 0 2 2 2 2 Grooming General Mobility Cooking Home Maintenance Shopping = = = = = 2 3 4 1 4

Legend: Level 0 Level 1 Level 2 Level 3 Level 4

- Full self care - Requires use of equipment or device - Requires assistance or supervision from another person - Requires assistance or supervision from another person or device - is dependent and does not participate

Sleep-Rest Pattern
The patient sleeps randomize, sometimes around 8:30pm or 11:00pm and wakes up at 5:30 am. But whenever the pain attacks him, he can hardly sleep at night.

Cognitive-Perceptual Pattern
The patient has no hearing difficulty. He wears reading eyeglasses and he is a near-sighted. He has a good memory and can recall past events clearly. Joint pain is the only factors that affect his activities of daily living.

Self-Perception and Self-Concept Pattern

The patient states that he is very anxious and irritable whenever pain attacks him. He believed that his condition is a part of aging process.

Role-Relationship Pattern
The patients family structure is nuclear. They have their own house and his wife is usually in-charge of the household chores. His eldest son is working abroad and his youngest son is living with them and is currently working. He doesnt have any problems regarding his family affairs since his two children are all educated and stable. He has a good relationship with his co-workers but he often misses to work lately because of his hospitalization.

Coping-Stress Tolerance Pattern

The patient took his medications whenever he feels pain. He also knows of his diet restrictions but still he continues to eat it. After the excision of his tophi on March 19, 2011, he gradually decreases his alcohol drinking habit but not smoking.

Value-Belief Pattern
The first time when patient learned of his condition; their belief in God becomes even stronger. They rely everything to Him and believe in miracles He do.

PHYSICAL
ASSESSMENT

Date assessed: Dec. 04, 2011 Time assessed: 8:00 a.m.

A. General Survey
Received patient lying in bed with IVF of PLR 1L for 24 hours, he is in pain (10/10) and irritable and upon observation patient X looks pale and weak with rapid shallow breathing. (+) swelling on his both knees.

Vital Signs
Dates: Dec 03,2011 Temperature: 36.5 C 25 cpm Respiratory Rate: Pulse Rate: 76 bpm 140/90 mmHg Blood Pressure: Dec 04,2011 (8am) 36.4 C 24 cpm Dec.04, 2011 (12pm) 36.9 C 19 cpm Dec 05,2011 36.6 C 19 cpm 81 bpm 130/80 mmHg

80 bpm 89 bpm 140/100 mmHg 130/80 mmHg

B. INTEGUMENT
Skin:
Upon inspection, Patient X has a pale light brown complexion, uniform in color except those areas exposed to the sun. His skin is rough and dry as noted. He has scar in both elbow with the length of 2.5 inches.

Nails:
His fingernails and toenails are concave and short, intact nailbed and pale in color, Blanche test was performed and capillary refill was 4-5 seconds (1-2 sec.)

Hair:
Upon inspection, Patients X hair is evenly distributed with smooth, short, and thick black hair with minimal white hair, theres no presence of dandruff and lice, no presence of infestations and no lesions.

HEENT
Head:
Upon inspection, he has a round with smooth skull contour. No nodules, masses and tenderness. Facial features are symmetrical.

Eyes:

Patient Xs eyebrow is fairly distributed; eyelashes are slightly short and curl. His eyes are black in color and pale conjunctiva, no noted discharge. He can able to read but most likely to wear reading eyeglasses. He is nearsighted.

Ears:

Smooth and soft to touch, its color is the same as his color of the skin. No presence of any discharge, he can recognize to any sound. Symmetrical upon inspection, and auricle aligned with outer canthus of eye. Ears also recoil.

Nose:

Smooth to touch, no presence of any discharge and deformities. He can recognize good and bad smell. Nasal septum is intact and in midline. Air moves freely as the client breathes through nares.

Mouth/Throat/Pharynx/Teeth/Tongue:

Upon assessment, patients lips are pale in color, symmetry and contour, no noted sores and gums. Tongue is positioned in the center.

Neck/Lymph Nodes: No noted lesions, no palpable lymph nodes.

Thorax: Spine is vertically align, has intact skin, no noted lesion. Chest circumference is about 95cm. Theres a rapid and shallow breathing. Chest excursion was done and noted equal expansion of chest on both sides. Cardiovascular: Upon auscultation, he has a normal heart sound and normal heart rate and regular rhythm. Abdomen: Abdomen circumference is 120 cm, No nodes palpable. Abdomen is symmetric in contour. Has an audible bowel sound. No evidence of enlargement of the spleen or liver. Musculo-Skeletal/ Extremities: Upper: Upon inspection, theres metacarpophalengeal joints.

presence

of

tophi

in

patients

both

Lower: The patient has a (+) swelling on both knees. Upon performing the range of motion, the score was 2/5

felt.

Neurological: Upon assessment, Patient X was very irritable and just focusing on his pain

being

ANATOMY AND PHYSIOLOGY

PATHOPHYSIOLOGY

Predisposing Factors: Age: 55years old Gender: Male (9:1)unction Hereditary

Precipitating Factors: Diet (monggo, stringbeans, tuna) Lifestyle (smoking, alcohol drinker)

Excessive amount of protein is ingested

Proteins are converted into purine

The end product of purine is Uric Acid

But because of decrease functional level of the kidney, uric acid could not be able to excrete in the body.

Therefore, there would be an increase amount of Uric Acid

HYPERURECEMIA (Uric Acid = 10.5mg/dL)

Monosodium urate crystals in tendons, joints (metacarpophalangeal joint)

ACCUMULATION OF TOPHI

Triggers Local Inflammatory Response Release of Chemical Mediators Histamine, prostaglandin, leukotrienes, bradykinin causes swelling of the joints

Mediators cause capillaries to dilate

Dilation causes the skin to become red

REDNESS

Causes pain to knee

PAIN and SWELLING on both knees

GOUTY ARTHRITIS

LABORATORY

I. HEMATOLOGY
HEMOGLOBIN HEMATOCRIT WBC RBC RESULT 9.6 .30 12,900 3.3 NORMAL VALUES M 14-16 mg/dl F 12- 14 mg/dl M - .42 - .52 cv/L F - .37 - .47 cv /L 5 10 x 10 9/L M 5.5 6.5 x 10 12/L F 4.5 5.5 x 10 12/L

DIFFERENTIAL COUNT SEGMENTERS LYMPHOCYTES MONOCYTES

80 20 3

55-65 % 20-40 % 2-8 %

URINALYSIS
COLOR TRANSPARENCY REACTION SPECIFIC GRAVITY SUGAR ALBUMIN PUS/WBC RESULT Light yellow Slightly hazy 6.5 1.010 Negative Trace 3-5 NORMAL VALUES 5-7 1.002-1.30 Negative Negative 0-2 / hpf

RBC EPITHELIAL CELLS AMURATES

6-8 / hpf Some Negative

0-2 / hpf Negative Negative

III. COMPLETE BLOOD COUNT (CBC)

RESULT CREATININE BLOOD URIC ACID 2mg/dL 10.5 mg/dl NORMAL VALUES 0.5 1.7 mg/dl M : 3.4 7.0 mg/dl F: 2.5 6.0 mg/dl INTERPRETATION Slightly increased Elevated purine deposits in the blood or hyperurecimia

DRUG STUDY

DRUG/CLASSI DOSAGE/RO FICATION UTE OF ADMINISTRA TION/FREQU ENCY Generic Name: Etoricoxib Brand Name: Arcoxia

ACTION

CONTRAINDI CATION

SIDE EFFECTS

NURSING CONSIDERATION

Inhibits 120 mg, OD, 6 prostaglandin pm synthesis by decreasing enzyme needed for biosynthesis,analg esic and antiinflammatory INDICATION Relief of chronic musculoskele tal pain Relief of acute pain To treat acute gouty arthritis

Patients with hypersensiti vity to any component of Arcoxia. Congestive heart failure Patients with hypertensio n Pregnancy

feeling sick (nausea), vomiting heartburn diarrhea swelling of the legs, ankles or feet high blood pressure dizziness insomnia drowsiness mouth ulcers .

Caution for those pt. who has heart dse. * Drink adequate fluid to avoid dehydration. * Stop the medication immediately if gastrointestinal lesions occur. * Monitor blood pressure regularly while taking this medication.

DRUG/CLASSI DOSAGE/RO FICATION UTE OF ADMINISTRA TION/FREQU ENCY Generic Name: Goutnil Brand Name: Colchicine

ACTION

CONTRAINDIC SIDE ATION EFFECTS

NURSING CONSIDERATION

Inhibits 1 tab, OD, PO, microtubule 6 pm formation of lactic acid in leukocytes, which decreases phagocytosis and inflammation in joints. INDICATION For the treatment of acute flares of gout.

Contraindic ated in pregnancy, hypersensiti vity serious GI, renal, hepatic Cardiac disorders.

diarrhea, vomiting

anorexia malaise peptic ulcer hematuria oliguria, chills, dermatitis

Assess pain and mobility of joints. Monitor I&O ratio observe for decrease in urine output; CBC, before and during therapy; may cause Assess for toxicity; weakness, abdominal pain, nausea, vomiting, diarrhea.

DRUG/CLASSI DOSAGE/RO FICATION UTE OF ADMINISTRA TION/FREQU ENCY Generic Name: Essential 1 tab, PO, TID, Amino Acids 8-1-6 Brand Name: Ketosteril

ACTION

CONTRAINDIC ATION

SIDE EFFECTS

NURSING CONSIDERATION

Normalizes metabolic process, promotes recycling product exchange. Reduces ion concentration of potassium, magnesium and phosphate. INDICATION Protein energy malnutrition.

Allergy and Hypercalcemia hypersensiti may develop. vity to any content of this drug Hypercalce mia

Evaluate for any contraindications Warn the patient about possible side effects and how to recognize them Give with food if GI upset occurs Frequently assess for hypercalcemia.

Drug

Classification

Indication

Contraindications

Side effects

Nursing Considerations >Caution for those patient with heart disease. >Drink adequate fluid to avoid dehydration. >Monitor blood pressure regularly while taking this medication.

Generic name: Parecoxib Brand name: Dynastat Dosage: 40mg,PRN Route: P.O

For moderate Non-steroidal pain. antiinflammatory drug(NSAIDs) Action: NSAIDs inhibit cyclooxygenas e enzynes , which are involved in the synthesis of prostaglandins and thereby reduce pain and inflammation.

>Contraindicated in patients with inflammatory bowel disease, heart failure, peptic ulcer, severe liver impairment, and hypersensitivity.

>GI: Ulcer and gastrointestin al bleeding. >Heart: slow heart rate, high /low blood pressure. >Skin: swelling, rash, itching, and DOB >Misc: back pain, agitation, disturbed sleeping, decrease urine output

Home Medications
Drug Classification Anti-gout Action: Alleviates gout symptoms Indication >To prevent gouty attack. Contraindicatio ns >Contraindicated in patients hypersensitivity to drug and in those with idiopathic hemochromatosis . Side effects >CNS: drowsiness and headache >GI: Nausea ,vomiting, Diarrhea, abdominal pain. >Skin: Rash. Nursing Considerations >Assess patients uric acid level, joint stiffness, and pain before and during therapy. >Monitor fluid intake and output. >Be alert for adverse reaction and drug interaction. >Give drug with or immediately after meals to minimize adverse GI reactions. >Have patients drink plenty of fluid while taking drug, unless contraindicated

Generic name: Allopurinol Brand name: Aloprim Dosage: 200mg, TID Route: P.O

Drug

Classification Indication Contraindications Analgesic Moderate Action: to severe Unknown; pain. centrally acting synthetic analgesic compound not chemically related to opioIds that is though to bind to opioids receptors and inhibit re uptake of norephineprine and serotonin. >Contraindicated in patients hypersensitive to the drug or any of its component and in those with a cute intoxication from alcohol, hypnotics, centrally acting analgesic, opioids, or psychotropic drugs. >Use cautiously in patients at risk for seizures or respiratory depression.

Side effects >CNS: Dizziness, vertigo, headache. Confusion, anxiety, malaise, nervousness, sleep disorders and seizure. >EENT: visual disturbances. >GI: Nausea, constipation, vomiting, dyspepsia, dry mouth, diarrhea, abdominal pain >Musculoskele tal: Hypertonia >Skin: sweating, rash.

Generic name: Tramadol Brand name: Ultram Dosage: 500mg,tab Route: P.O

Nursing Considerations >Assess patients pain before starting therapy and regularly thereafter to monitor the drug effectiveness. >Monitor CV and respiratory status. >Monitor patient for drug dependence. >Be alert for adverse reactions and drug interactions. >Give drug before the onset of intense pain. >If respiratory rate decreases or falls below 12bpm, with hold dose and notify physician. >Because constipation is a common adverse effect, anticipate need for laxative therapy. >Tell ambulatory patient to be careful when getting out of bed.

IVF

IV FLUIDS PNSS Plain Normal Saline Solution iL x 3132gtts/min , q8

CLASSIFICATION

INDICATION CONTRAINDICATION Administered to prevent dehydration for patient who cannot consume liquids and nutrients by mouth and sue as a solvent for drugs that are to be administered parenterally

Isotonic ACTION: Replace body fluids and is the safest fluid to give quickly in large volumes

SIDE NURSING EFFECTS PRECAUTIONS Not known Fever Check and verify contraindication Hypervol the Doctors . emia order regarding Electrolyt the type of IVF to e be used and also imbalanc its volume and e rate. Extravas Before giving the ation loading dose, Infection obtain the at the baseline data injection (heart rate and site rhythm, B.P., and electrolytes Maintain sterility when preparing and administering the medication Document the procedure and note the patients reaction

IV FLUIDS
Plain Lactated Ringers Solution iL x 24 hr

CLASSIFICATI INDICATION CONTRAINDICATI ON ON

Isotonic ACTION: Isotonic hydration; replace electrolytes and extra-cellular fluid losses; mild to moderate acidosis (the lactate is metabolized into bicarbonate which counteracts the acidosis Lactated Ringers Injection, USP is indicated as a source of water and electrolytes or as an alkalinizing agent.

SIDE EFFECTS
urticaria pruritis; laryngeal edema coughing, sneezing difficulty of breathing

NURSING PRECAUTIONS
Observe for fluid overload. If patients serum is above 7.5 (alkalotic), dont give lactated ringers soloution. Do not administer simultaneously with blood through same administration set because of the likelihood of coagulation.

Not known contraindicatio n

NCP

Assessment Subjective: Sobrang sakit ng tuhod ko, as verbalized by the patient. Objective: o Pain scale of 10/10 o Pale looking o Facial Grimace o Guarding Behavior o Redness and Swelling of the affected area. o Irritability o Aspirated 94mL in the R leg and 80mL in the L leg after arthrocentesi s o Changes in vital signs BP: 140/90 RR: 25 PR: 76

Diagnosis Acute pain related to deposition of urate crystals as evidenced by aspirated uric acid in the joint of both knee

Planning After series of nursing intervention, patients subjective perception of pain will decreases, as documented by a pain scale from 10 to 7, absence of irritability, facial grimace and guarding behavior. Patient will feel more comfortable.

Intervention INDEPENDENT: >Obtain clients assessment of pain to include characteristics, onset/duration, frequency and aggravating factors. Reassess each time pain occurs/is reported. >Provide comfort measures such as therapeutic touch, repositioning, quiet environment and calm activities. >Instruct in use of relaxation techniques such as focused breathing.

Rationale >Rule out worsening of underlying condition/development of complications. >Promotes nonpharmacological pain management. >Distracts attention and reduce tension.

Evaluation Goal met. Patients descriptive assessment of pain decreases from 10 to 7. There is absence of facial grimace and patient can interact with others without irritability seen.

Assessment

Diagnosis

Planning

Intervention >Encourage diversional activities such as watching TV or listening to radio and socialization to others. >Instruct patient to report pain as soon as it begins. >Facilitate coordination across healthcare providers to provide rest periods between care activities. DEPENDENT: >Administer Arcoxia (120 mg OD) as prescribed by the physician. Collaborative: > Collaborate with the dietician regarding the Low Purine Diet >Discuss with the health team concerning the Blood Chemistry.

Rationale >Divert attention from pain. >Timely intervention is more likely to be successful in alleviating pain. >Relaxation decreases oxygen demand and could decrease level of pain. >Analgesic drugs lessen the pain. > To control the amount of protein digested in the body. >It permits the health team to see if there is deviation in normal values.

Evaluation

ASSESSMENT SUBJECTIVE: Hindi ako makatulog sa gabi sa sakit., As verbalize by the patient. OBJECTIVE: Severe pain in the joints of the knee with a pain scale of 10/10 Body weakness Restlessness Irritability

DIAGNOSIS Sleep disturbance related to joint pains

PLANNING After 1 day nursing interventio n the patient will report improvem ent in sleep and rest pattern.

NURSING INTERVENTION INDEPENDENT: Note environmental factors affecting sleep, including sleep environment, excessive noise in life. Determine client usual sleep pattern Observe physical signs of fatigue (frequent yawning, restlessness, irritability, disorientation) Distinguish clients beneficial bedtime habits. Suggest abstaining from day time naps.

RATIONALE

EVALUATION Goal Met. Patient was able to report improvement in sleep and rest patter with a pain scale of 7/10.

Provide comparative baseline in sleeping patterns

They impair ability to sleep at night.

ASSESSMENT

DIAGNOSIS

PLANNING

NURSING INTERVENTION
Recommend quite activities such as reading, and listening to soothing in the evening. Instruct in relaxation technique music therapy Limit evening fluid intake

RATIONALE

EVALUATION

To reduce stimulation so client can relax

To decrease tension and prepare patient for rest and sleep To reduce need for night time elimination

Provide calm and quite environment and manage controllable sleepdisturbing factors. DEPENDENT: Administer (Arcoxia 120 mg OD) pain reliever

To reduce pain

ASSESSMENT SUBJECTIVE: Hindi ko maigalaw ang paa ko, as verbalized by the patient., As verbalize by the patient. OBJECTIVE: Severe pain in the joints of the knee with a pain scale of 10/10 Limited range of motion Difficulty turning SUGGESTED FUNCTIONAL LEVEL CLASSIFICATION : 2- Requires help from another person for assistance, supervision or teaching.

DIAGNOSIS PLANNING Impaired Physical Mobility related to joint pain.

NURSING INTERVENTION After 2 INDEPENDENT: days of Encourage nursing verbalization intervention regarding , patient will limitations in attain and mobility. maintain optimal function mobility and increase strength of affected body part.

RATIONALE

EVALUATION

Instruct in use of side rails, roller pads Support affected body parts/joints using pillows/rolls.

Goal Partially Mobility is not met. Patient necessarily related can slightly to deformity. Pain, move his stiffness and both feet, fatigue may and gradually temporarily limit increases mobility. The strength of degree of mobility affected body is not synonymous part. with the degree of independence. Decreased mobility may influence a persons selfconcept and lead to social isolation. For position changes/transfers. To maintain position of function and reduce risk of pressure ulcers.

ASSESSMENT .

DIAGNOSIS

PLANNING

NURSING INTERVENTION Encourage participation in self-care, occupational/diversional/ recreational activities such as sitting with less support by others, gradually. And dangling activity while sitting on the side of the bed. Provide bed rest during the acute attacks with the affected extremity elevated Monitor joint range-ofmotion ability and appearance of joints. Position the joint in mild flexion during acute attack DEPENDENT: Administer Arcoxia as ordered by the physician

RATIONALE

EVALUATION

Enhances selfconcept and sense of independence

To permit lement in maximal effort/involvemen t in activity.

ASSESSMENT SUBJECTIVE: Nahihirapan ako tumayo kaya kailangan ko ng katulong. As verbalize by the patient OBJECTIVE: Vital signs: T- 36.5 RR- 25 PR- 76 BP- 140/90 Limited range of motion Body weakness Pain scale of 10/10 SUGGESTED FUNCTIONAL LEVEL CLASSIFICATION: 2- Requires help from another person for assistance, supervision or teaching.

DIAGNOSIS Activity in tolerance related to joint pains

NURSING INTERVENTION After 2 days INDEPENDENT: of nursing Note client intervention, reports of patient will be weakness, able to fatigue, pain, identify difficulty in techniques to accomplishing enhance task and activity insomnia. intolerance. A certain ability to stand and move about and degree of assistance

PLANNING

RATIONALE

EVALUATION Goal Partially met. Patient can slightly move his both feet, and gradually increases strength of affected body part but still needs assistance.

Symptoms maybe result or contribute intolerance of activity To determine current status and needs associated with participation in needed or desired activities

ASSESSMENT

DIAGNOSIS

PLANNING

NURSING INTERVENTION

RATIONALE

EVALUATION

Adjust patients activities. Reduce intensity level or discontinue activities that may cause undesired physiologic changes Balance rest period Provide positive atmosphere while acknowledging difficulty of the situation of the client Assist client in learning demonstrating appropriate safety measures

To prevent over exertion

To reduce fatigue

Helps minimize frustration and rechannel energy

To prevent injury

DISCHARGE PLANNING

Medication

1. 2.

Encourage the patient to continue taking his medications. Take home meds: Tramadol, 500mg tab for 7 days qid Allopurinol, 200mg tab for 7 days tid Encourage the patient to exercise and when he exercise include range of motion to reduce stiffness of the joints and improved mobility of the joints Encourage the patient to follow faithfully the regimen for gouty arthritis, especially the medications as ordered by the doctor. Had undergone arthrocentesis to relieve the pain in both knees. Encourage the patient to take his medication on right time as prescribe for faster recovery. Encourage the patient to exercise every morning Encourage the patient to eat low purine and low fats Encourage the patient to stop drinking alcohol drinks Encourage the patient to increase his fluid intake Encourage the patient about the follow up on: December 14 2011 at OPD of Los Baos Doctors Hospital a The diet as ordered should be low in purine and low in fats Always pray for the guidance of the lord in spiritual health affects the wellness of an individual greatly. Straighten relationship with lord by showing love and respect to the other people around you and your family

Exercise Treatment

Health Teaching

Out Patient Follow Up Diet Spiritual

EVALUATION

PROGNOSIS

Thank you!!