A 57-year-old male patient with gout and chronic kidney disease has demonstrated persistent hyperuricemia and increased pain despite his current treatment. Considering his diagnosis and lab results, which nursing intervention is most appropriate to prioritize in the management of his condition?

C) Educate the patient about the potential need to discontinue hydrochlorothiazide to reduce uric acid levels.

A) Encourage the patient to increase fluid intake to improve kidney function and help excrete uric acid.

B) Administer an increased dose of nonsteroidal anti-inflammatory drugs (NSAIDs) to manage acute pain and inflammation.

C) Educate the patient about the potential need to discontinue hydrochlorothiazide to reduce uric acid levels.

D) Advise the patient to engage in weight-bearing exercises to improve joint mobility and function.

A patient with a history of hypertension and gout is experiencing severe pain and swelling in the right foot, with potential infection around a tophus. Which of the following nursing interventions is most appropriate to prioritize at this time?

D) Contact the healthcare provider to report the potential secondary infection for further evaluation.

A) Administer prescribed antibiotics to address the potential infection.

B) Elevate the affected foot to reduce swelling and encourage venous return.

C) Apply warm compresses to the affected area to alleviate pain and improve circulation.

D) Contact the healthcare provider to report the potential secondary infection for further evaluation.

A patient with a history of hypertension and hyperuricemia is being treated for acute gout with colchicine and an increased dose of allopurinol. The healthcare team is concerned about a potential secondary infection near a tophus. Which nursing intervention is the most appropriate to address this concern?

C) Cleanse the area with antiseptic solution and monitor for signs of infection.

A) Apply a warm compress to the affected area to promote circulation.

B) Administer an additional dose of colchicine to reduce inflammation.

C) Cleanse the area with antiseptic solution and monitor for signs of infection.

D) Increase the patient's fluid intake to facilitate renal clearance of uric acid.

A patient with a history of gout and hypertension presents with an infected tophus. Considering the elevated white blood cell count and erythrocyte sedimentation rate, which action should the nurse prioritize after initiating empirical antibiotic therapy?

A) Monitor the patient's blood pressure closely to avoid complications related to hypertension.

B) Educate the patient on the importance of increasing fluid intake to help reduce uric acid levels.

C) Assess the patient's pain level and consider advocating for a corticosteroid to manage inflammation.

D) Schedule regular follow-up appointments to monitor the patient's uric acid levels and adjust gout medication.

A patient with an elevated white blood cell count and ESR is suspected of having a secondary infection at the site of a tophus. Empirical antibiotic therapy has been initiated. Which nursing intervention is most important to implement first to ensure the effectiveness of the antibiotic therapy?

B) Obtain a culture and sensitivity test from the aspirate of the tophus.

A) Administer the prescribed antibiotic and monitor for allergic reactions.

B) Obtain a culture and sensitivity test from the aspirate of the tophus.

C) Assess the patient's pain level and provide analgesics as needed.

D) Educate the patient about the importance of completing the entire course of antibiotics.

A patient diagnosed with a MRSA infection is receiving vancomycin. Which nursing action is most important to ensure the efficacy and safety of this medication?

C) Assess the patient's vancomycin trough levels periodically.

A) Monitor the patient's blood pressure regularly.

B) Check the patient's blood glucose levels daily.

C) Assess the patient's vancomycin trough levels periodically.

D) Encourage increased fluid intake to prevent dehydration.

A patient with an MRSA infection in a joint presents with increased fever, pain, and swelling. The infection is not responding to the initial antibiotic therapy. What is the most appropriate nursing intervention to prioritize at this time?

A) Administer the prescribed vancomycin and monitor the patient for signs of nephrotoxicity.

B) Encourage the patient to increase fluid intake to manage dehydration from the fever.

C) Apply warm compresses to the affected joint to alleviate stiffness and pain.

D) Initiate contact precautions to prevent the spread of MRSA within the healthcare facility.

A patient with a history of gout and MRSA infection is being treated with vancomycin and antihypertensive therapy. Following the incision and drainage of an abscess, the patient reports significant stiffness and difficulty ambulating. Which nursing intervention is most appropriate to address the patient's mobility concerns and promote recovery?

B) Initiate a passive range of motion exercise program

A) Encourage bed rest to prevent further joint damage

B) Initiate a passive range of motion exercise program

C) Administer analgesics prior to physical therapy sessions

D) Recommend a high-protein diet to support muscle strength

A patient with a history of MRSA infection and gout is undergoing vancomycin therapy and has recently had an incision and drainage procedure for a small abscess. The healthcare team is considering introducing physical therapy to address mobility challenges. Which nursing intervention should the nurse prioritize to prevent complications related to prolonged immobility while the patient is on bed rest?

A) Encourage the patient to perform active range of motion exercises in bed.

B) Increase the frequency of vital signs monitoring to assess for infection.

C) Recommend the use of compression stockings to prevent deep vein thrombosis.

D) Advise the patient to limit fluid intake to prevent fluid overload.

gout - Nursing Case Study

Pathophysiology

• Primary mechanism: Gout is primarily caused by hyperuricemia, where excessive uric acid accumulates in the blood due to overproduction or underexcretion, leading to the formation of needle-like monosodium urate crystals in joints.

• Secondary mechanism: The presence of these urate crystals triggers an inflammatory response, where immune cells release inflammatory mediators, causing swelling, redness, and intense pain in the affected joint.

• Key complication: Recurrent gout attacks can lead to chronic tophaceous gout, characterized by the formation of tophi (large urate crystal deposits) and joint damage, potentially resulting in decreased joint function and mobility.

Patient Profile

Demographics:

57-year-old male, construction worker

History:

• Key past medical history: Hypertension, chronic kidney disease stage 2, obesity

• Current medications: Lisinopril 10 mg daily, Hydrochlorothiazide 25 mg daily, Allopurinol 300 mg daily

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Severe pain and swelling in the right big toe

• Key symptoms: Red, swollen, and tender joint in the right big toe, difficulty walking, mild fever, occasional chills

• Vital signs: Blood pressure 150/95 mmHg, heart rate 98 bpm, respiratory rate 20 breaths per minute, temperature 38.2°C (100.8°F)

Section 1

Following the initial assessment of the 57-year-old male patient, further diagnostic tests were conducted to better understand the severity of his gout and any developing complications. The lab results revealed a serum uric acid level of 9.8 mg/dL, significantly higher than the normal range, confirming persistent hyperuricemia despite the patient's current medication regimen. Additionally, a renal function panel indicated a slight deterioration in kidney function, with a serum creatinine level of 1.6 mg/dL, up from a baseline of 1.3 mg/dL, suggesting a potential impact on his chronic kidney disease.

As the day progressed, the patient reported an increase in pain intensity, now rated as 9 out of 10 on the pain scale, and swelling around the right big toe had extended to the midfoot. The attending nurse noted a visible tophus beginning to form near the affected joint, raising concerns about the development of chronic tophaceous gout. The patient's blood pressure remained elevated at 152/96 mmHg, and his temperature persisted at 38.0°C (100.4°F), indicating ongoing systemic inflammation.

In response to these findings, the healthcare team is considering adjusting the patient's treatment plan to better manage his gout and prevent further complications. This includes re-evaluating his current medication regimen, especially the use of hydrochlorothiazide, which may contribute to hyperuricemia, and exploring alternative antihypertensive options. The team is also contemplating the initiation of more aggressive anti-inflammatory treatment to control acute symptoms and prevent joint damage, while closely monitoring the patient's renal function to avoid exacerbating his chronic kidney disease. These actions aim to stabilize the patient's condition and improve his quality of life.

Section 2

Following the healthcare team's decision to adjust the patient's treatment plan, the patient was transitioned from hydrochlorothiazide to losartan, an angiotensin II receptor blocker known for its mild uricosuric effects, potentially benefiting both his hypertension and hyperuricemia. Additionally, the team initiated colchicine for acute gout management and increased the dose of allopurinol to better control his serum uric acid levels. Over the next 48 hours, the patient's response to these interventions was closely monitored.

Despite these changes, the patient continued to experience severe pain and swelling in the right foot, with the tophus near the joint becoming more pronounced. His pain level fluctuated between 7 and 8 out of 10, indicating only partial relief. A repeat renal function panel showed a serum creatinine level that remained stable at 1.6 mg/dL, but his serum uric acid level decreased slightly to 8.7 mg/dL, suggesting some improvement. However, his blood pressure persisted at elevated levels, averaging 148/92 mmHg, and his temperature remained slightly elevated at 37.8°C (100.0°F), indicating ongoing inflammation and systemic stress.

Given these findings, the healthcare team is considering the potential development of a new complication: secondary infection in the area of the tophus due to its proximity to the skin's surface and the ongoing inflammatory process. A mild erythema and warmth around the tophus have raised concerns, prompting the team to order a complete blood count (CBC) and erythrocyte sedimentation rate (ESR) to assess for possible infection. These results will guide further interventions and the next steps in managing the patient's complex condition, emphasizing the importance of comprehensive care and continuous reassessment.

Section 3

New Diagnostic Results

The results of the complete blood count (CBC) and erythrocyte sedimentation rate (ESR) returned, offering crucial insights into the patient's condition. The CBC revealed a white blood cell count of 12,500/mm³, which is elevated, suggesting a possible infectious process. The ESR was significantly increased at 45 mm/hr, corroborating the presence of systemic inflammation. These findings, combined with the erythema and warmth surrounding the tophus, strongly indicate the development of a secondary infection at the site, likely exacerbating the patient's pain and swelling.

In light of these diagnostic results, the healthcare team decided to initiate empirical antibiotic therapy targeting common skin pathogens, while awaiting culture results from an aspirate of the tophus to tailor the antibiotic treatment more precisely. The decision underscores the complexity of managing comorbid conditions, as the team balances addressing the acute infection while continuing to control uric acid levels and blood pressure. The implications of the infection on the patient's overall health status require vigilant monitoring, as the infection could further complicate his ability to mobilize and participate in daily activities.

The team also revisited the patient's pain management strategy, considering the potential benefits of adding a low-dose corticosteroid to help reduce inflammation and provide additional pain relief. However, the risks associated with steroid use, particularly in the context of infection and hypertension, necessitate careful deliberation. This evolving scenario emphasizes the need for ongoing clinical reasoning, as the team must prioritize treatment goals while mitigating potential adverse effects, ensuring that the patient's complex needs are addressed holistically.

Section 4

As the healthcare team continued to manage the patient's condition, a new complication arose. Despite the initiation of empirical antibiotic therapy, the patient's fever persisted, and his pain remained unrelieved, prompting further investigation. A repeat CBC showed a further increase in the white blood cell count to 14,000/mm³, indicating that the infection might not be responding to the initial antibiotic regimen. Additionally, the patient's blood pressure increased to 158/92 mmHg, raising concerns about the impact of both the infection and potential dehydration from ongoing fever on his cardiovascular status.

The patient's mobility was further compromised as he reported increased stiffness and pain in the affected joint, now extending to adjacent areas. Physical examination revealed increased erythema and swelling extending beyond the original tophus site, suggesting a possible abscess formation. These findings prompted the healthcare team to consider imaging studies, such as an ultrasound or MRI, to assess the extent of the soft tissue involvement and guide any necessary surgical intervention.

The culture results from the aspirate of the tophus returned, identifying methicillin-resistant Staphylococcus aureus (MRSA) as the causative organism. This necessitated a change in the antibiotic regimen to one more effective against MRSA, such as vancomycin. The team also re-evaluated the decision to use corticosteroids, weighing the potential benefits of reducing inflammation against the risk of further immunosuppression. This situation illustrated the need for dynamic clinical reasoning, as the team sought to address the evolving infection while managing the complexities of the patient's comorbid conditions and maintaining functional mobility.

Section 5

As the healthcare team adjusted the treatment plan to address the MRSA infection, they initiated vancomycin therapy and closely monitored the patient for any adverse reactions. Over the next 48 hours, the patient's fever began to subside, suggesting a positive response to the new antibiotic regimen. However, his blood pressure remained elevated at 160/94 mmHg, prompting the team to initiate antihypertensive therapy to mitigate any cardiovascular strain. The patient's pain and swelling showed slight improvement, but he continued to report significant stiffness and difficulty ambulating. This raised concerns about prolonged immobility and its potential impact on his overall recovery and quality of life.

The results from the imaging study, specifically an ultrasound, revealed a small abscess formation adjacent to the original tophus site. This finding necessitated a multidisciplinary approach involving both the infectious disease specialist and an orthopedic surgeon. Together, they decided to perform an incision and drainage procedure to alleviate the abscess and further reduce the infection load. Post-procedure, the patient's range of motion in the affected joint improved slightly, indicating a potential decrease in pressure and inflammation.

Despite these interventions, the team remained vigilant for new complications, particularly given the patient's history of gout and the ongoing risk of joint damage or further infection. They also considered the introduction of physical therapy to address mobility challenges and prevent muscle atrophy, which would be essential in promoting the patient's functional recovery. This comprehensive management strategy underscored the importance of integrating multiple clinical perspectives to optimize patient outcomes in the face of evolving medical challenges.