GOUT

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GOUT
Definition
This is a disorder of uric acid metabolism whereby urate crystal deposits in the joints and other body tissues. It's usually caused by excessive concentration of uric acid in the blood (hyper uricermia) the disease affects toe, foot, ankle, knee, hand and elbow joints. It's common in males than females.

Risk/Predisposing Factors
Ø Obesity
Ø High Alcohol intake
Ø Genetic predisposition
Ø High intake of foods rich in purines e.g sea foods
Ø Drugs e.g diuretics
Ø Injury to joints
Ø Long standing kidney disease.

PATHOPHYSIOLOGY
Excessive concentration of uric acid in the blood either due to over production or faulty disposal or elimination to the kidney leads to accumulation and deposition of urate crystal within the joint tissues, thereby setting up irritation and local inflammatory response causing pain, tenderness and swelling of the affected joint.
Small masses of the urate crystals, called tophi are also formed in the cartilage, kidneys and soft tissues of other parts of the body resulting in systemic symptoms like anorexia, nausea and fever.
PATHOPHYSIOLOGY FLOW CHART OF GOUT
Excessive concentration of uric acid in the blood
                                            ⬇
Accumulation and deposition of urate crystals within the joint
                                            ⬇
                 Irritation and inflammation of the joint
                                            ⬇
                     Pain, tenderness swelling
                                            ⬇
                Tophi (masses of urate crystals)
         Deposited in the kidneys and soft tissues
                                            ⬇
                 Systemic symptoms e.g Anorexia

CLINICAL MANIFESTATION
Ø Severe pain
Ø Tenderness in the affected joint
Ø Swelling of the affected joint
Ø Warm, tight, shiny and red skin on the affected joint
Ø Nausea
Ø Anorexia
Ø Fever
Ø Headache
Ø Constipation

DIAGNOSTIC EVALUATIONS
Ø Examination of the joint and full medical history of severe pain, tenderness and swelling
Ø Blood analysis will reveal Elevated uric acid level.
Ø Aspiration of joint fluid to confirm the presence of uric acid crystals.
Ø X-ray of affected areas may reveal joint damage

MEDICAL MANAGEMENT
Ø Acute treatment is managed with colchicine and NSAIDs. These medications are continued until the pain is controlled.
Ø Chronic gout is treated with ebuxostat, allopurinol, or a uricosuric agent to reduce the amount of uric acid in the system. These  medications  are  used  in  the  long  term  to  reduce  the  amount  of painful flares that occur.
Ø Administer colchicine during an acute episode to decrease the inflammatory response resulting from uric acid deposits. This will help reduce pain.
Ø Administer NSAID to decrease inflammation to aid in pain relief {indomethacin, ibuprofen, naproxen} Aspirin should be avoided as it can reduce the amount of uric acid excreted by the body.
Ø Administer xanthine oxidase inhibitor medication to reduce total body uric acid.  Given as long-term treatment to patients with recurrent episodes of gout. Allopurinol, ebuxostat.
Ø Administer uricosuric medications. when the total body  amount of urate needs  to  be  decreased. Not  used in patients who are already excreting  a large amount of uric  acid. Given to patients  with chronic gout or  recurrent episodes. probenecid, sulfinpyrazone
Ø Low-fat
Ø Immobilize the joint for comfort.

NURSING MANAGEMENT
Ø On admission, patient is placed on bed rest and the affected part Immobilize
Ø Hot or cold applications to the affected joints will provide some relieve
Ø Nutrition: Restrict food high in purines. Purines produce uric acid. Foods high in purines include shellfish, organ meats(brain, liver, kidney), yeast extract as milk, Reduce alcohol intake which can cause diuresis and increase the concentration of the internal environment which encourages accumulation of uric acid.
Ø Have the patient drink 3 liters of fluid  every day to avoid crystallization of uric  acid in the kidneys.  Increased fluids help  flush the uric acid through the kidneys
Ø Maintain body weight to reduce stress on the affected joints

NURSING DIAGNOSIS
Ø Chronic pain related to inflammatory response and irritation of the joints by uric acid evidence by patients complain.
Ø Hyperthermia related to inflammatory process evidence by temperature of 38oc
Ø Knowledge deficit as regard management of the condition evidence by frequently questioning and non compliance to the treatment plan.

COMPLICATIONS
Ø Permanent damage to the joints
Ø Kidney stones
Ø Deformity
Ø Loss of function

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