GOUT

By

Dr. Raafat AL-Awadhi

Lecture 2
GOUT
 GOUT (GOUTY ARTHRITIS)
 Introduction:

• Gout is a type of arthritis that happens when there is too much

uric acid in blood and it forms sharp crystals in one or
more joints. This usually happens in big toe, but it also can
be in knee, ankle, foot, hand, wrist, or elbow.
• Definition:

Gouty arthritis is usually an extremely painful attack with a

rapid onset of joint inflammation which is precipitated by the
deposition of uric acid crystals in the lining of the joint (synovial
lining) and the fluid within the joint.
Gout
 C AU S E S & RISK FAC TO RS

 Age and gender

Men produce more uric acid than women, though women’s

levels of uric acid approach those of men after the
menopause.
 Genetics•

Lifestyle choices: Alcohol consumption interferes with

the removal of uric acid from the body. And diet

Medications - Include some diuretics and drugs

containing salicylate. And low dose Asprin and ACE B blocker
 C AU S E S & RISK FAC TO RS
Weight - Being overweight increases the risk of gout as there
is more turnover of body tissue, which means production of
uric acid as a metabolic waste product .( ‫)كيلوبال ضمح نم ديزمال مسجال جتني‬

Higher levels of body fat also increase levels of systemic

inflammation as fat cells produce pro-inflammatory cytokines.
 Recent trauma or surgery

Other health problems –Uncontrolled of HTN and Renal

insufficiency and other kidney problems can reduce the
body's ability to efficiently remove waste products, leading to
elevated uric acid levels.
 CLASSIFICATION
• Acute gout: This stage occurs when the urate crystals that have been
deposited suddenly cause acute inflammation and intense pain. This sudden
attack is referred to as a "flare" and will normally subside within 3-10 days.
Flares can sometimes be triggered by stressful events, alcohol and drugs, as
well as cold weather.
• • Interval or intercritical gout: This stage is the period in-between
attacks of acute gout. Subsequent flares may not occur for months or years,
though if not treated, over time, they can last longer and occur more frequently.
During this interval, further urate crystals are being deposited in tissue.
• Chronic tophaceous gout:
• Chronic tophaceous gout is the final stage and the most debilitating form of
gout. Permanent damage may have occurred in the joints and the kidneys. The
patient can suffer from chronic arthritis and develop tophi - big lumps of urate
crystals - in cooler areas of the body such as the joints of the fingers. It takes a
long time without treatment to reach the stage of chronic tophaceous gout -
around 10 years.
 PATHOPHYSIOLOGY

• An elevated serum urate level, together with local factors, can result in the

deposition of urate crystals into the joints. Once crystals are deposited

into a joint, they can be released into the joint space and initiate an

inflammatory cascade causing acute gouty arthritis.

 CLINICAL MANIFESTATIONS

• sudden Pain areas: in the joints, ankle, foot, knee, or

toe

• Joints: lumps, stiffness, or swelling

• Also common: physical deformity or redness

• Limited range of motion

Gout
 DIAGNOSTIC TEST

• • History collection

• Physical examination•

• Joint Fluid Analysis: Once joint fluid is obtained, it

is analyzed for uric acid crystals and infection.

• • Blood test to measure the amount of uric acid in your

blood

• Uric acid urine test: Periodically test urine for uric acid, can
help predict and monitor the formation of kidney stones.
Kidney stones are a complication of gout in some people.
 MANAGEMENT CONT'D...
Non-Pharmacologic Management:•

• Maintain a high fluid intake (2-4 liters a day)

• Avoid alcohol

• Maintain a healthy body weight

• Gout diet: the primary dietary goal for gout is to limit

your intake of foods with high amounts of purine in them.

Limit fish, meat, seafood's and poultry intake.

 MANAGEMENT
• Pharmacologic Management:•

• NSAIDs are the usual first-line treatment for gout.

• Colchicine is an alternative for those unable to

tolerate NSAIDS.

• Glucocorticoids have been found to be as effective as NSAIDS

and may be used if contraindications exist for NSAIDS

• Allopurinol blocks uric acid production

 Gout
Treatment
Acute Indomethacin vs. Colchicine
gout•indications
• first line of treatment
• medications
•indomethacin (indocin) 50mg tid
• NSAID
• inhibits phagocytosis
•colchicine
•indicated in acute attacks if patient has a
history of peptic ulcers
•inhibits inflammatory mediators
•can be given intravenously
• oral, intraarticular or IV glucocorticoid
•Indication patient unable to take NSAID or
 Gout
Treatment
Chronic gout
• allopurinol
• indications
• first line of treatment for chronic gout
attack
• medications
• allopurinol is an xanthine oxidase
inhibitor

•colchicine
• indications
• for prophylaxis after recurrent
attacks
 NURSING MANAGEMENT

• All patients should be encouraged to modify their

lifestyle including limiting alcohol intake ، encouraging
weight loss where appropriate and decreasing food rich
in purines.

•Foods High in Purines:

• Very High - Some meats, turkey, alcoholic beverage
• - Moderately High - mutton, veal, pea, mushroom, fish•
• Co-morbid medical conditions should also be
controlled including hypertension, diabetes and
hyperlipidemia.
 Lecture 3
Systemic Lupus Erythematosus
(SLE)
Systemic Lupus Erythematosus
Systemic Lupus Erythematosus
Systemic Lupus Erythematosus
Systemic Lupus Erythematosus
Systemic Lupus Erythematosus
 DIAGNOSIS CRITERIA
• The eleven criteria used for diagnosing SLE: American College of rheumatology)
• 1- Malar or butterfly rash
• 2- Discoid rash
• 3- Photosensitivity.
• 4- Painless oral ulcer.
• 5- Peripheral joints arthritis: 2 or more peripheral joints.
• 6- Pleurisy or pericarditis.
• 7- Proteinuria.
• 8- Psychosis or seizures.
• 9- Pancytopenia
• 10- +ve ANA antibody.
• 11-+ve anti ds DNA ab > 15 IU/ml or anti-smith ab.
• The diagnosis of SLE is strongly suggested, when a person has 4 or more of these
criteria.
 TREATMENT

• 1. A conservative regimen of physical and emotional rest is required

• .2.protection from direct sunlight

• .3. A healthful diet

• .4.prompt treatment of infections.

• 5. Pregnancy must be planned for times when the disease is under

control, and the patient is on allowable medications.

 MEDICATION
• 1-NSAIDs:• Non steroidal anti-inflammatory drugs (NSAIDs) such as
ibuprofen and naproxen
• .2- Anti-malarials:
• (Plaque nil) It may be used alone or in combination with other drug.
• hydroxychloroquine, quinacrine (available compounded), Chloroquine
• • Used in lupus over 50 years
• Mildest immunosuppressant
• Very safe, risk of retinal toxicity low Eye exam once year
• 3. Corticosteroid:
• 4- Immunosuppressive :
•For some patients whose kidneys or central nervous system are affected
by lupus, such as cyclophosphamide (Cytoxan)
•Restrain the overactive immune system by blocking the production
of immune cells.
 NURSING MANAGEMENT1
• 1. Minimize appearance of lesions.
• 2. Alleviate discomfort
• 3. Minimize fatigue.
• 4.Maintain weight at optimal range
• 5.Teach the patient to recognize fever and signs and symptoms of infection
• .6.Maintain joint function and increase muscle strength.
• 7. Recognize anemia and develop a plan of care
• 8. Minimize episodes of bleeding.
• 9. Minimize incidence of infection
• 10. Educate the patient about immunizations
• 11. Educate patient nutritional status.
 NURSING DIAGNOSIS

• 1. Impaired skin integrity related to inflammation

as evidence by skin rash.
• INTERVENTION
• 1. Wear protective eyewear.
• 2. Wear a wide-brimmed hat and carry an umbrella.
• 3. Wear maximum protection sunscreen (SPF 15 or above) in
the sun. Sunbathing is contraindicated.
• 4. Avoid ultraviolet ray.
 NURSING DIAGNOSIS

• 2. Acute pain related to inflammation as evidence

by Verbalized complaint of joint pain or stiffness
• INTERVENTION
• Assess for the signs of joint inflammation (warmth, redness, swelling) or
decreased motion
• Encourage the use of ambulation aids when pain is related to weight-
bearing.
• Encourage the use of non pharmacological measures of pain control
such
as relaxation, distraction, or guided imagery.
• Consult an occupational therapist for the proper splinting of affected
joints.
 NURSING DIAGNOSIS

• 3. Imbalance nutrition:
• less than body requirement related to poor appetite
• INTERVENTION
• Monitor calorie intake, weight
• Provide menu suggestion for high protein & calorie foods
• Give high protein and calorie diet.
• Provide liquid and frequent diet.
• Plan periods of rest after food intake.
 NURSING DIAGNOSIS

• 4. Deficient knowledge about self-management to

be performed at home.
• INTERVENTION•
• Teach the patient about self-care.
• Give strong message to stop smoking•
• Advise the patient to take regular treatment•
• Teach about exercise.
 LECTURE 4

OSTEOMYELITIS
 OSTEOMYELITIS
Definition
• Osteomyelitis is an infection of the bone by one of three modes:
• Extension of soft tissue infection from pressure
ulcer or incision.
• Direct bone contamination from bone surgery, open fracture,
or traumatic injury.
• Blood borne infection spread from other sites like tonsils,
infected teeth, and upper respiratory infections).
• Patients who are at high risk for osteomyelitis include those who
are poorly nourished, elderly, or obese, those with impaired
immune system, those with diabetes, rheumatoid arthritis, and
those receiving long-term corticosteroid therapy. 5
5
OSTEOMYELITIS

o
1
 OSTEOMYELITIS
 PATHOPHYSIOLOGY
• Staphylococcus aureus causes 70% to 80% of bone infections.
Other pathogens found in osteomyelitis include Proteus,
Pseudomonas species, Escherichia coli., and penicillin-
resistant, nosocomial, gram-negative infections.
• The initial response to infection is inflammation, increased
vascularity, and edema. After 2 or 3 days, thrombosis of
the blood vessels occurs in the area, resulting in
ischemia with bone necrosis. Unless the infective
process is atreated
promptly, bone abscess forms. 5
7
OSTEOMYELITIS

o8
 OSTEOMYELITIS

 Clinical manifestation:-
1-Chill & Fever
2-Malaise
3-Bone pain
4-Edema & redness
5-Painful
6-Warm area
7-Muscle spasm
8-Swelling
9-Extremity tender
10-Pulsation pain 5
9

11-Increased pain
 OSTEOMYELITIS
 ASSESSMENT AND DIAGNOSTIC FINDINGS
•Diagnostic Evaluation:
1. Increase in WBCs.
2. Increase in ESR.
3. Positive blood culture.
4. Radiograph and bone scan
6
0
 OSTEOMYELITIS
 MEDICAL MANAGEMENT
• Medical Management aims to control and halt the infective
process, through IV antibiotic therapy (penicillin or
cephalosporin) for 3 – 6 weeks based on the results of blood
and wound cultures. After achieving infection control, the
antibiotic may be administered orally for up to 3 months.
• General supportive measures (eg, hydration, diet high in vitamins
and protein, correction of anemia) should be instituted.
• The area affected with osteomyelitis is immobilized to decrease
discomfort and to prevent pathologic fracture of the weakened
bone. Warm wet soaks for 20 minutes several times a day may be
6
prescribed to increase circulation. 1
 OSTEOMYELITIS
 NURSING MANAGEMENT

• Assessment. Physical examination reveals an inflamed,

markedly swollen, warm area that is tender. Purulent drainage
may be noted. The patient has fever. With chronic
osteomyelitis, the temperature elevation may be minimal,
occurring in the afternoon or evening.
• Nursing diagnoses.
• Acute pain related to inflammation and swelling
• Impaired physical mobility related to pain, use of
immobilization devices, and weight-bearing limitations.
• Risk for extension of infection: bone abscess formation
• Deficient knowledge related to the treatment regimen 6
2
 OSTEOMYELITIS
 NURSING MANAGEMENT
• Nursing Interventions.
• Relief of pain.
• Immobilize the affected part with a splint to decrease pain.
• Monitor the neurovascular status of the affected extremity.
• Elevate the affected part to reduce swelling and associated discomfort.
• Administer analgesics as prescribed.
• Improving physical mobility.
• The bone is weakened by the infective process and must be protected
by immobilization devices and by avoidance of stress on the bone.
• Gently place the joints above and below the affected part through their
range of motion. Encourage full participation in ADLs to
promote
general well-being. 6
3
 OSTEOMYELITIS

 NURSING MANAGEMENT

• Nursing Interventions
• Control and eradication of infection.
• Monitor the patient’s response to antibiotic therapy.
• Observe the IV access site for evidence of phlebitis,
infection, or infiltration.
• With long-term, intensive antibiotic therapy, monitor the
patient for signs of superinfection (eg, oral or vaginal
candidiasis, loose or foul-smelling
stools).
• Monitor the general health and nutrition of the patient. A
diet high in protein and vitamin C promotes healing.64
• Encourage adequate hydration.