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XIV. Introduction
According to www.patient.co.uk, research using the UK primary care database
reported the incidence of gout per 1,000 person-years to be 2.68 (4.42 in men and 1.32
in women) for the years 2000-2007. The prevalence increased with age. Asian
populations and people of the Pacific Islands have a much higher prevalence and more
severe disease. The male to female ratio is 9:1. The prevalence increases in women
after the menopause although this is partly reduced by hormone replacement therapy.
Factors such as the introduction of fructose-high corn sweetener and the rise in obesity
have led to a dramatic increase in the incidence of gout in developed countries such as
America.
Gout is a type of arthritis. It occurs when uric acid builds up in blood and causes
inflammation in the joints. Gout is caused by having higher-than-normal levels of uric
acid in your body. This may occur if: your body makes too much uric acid or your body
has a hard time getting rid of uric acid. If too much uric acid builds up in the fluid
around the joints (synovial fluid), uric acid crystals form. These crystals cause the joint
to swell and become inflamed.
The characteristic symptoms and signs of gout are the sudden onset of pain,
swelling, heat, and redness. This usually affects a single joint. The pain is typically
severe, reflecting the severity of inflammation in the joint. The affected joint is often
exquisitely sensitive to touch to the point that some patients experience pain from
something as simple as pulling the bed sheets over the affected area at night. Another
sign of gout is the presence of tophi. A tophus is a hard nodule of uric acid that
deposits under the skin.
When gout is mild, infrequent, and uncomplicated, it can be treated with diet and
lifestyle changes. When attacks are frequent, uric acid kidney stones are present, the
uric acid level is very high, tophi are present, or there is evidence of joint damage from
gout, medications are necessary to treat gout. Medications for the treatment of gout
generally fall into one of three categories: uric-acid-lowering medications (e.g.
allopurinol (Zyloprim, Aloprim)), prophylactic medications (medications used in
conjunction with uric-acid-lowering medications to decrease the risk for a gout flare
during the first six months of treatment, such as NSAIDs), and rescue medications to
provide immediate relief from gout pain (colchicine (Colcrys), NSAIDs and steroid
medications).

2. 2
XV. Anatomy and Physiology
THE SKELETAL SYSTEM
This section presents the skeletal system as presented by Elaine N. Marieb.
Essentials of Human Anatomy and Physiology (Ninth Edition).
The skeletal system provides an internal framework for the body, protects organs
by enclosure, and anchors skeletal muscles so that muscle contraction can cause
movement.
The skeleton is subdivided into two divisions: the axial skeleton, the bones that
form the longitudinal axis of the body, and the appendicular skeleton, the bones of
the limbs and girdles. In addition to bones, the skeletal system includes joints,
cartilages, and ligaments (fibrous cords that bind the bones together at joints). The
joints give the body flexibility and allow movement to occur.
The Axial Skeleton
The axial skeleton (trunk) is made up of the 80 bones in our upper body.
Bones of the axial skeleton include:
 Skull (facial and cranial bones)
 Hyoid
 Vertebrae in the spine (backbones)
 Ribs
 Sternum (breastbone)
 Our arms and shoulders hang from the axial skeleton.
The Appendicular Skeleton
There are 126 bones in the arms, shoulders, hips, and legs. The
appendicular skeleton is made up of our limbs or appendages—two arms and
two legs—our pelvis and right and left shoulders. Our arms hang from our
shoulders and legs attached to our hips.
Bones of the Upper Appendage (Arm)
 Shoulder girdle—scapula (shoulder blade), clavicle (collar bone)
 Humerus—long bone of the upper arm
 Radius—long bone of the forearm; connects with the humerus to
form the elbow
 Ulna—long bone of the forearm; connects with the humerus to
form the elbow
 Carpals—8 small bones of the wrist
 Metacarpals—small bones of the hand
 Phalanges—14 bones of the fingers (3 in each finger) and thumb (2
in the thumb)
Bones of the Lower Appendage (Leg)
 Pelvic Girdle—made up of the right and left hip bones which are
joined in the back with the sacrum and in the front at the
symphysis pubis
 Hipbone—made of the ilium, pubis and ischium
 Femur—long bone of the thigh and longest bone in the body;
connects with pelvis to form and hip joint and the tibia and fibula to
form the knee joint
 Tibia—long bone of the lower leg (shin bone); connects with the
femur to form the knee
 Fibula—thinner, long bone of the lower leg
 Patella—kneecap (Learn more about knee anatomy)
 Tarsals—small bones of the hand

3. 3
 Metatarsals—ankle
 Phalanges—bones of the toes (3 in each toe and 2 in the big toe)
The Joints
Joints, also called articulations, have two functions: they hold the
bones together securely but also give the rigid skeleton mobility.
Joints are classified into two ways – functionally and structurally. The
functional classification focuses on the amount of movement the joint allows. On
this basis, there are synarthroses, or immovable joints; amphiarthroses, or
slightly movable joints; and diarthroses, or freely movable joints. Freely
movable joints predominate in the limbs, where mobility is important. Immovable
and slightly movable joints are restricted mainly to the axial skeleton, where firm
attachments and protection of internal organs are priorities.
Structurally, there are fibrous, cartilaginous, and synovial joints.
 Fibrous: the articular surfaces (point on the bone’s surface where the
two bones meet) are held together by fibrous connective tissue. Very little
movement is possible. Examples of fibrous joints are sutures,
syndesmoses, and gomphoses.
 Cartilaginous (amphiarthroses): the bones in cartilaginous joints are
held together by cartilage which allows slight movement.
o Synchondroses-these are temporary joints where the cartilage
converts to bone by the time we are adults. The growth plates of
long bones are examples of this type of joint.
o Symphyses-these joints have a pad of fibrocartilage separating the
bones; an example is the symphysis pubis
 Synovial-the bony surfaces on the ends of the bones are covered with
articular cartilage and separated by a slippery, lubricating fluid called
synovia. They bones are held together in the joint by ligaments lined with
synovial membranes which produce the synovial fluid. These freely
moving joints are mostly found in our arms and legs. Synovial joints also
include:
o A joint cavity or joint space: space between the articulating
surfaces; articulating surfaces are the bone surfaces that move
against each other when the joint moves. The articulating surfaces
are covered with a layer of hyaline cartilage that cushions and
protects the bones. The synovial membrane defines the boundaries
of the joint space—everything outside of the synovial membrane is
outside the joint space. The synovial membrane is wrapped by
layers of connective tissue that form the joint capsule.
o An articular capsule: a sac-like structure that surrounds the joint
and has an outer layer lined with a synovial membrane (synovium)
that makes the synovial fluid. Synovial fluid acts as a lubricant,
forms a fluid seal and helps distribute the force placed on the joint.
o Reinforcing ligaments: tough, fibrous connective tissues that
connect the bones and reinforce the joint capsule. On the outside
of the joint capsule are thick strap-like bands, called collateral
ligaments. These ligaments direct the force that travels through the
joint and keep the joint on track. Outside of these structures are
the muscles that travel across the joint.
XVI. TEXTBOOK DISCUSSION
Definition
Gout can be defined as arthritis due to deposition of monosodium urate (MSU)
monohydrate crystals within joints causing acute inflammation and eventual tissue

4. 4
damage. It has been aptly described as, "... one of the most painful acute conditions
that human beings can experience ...".
Classification
The condition can be classified into primary or secondary gout depending on the
cause of hyperuricaemia:
 Primary gout occurs mainly in men aged 30-60 years presenting with acute
attacks.
 Normally, secondary gout is due to chronic diuretic therapy. It occurs in older
subjects, both men and women, and is often associated with osteoarthritis.
Causes
Gout is caused by the accumulation in the joint of crystals of a byproduct
chemical of metabolism known as uric acid. When uric acid crystals accumulate, it
causes inflammation in a joint. Joint inflammation causes pain, redness, heat, and
swelling of the joint.
Normal sUA levels in men (≤ 7 mg/dl) and women (≤ 6 mg/dl) are already close
to the limits of urate solubility (6.8 mg/dl at 37°C). An elevated uric acid level in the
bloodstream leads to uric acid accumulation in the tissues of a joint. Uric acid is
normally found in the body and is a normal byproduct of the way the body breaks down
certain proteins called purines. Causes of an elevated uric acid level (hyperuricemia) in
the bloodstream include genetics, obesity, certain medications such as diuretics (water
pills), and chronic decreased kidney function.
Risk factors
 Male sex
 Age (Middle-aged and elderly)
 Meat
 Seafood
 Alcohol (10 or more grams per day)
 Diuretics
 Obesity
 Hypertension
 Coronary heart disease
 Diabetes mellitus
 Chronic renal failure
 High triglycerides
 Purine-rich foods (Meat and fish purines)
Other factors since identified include chemotherapeutic drugs, psoriasis
and heart failure. The presence of previous joint morbidity and trauma may influence
which joint is affected.
Symptoms of Gout
All patients with gout should be aware of gout symptoms. These include:
 Severe pain
 Acute inflammation
 High Fever
 Presence of tophi
 The affected joint is sensitive to touch
 Fatigue

5. 5
Laboratory and Diagnostic Tests
 Clinical Chemistry
o Uric Acid
o Creatinine
o Potassium
o Sodium
 Hematology
 Gram Stain
 Bacteriology Report
 Urinalysis
Treatments
 Nursing Management:
 Dress wound with betadine and OS to prevent further infection and
facilitate healing.
 Drug administration to cure gout by reducing uric acid synthesis and to
reduce blood pressure.
 Vital signs taking and recording in order to monitor for any signs of
inflammatory process and hypertension.
 Positioning of lower extremities in order to relieve pressure and to
improve circulation in the left foot.
 Medical Management:
 Cardiac glycosides
 Antigout drug to reduce uric acid synthesis
 Antihypertensive to reduce blood pressure
From the
Textbook
Manifested by the
Patient
Rationale
Severe pain  Caused by proteins called
interleukins, which are produced by
the body to fight off infection
Acute
inflammation

High Fever Indicates an inflammatory process
Tophi 
Sensitive to
touch

Fatigue

6. 6
XVII. PATHOPHYSIOLOGY
Predisposing Factors:
*Age: 68 years old
*Sex: Male
*Hypertension
*Heart Problem
Precipitating Factors:
*Meat (High Purine)
*Alcohol Drinker (since
38 years old)
Overproduction/
underexcretion of
uric acid
Hyperuricemia
Crystal Formation
Microcrystal Release
Inflammatory Cascade Heat
Redness
Pain
Swelling
Loss of
Function
Tophi
Gout Flare
Fever

7. 7
XVIII. VITAL INFORMATION
ADMITTED: DATE: February 21, 2014
TIME: 2:08 PM
NAME Mr. L. L. L. S.
AGE 68 years old
NATIONALITY Filipino
STATUS Married
RELIGION Roman Catholic
PLACE OF BIRTH Burias, Mambusao, Capiz
PROVINCIAL ADDRESS Burias, Mambusao, Capiz
DATE OF BIRTH August 24, 1946
OCCUPATION Farmer
SPOUSE Mrs. E. L.
RM./WARD MSW
CHIEF COMPLAINT Non-healing Wound Left Foot
ADMITTING DIAGNOSIS Infected Non-Healing Wound
Left Foot
FINAL DIAGNOSIS
ATTENDING PHYSICIAN Dr. C. R.
XIX. ASSESSMENT
Clinical Assessment
PAST MEDICAL HISTORY

8. 8
Patient L. has developed a particular heart problem (the term was unknown to
him) when he was 52 years old which caused him his first hospitalization. After 3 years,
he developed the gouty arthritis in which, according to him, also caused him to go-
back-and-forth the hospital (SACH) two times. During his admissions, his doctors gave
him medications like Arcoxia, Danilon, Voltaren and a lot more.
Patient L. was an alcohol drinker since he was 38 years old but according to him,
he already stopped 4 years ago since he’s already aware that this could worsen his
condition.
HISTORY OF PRESENT ILLNESS
Four days prior to admission (February 21, 3014), Patient L. was brought to
Mambusao District Hospital and was advised to self-drain and dress the wound at
home. Three days after, the wound did not heal so Pt. L decided to seek medical
consultation at St. Anthony College Hospital. The physical findings revealed nonhealing
wound at the 2nd digit of left foot.
Vital Signs Monitoring
DAY 1 – FEBRUARY 23, 2014
8 AM 12 PM
T = 36.6 ˚ C T = 36.2 ˚ C
CR = 75 bpm CR = 70 bpm
PR = 73 bpm PR: 68 bpm
RR = 16 RR = 15
S/U = 1/3 S/U: 0/0
XX. LABORATORY AND DIAGNOSTIC DATA
CLINICAL CHEMISTRY
Test Name Result Normal Values Rationale
Uric Acid
(Feb. 22, 2014) 502.8 umol/L (H) 155.0 – 428.0
Indicates
overproduction of
uric acid
Creatinine
(Feb. 23, 2014) 105.5 umol/L 53.0 – 115.0
Potassium
(Feb. 22, 2014) 3.9 mmol/L 3.5-5.1
Sodium
(Feb. 22, 2014) 133 mmol/L (L) 136-145
HEMATOLOGY
(Feb. 21, 2014)
*CBC
Hematocrit
Hemoglobin
RBC Count
WBC Count
*Differential Count
Segmenters
Basophils
Eosinophils
Lymphocytes
0.32 vol (fr) (L)
109 gms/L (L)
3.5 x 10̂12/L (L)
10.5 x 10̂9/L
69 % (H)
0 %
8 % (H)
16 % (L)
0.42 - 0.52
135 – 180
4.7 – 6.0
4.0 – 10.5
50 – 65
0 – 1
1 – 4
25 -30
*Indicates bleeding
*Indicates infection
*Indicates infection
*Indicates infection

9. 9
Monocytes
*Indices
MCV
MCH
MCHC
Platelet: Adequate
7 % (H)
92 fL
31 pg
34 g/dL
2 -5
78 – 100
27 – 31
32 - 36
*Indicates severe
infection
CLINICAL MICROSCOPY (Urinalysis)
(Feb. 23, 2014)
Macroscopic
Color
Transparency
Reaction
Specific Gravity
Protein
Glucose
Microscopic
Amorphous
Urates
RBC
WBC
Epithelial Cells
Bacteria
Pstraw
Shazy
6.0 pH
1.005
(-)
(-)
Occasional
0-2 /hpf
0-2 /hpf
Occasional
Occasional
BLOOD TYPING
(Feb. 21, 2014)
Blood Type “O”
Rh Pos (+)
MICROBIOLOGY
(Feb. 22, 2014)
Wound Gram Stain > Squamous Epithelial Cells – Occasional
>Organism Seen / OIF – Occasional (+)
cocci in singles; occasional gram (-) bacilli
in singles and pairs
BACTERIOLOGY REPORT
(Feb. 23, 2014)
Nature of Specimen:
Organism Identified:
Sensitive to:
Resistant to:
Wound
Final Report: Pseudomonas Aeruginosa
-piperacillin/tazobactam
-ceftazidime
-cefepime
-imipenem
-meropenem
-amikacin
-gentamicin
-ciprofloxacin
-ampicillin
-amoxicillin/clavulanic acid
-cefuroxime
-cefuroxime axetil
-cefoxitin
-coustin
-trimethoprim
-sulfonamides

10. 10

11. 11
XXI. DRUG STUDY
Name of
Drug
Dosage,
Route and
Frequency
Classification
of Drug
Action Mechanism of
Action
Indications Side Effects Contraindications Nursing
Responsibilities
Lanoxin 0.25 mg/tab
½ tab OD
*Functional
Class: Inotropic
antidysrhythmi
c, cardiac
glycoside
*Chemical
Class: Digitalis
preparation
Antidysrhyt
hmic
Inhibits sodium-
potassium
ATPase, which
makes more
calcium available
for contractile
proteins,
resulting in
increased cardiac
output
1. Rapid
digitalization in
CHF,
2. Atrial
fibrillation,
3. Atrial flutter,
4. Atrial
tachycardia;
5. Cardiogenic
shock,
6. Paroxysmal
atrial tachycardia
*CNS:
drowsiness,
apathy,
confusion,
disorientation,
fatigue,
depression,
hallucinations
*GI: nausea,
vomiting,
anorexia,
abdominal pain,
diarrhea
*CV:
Dysrhythmias,
hypotension,
bradycardia, AV
block
*EENT: Blurred
vision, yellow-
green halos,
photophobia,
diplopia
*Hypersensitivity to
digitalis
*Ventricular
fibrillation
*Ventricular
Tachycardia
*Carotid Sinus
Syndrome
*2nd- or 3rd- degree
heart block
1. Assess and
document apical pulse
for 1min before giving
drug; if pulse <60 in
adult or is significantly
different, take again in
1hr; if <60 in adult,
call prescriber; note
rate, rhythm,
character.
2. Do not give at same
time as antacids or
other drugs that
decrease absorption.
3. Instruct patient to
notify prescriber of any
loss of appetite, lower
stomach pain,
diarrhea, weakness,
drowsiness, headache,
blurred or yellow-green
vision, rash,
depression; teach toxic
symptoms of this drug

12. 12
and when to notify
prescriber.
4. Advise patient to
maintain a sodium-
restricted diet as
ordered; to take
potassium
supplements as
ordered to prevent
toxicity.
Name of
Drug
Dosage,
Route and
Frequency
Classification
of Drug
Action Mechanism of
Action
Indications Side Effects Contraindications Nursing
Responsibilities
Allopurinol 300 mg 1
cap OD
*Functional
Class: Antigout
drug
*Chemical
Class: Xanthine
enzyme
inhibitor
Antigout Inhibits the
enzyme xanthine
oxidase,
reducing uric
acid synthesis.
1. Chronic gout,
2. Hyperuricemia
associated with
malignancies,
3. Recurrent
Calcium oxalate
calculi,
4. Chaga’s
disease,
5. Cutaneous/
visceral
leishmaniasis
*CNS: headache,
drowsiness,
neuritis,
paresthesia
*GI: nausea,
vomiting,
anorexia, malaise
*EENT:
Retinopathy,
cataracts,
epistaxis
*Hypersensitivity 1. Assess for pain
including location,
characteristics, onset/
duration, frequency,
quality, intensity or
severity of pain,
precipitating factors.
2. Monitor uric acid
levels q2wk; normal
uric acid levels are 6
mg/dL or less; check
I&O ratio; increase
fluids to 2L/day to

13. 13
*HEMA:
Agranulocytes,
thrombocytopenia
, aplastic anemia,
pancytopenia,
leucopenia, bone
marrow
suppression,
eosinophilia
*INTEG: Fever,
chills, dermatitis,
pruritis, purpura,
erythema,
ecchymosis,
alopecia
prevent stone
formation, toxicity.
3. Monitor nutritional
status: discourage
organ meat, sardines,
salmon, legumes,
gravies (high-purine
foods), alcohol.
Name of
Drug
Dosage,
Route and
Frequency
Classification
of Drug
Action Mechanism of
Action
Indications Side Effects Contraindications Nursing
Responsibilities
Vasalat 5 mg 1 tab
OD
*Functional
Class:
Antianginal,
calcium
channel
blocker,
antihypertensiv
e
*Chemical
Antianginal
and
antihyperte
nsive
Inhibits calcium
ion influx across
cell membrane
during cardiac
depolarization;
produces
relaxation of
coronary
vascular smooth
1. Chronic stable
angina,
2. Hypertension,
3. Vasospastic
angina
*CNS: headache,
fatigue, dizziness,
anxiety,
depression,
insomnia,
paresthesia,
somnolence,
asthenia
*Sick sinus
syndrome
*2nd- or 3rd- degree
heart block
*Hypotension less
than 90 mmHg
systolic
*Hypersensitivity
1. Monitor B/P and
pulse; if B/P drops, call
prescriber.
2. Monitor cardiac
status: B/P, pulse,
respirations, ECG
3. Advise patient to

14. 14
Class:
Dihypyridine
muscle,
peripheral
vascular smooth
muscle dilates
coronary
vascular arteries;
increases
myocardial
oxygen delivery
in patients with
vasospastic
angina.
*GI: nausea,
vomiting,
diarrhea, gastric
upset,
constipation,
abdominal
cramps,
flatulence,
anorexia
*INTEG: Rash,
pruritus, urticaria,
hairloss
*GU: Nocturia,
polyuria
avoid hazardous
activities until
stabilized on drug,
dizziness is no longer a
problem.
4. Teach patient to use
as directed even if
feeling better; may be
taken with other
cardiovascular drugs
(nitrated, B-blockers).

15. 15
XXII. Nursing Care Plan
Assessment Diagnosis Planning Interventions Evaluation
Subjective Data:
“Nagbuswang akon bukol sa
tiil.”
Pain Scale = 5
Objective Data:
* Ulcer is notedat the 2nd
digital of the left foot
*Swelling is noted
*Presence of redness
Impaired Skin Integrity
related to nonhealing
wound
After the nursing
intervention, the
patient will be able to
display timely healing
of wound and ability
to manage situation.
1. Monitor vital signs especially
temperature to observefor any changes
in the patient’s status.
2. Administer antigout medication per
physician orders: Allopurinol300 mg 1
capsule once a day in order to treat the
root of present condition.
3. Keep the area clean and dry, carefully
dress wounds, preventinfection to
assistbody’s naturalprocess of repair.
4. Elevate patient’s left foot to prevent
pressureand facilitate circulation and
the normalprocess of repair.
5. Encourage early ambulation or
mobilization. Promotes circulation and
reduces risks associated with mobility.
6. Keep the patient rested and
comfortable.
GOAL PARTIALLY MET.
The patient can manage
his situation as evidence
by frequent ambulation
and fewer complaints
about pain.
Pain Scale= 3

16. 16

17. 17
XXIII. Dischare Planning
 Medications:
 Lanoxin 0.25 mg/tab ½ tab OD (8 am)
 Allopurinol 300 mg 1 cap OD
 Vasalat 5 mg 1 tab OD (12 NN)
 Exercise:
 Encourage the patient to exercise regularly, as well as to perform daily
activities that could help in the development of the patient’s fitness.
 After discharge, the patient can already perform activities that is tolerable
to him.
 Treatment:
 Encourage the patient to comply with the medications prescribed by his
attending physician in order to aid in his complete recovery.
 Explain to the patient, as well as to the folks, the significance of adhering
to the medications prescribed.
 Health Education:
 Instruct the patient to refrain from doing activities that can cause so much
fatigue such as heavy work.
 More importantly, advise patient to never go back on alcohol drinking
because it is one of the risk factors of gout.
 Out-Patient Follow-up
 Diet
 Encourage the patient to avoid from eating high purine foods such as
meat and fish. Vegetable rich in purine is acceptable.
 The patient was advised to have a low salt, low fat diet.
 Spirituality
 The family was encouraged to continue attending masses every Sunday
and participating in the Church’s celebrations.
 The family, especially the patient, was advised to pray together regularly
in order to strengthen their faith to God.

18. 18
XXIV. NURSING CARE PLAN
XXV. DISCHARGE PLANNING