Gout gives pain, just like you.

GOUT

DO YOU KNOW WHAT IS GOUT ?

An autoimmune disorder and a form of arthritis, joint inflammation which affect many joints in human body.

Joint that commonly involved is the first metatarsophalangeal joint (big toe) and called podogra.

WHY I POSSIBILY CAN SUFFERING GOUT ?

1. Diet

• Increase consumption of purine, examples: shellfish,red meat,organ meat 
• Drinking sweetened beverages with fruit sugar(fructose) that can increase level of uric acid
• Excessive consumption of alcohol drink
• Dehydrated

2. Obesity

• If you are overweight, body will produces more uric acid and kidney will have more difficulty eliminating uric acid

3. Medical condition

• There are certain diseases that can increase the risk of gout. For example, untreated high blood pressure, diabetes, kidney disease and the others.

4. Medication (Diuretics. Eg: Thiazide, aspirin)

• Diuretics increase urination, which reduces the amount of fluid in body. The remaining fluid is more concentrated, which can increase the risk of developing the crystals that cause gout. 

5. Family history of gout

• If you have any family members who had gout, it increased the risk of you to develop gout.

WHAT IS THE PATHOPHYSIOLOGY ?

HOW DO I KNOW THAT I POSSIBLY HAS GOUT ?

 Sudden onset of severe pain

• The pain is likely to be most severe within the first four to 12 hours after it begins .
• Usually attack joint at the big toe (first metatarsophalangeal joint)

Lingering discomfort

• After the most severe pain subsides, some joint discomfort may last from a few days to a few weeks.

Affected joint become swollen, redness and warmth 

• It is due to inflammatory response.

Hyperuricemia 

• serum urate concentration > 6.8mg/dl

More than one attack of acute arthritis 

• Which means more of joint inflammation, gout flare.

Limited range of motion 

• May not able to move joint as normally due to stiffness of joint and because of the pain.

WHAT ARE THE TESTS REQUIRED ?

Joint fluid test. 

Doctor may use a needle to draw fluid from your affected joint. 

Urate crystals may be visible when the fluid is examined under a microscope.

Blood test.

A blood test to measure the levels of uric acid and creatinine in your blood.

Some people have high uric acid levels, but never experience gout. 

And some people have signs and symptoms of gout, but don't have unusual levels of uric acid in their blood.

• X-ray imaging. 
• Joint X-rays can be helpful to rule out other causes of joint inflammation.

Ultrasound.

Musculoskeletal ultrasound can detect urate crystals in a joint or in a tophus. This  technique is more widely used in Europe than in the United States.

 

Dual energy CT scan. 

This type of imaging can detect the presence of urate crystals in a joint, even when it is not acutely inflamed. 

This test is not used routinely in clinical practice due to the expense and is not widely available.

IS THERE ANY MEDICAL TREATMENT?

• Treatment for gout usually involve medication. Medication given to the patient is based on patient current health status.

•  Gout medications can be used to treat acute attacks and prevent future attacks. Medications can also reduce your risk of complications from gout, such as the development of tophi from urate crystal deposits.

WHAT ARE THE MEDICATIONS ?

There are two types of medicines used in gout which is medicines for gout attack and medicines to prevent gout attacks and gout complications.

1. Medicines to treat gout attacks

a)        Nonsteroidal anti-inflammatory drugs (NSAIDs)

• Example; ibuprofen (Advil, Motrin IB) , naproxen sodium (Aleve), indomethacin (Indocin) or celecoxib (Celebrex)

Your doctor may prescribe a higher dose to stop an acute attack, followed by a lower daily dose to prevent future attacks. NSAIDs carry risks of stomach pain, bleeding and ulcers.

b)       Colchicine

• Example; Colcrys, Mitigare

A type of pain reliever that effectively reduces gout pain. Side effects such as nausea, vomiting and diarrhea can happen especially if taken in large doses.

c)        Corticosteroids

• Example; drug prednisone

This medication can control gout inflammation and pain. Corticosteroids are used only in people with gout who can not take either NSAIDs or colchicine. 

The side effects of corticosteroids may include mood changes, increased blood sugar levels and elevated blood pressure.

2. Medicines to prevent gout attacks and gout complications.

a)        Xanthine oxidase inhibitors (XOIs)

• Example; such as allopurinol (Aloprim, Lopurin, Zyloprim) and febuxostat (Uloric)

Medications that block uric acid production by limiting the amount of uric acid produced. 

Side effects of allopurinol include a rash and low blood counts. 

The side effects of Febuxostat include rash, nausea, reduced liver function and an increased risk of heart-related death.

b)       Uricosurics

• Example; probenecid (Probalan) and lesinurad (Zurampic).

Uricosuric is a medication that improves the uric acid removal. 

Uricosuric drugs improve the kidney’s ability to remove uric acid from the body by lowering the uric acid levels and reduce the risk of gout, but the level of uric acid in your urine is increased. 

Side effects include a rash, stomach pain and kidney stones. Lesinurad can be taken only along with an XOI.

ARE THERE ANY SURGICAL INTERVENTION?

1. Tophi Removal Surgery

The procedure done by making incision over the tophi to remove the tophi.

2. Joint Fusion Surgery (also called Arthrodesis)

This procedure fuses together the two bones that make up the aching joint.

It causes the bones to become one solid bone, make the joint more stable and help to bear more weight on it.

3. Joint Replacement Surgery

This surgery is done by removing the damaged or diseased parts of a joint and replaces them with new, man-made parts. 



CAN I HAVE A NURSING CARE PLAN FOR GOUT PATIENT THAT IN PAIN ?


Diagnosis

• Acute pain related to inflammation of joint and muscle spasm as evidence by patient verbalization and pain score is 4/10.

Goal

• Patient will verbalize reduce in pain and state that the pain score is 1/10.

Interventions

• Assess the severity of pain by asking the score of pain from 0 to 10 and assess patient facial expression. This is for proper management of the pain.

• Encourage adequate fluid intake to promote uric acid excretion in urine
  

• Encourage frequent changes of position. This is to prevent joint stiffness.
  


• Apply warm compress to the affected area. Warm compress promotes relaxation of muscle and reduces pain.

• Administer medication, like colchicine. This is to relieve pain. Colchicine can be given for acute pain specific to gout attack.

• Educate the patient to practice the non-pharmacological techniques to help decrease pain during gout attacks.

Evaluations 

• Patient verbalized the pain is reduced and stated the pain score is 1/10.

WHAT SHOULD NURSE EDUCATE PATIENT THAT SUFFERING GOUT ?

1 Dietary changes

• Reduce intake of food that contain high uric acid or purine. For example, spinach, cauliflower, seafood, and avoid alcoholic beverages. 
  

IS THERE ANY COMPLICATION THAT CAN ARISE AFTER ?

  

    Recurrent gout

(if left untreated, gout may cause destruction and erosion of the joint affected)

Advanced gout

(untreated acute gout causing deposition of urate crystals formed under skin nodules called Tophi which it can develop in several areas such as elbows, feet, hand, fingers, Achilles tendons along back of ankle – Tophi swollen and tender during gout attacks)

 Kidney stones

(elevated level of uric acid in blood causing formation of urate crystals in urinary tract of person with gout)