Gout

WHAT WENT WRONG?
This is a metabolic disorder in which the body does not properly metabolize
purine-based proteins. As a result, there is an increase in the amount of uric acid,
which is the end product of purine metabolism. As a result of hyperuricemia,
uric acid crystals accumulate in joints, most commonly the big toe (podagra),
causing pain when the joint moves. Uric acid is cleared from the body through
the kidneys. These patients may also develop kidney stones as the uric acid crys-
tallizes in the kidney.
A person may also develop secondary gout. This is due to another disease pro-
cess or use of medication, such as thiazide diuretics or some chemotherapeutic
agents.

PROGNOSIS
Gout is typically a chronic disorder. Patients need to understand the disease and its
treatment so that medications can be initiated at the earliest point during a painful
flare. Repeated flares in the same joint will ultimately cause joint damage. Chronic
elevation of serum uric acid is associated with progression of atherosclerosis.

SIGNS AND SYMPTOMS

• Acute onset of excruciating pain in joint due to accumulation of uric acid
within the joint
• Redness due to inflammation around the joint
• Nephrolithiasis (kidney stones) due to uric acid deposits in the kidney

TEST RESULTS

• Elevated erythrocyte sedimentation rate (ESR).
• Elevated serum uric acid level—not seen in all patients with gout. Typical of
primary gout patients prior to episode of acute joint pain.
• Elevated urinary uric acid levels.
• Arthrocentesis shows uric acid crystals within the joint fluid.

TREATMENT
Acute treatment is managed with colchicine and nonsteroidal anti-inflammatory
medications. These medications are continued until the pain is controlled. Chronic
gout is treated with allopurinol or an 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.

• Administer colchicine during an acute episode to decrease the inflammatory
response resulting from uric acid deposits. This will help reduce pain.
• Administer NSAID to decrease inflammation to aid in pain relief
• indomethacin, ibuprofen, naproxen
• Not aspirin; regular dosing causes retention of uric acid.
• Administer xanthine oxidase inhibitor medication to reduce total body uric
acid. Given as long-term treatment to patients with recurrent episodes of gout:
• allopurinol
• 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
• Low-fat, low-cholesterol diet—elevated uric acid levels accelerate athero-
sclerosis.
• Immobilize the joint for comfort.


NURSING DIAGNOSES
• Impaired mobility
• Acute pain
NURSING INTERVENTION
• Have the patient drink 3 liters of fluid per day to avoid crystallization of uric
acid in the kidneys. Increased fluids help flush the uric acid through the
kidneys.
• Monitor uric acid levels in serum.
• Assist with positioning for comfort.
• Avoid touching inflamed joint unnecessarily. May need to keep clothing or
bed linen away from area.
• Explain to patient:
• Which foods are high-purine proteins—turkey, organ meats, sardines,
smelts, mackerel, anchovies, herring, bacon.
• Avoid alcohol, which inhibits renal excretion of uric acid.