FINAL CASE-GOUT... Print

Divine Word College of Laoag
School of Nursing
Laoag City
A case study presented to the

Clinical Instructors of School of Nursing
Thopaceous Gouty Arthritis, septic arthritis
Presented by:
Aaron Dondoyano
Paul Galat
Aimen Gallegos
Noemi Maruquin
Irvin Ross Molina
Ma. Editha Ofely Morales
Camille Pan
Gemaryvive Quiaoit
Juvel Rafael
March 2010
PERSONAL DATA
Name of Patient: Mr. Emong Aguilla
Address: Bacarra, Ilocos Norte
Hospital number: 438633
Sex: Male
Age: 40 years old
Date of Birth: December 11, 1969
Civil Status: Married
Educational Attainment: High School Graduate
Occupation: Tricycle Driver
Chief of complaint: Swelling of the right lower extrimities
Admitting Diagnosis: Thopaceous Gouty Arthritis, R/O Septic Arthritis
Final Diagnosis: Thopaceous Gouty Arthritis, Septic Arthritis
Date and time of admission: February 11, 2010
Attending Physician: Dr. Gout
ANATOMY AND PHYSIOLOGY
SKELETAL SYSTEM
Sitting, standing, walking, picking up a pencil and taking a breath all involve the skeletal
system. Without the skeletal system to support our bodies, we would have no rigid framework to
support the soft tissues of the body and no systems of levers so critical for movement. The
skeletal system consists of bones and their associated connective tissues, including cartilage,
tendons and ligaments.
FUNCTIONS OF THE SKELETAL SYSTEM
1. Bone is made up of several different tissues working together: bone or osseous tissue,
cartilage, dense connective tissue, epithelium, adipose tissue and nervous tissue. It is
complex and dynamic living tissue. It continually engage in a process called remodeling-
building new bone tissue and breaking down old bone tissue.
 Support. Bone provides a rigid framework that supports the soft tissues of the
body and maintains the body’s shape.
 Protection. Bones protect internal organs that are critical to survival.
 Assistance in Movement. Because skeletal muscles attach to bones, when
muscles contract, they pull on bones. Together bones and muscles produce
movement.
 Mineral homeostasis. Bone tissue stores several minerals, especially calcium and
phosphorus. On demand, bone releases minerals into the blood to maintain
critical mineral balances and to distribute the minerals to other parts of the body.
 Blood cell formation. Blood cells are produced in the marrow of many bones.
2. Cartilage is somewhat rigid but more flexible than bone.
 Model for Bone Growth. Cartilage is abundant in the embryo and the fetus,
where it provides a model from which most of the adult bones develop. Cartilage
is a major site of skeletal growth in the embryo, fetus and child.
 Smooth joint surfaces. In the adult, the surfaces of bones within movable joints
are covered with cartilage, which provides a smooth cushion between adjacent
bones.
 Support. Cartilage also provides a firm, yet flexible support within structures,
such as nose, external ears, ribs and trachea.
3. Tendons and ligaments form attachments. Tendons and ligaments are strong bands of
fibrous connective tissue.
 Tendons. Attach muscle to bones.
 Ligaments. Attach bones to bones.
TYPES OF BONES
1. Long bone
The long bones are those that are longer than they are wide, and grow primarily
by elongation ofthe diaphysis, with an epiphysis at the ends of the growing bone.
The long bones include the, femurs, tibias, and fibulas of the legs, the humeri, radii, and
ulnas of the arms, metacarpals and metatarsals of the hands and feet, and the phalanges of the
fingers and toes.
2. Short bones
Short bones are somewhat cube-shaped because they are nearly equal in length and in
width. They consist of spongy bone tissue except at the surface, where there is a thin layer of
compact bone tissue.
Examples of short bones are wrist or carpal bones, and ankle or tarsal bones.
3. Flat bones
Are generally thin and composed of two nearly parallel plates of compact bone tissue
enclosing a layer of spongy bone tissue. Flat bones afford considerable protection and
provide extensive areas for muscle attachment. Flat bones include the cranial bones, which
protect the brain; the breastbone and ribs, which protect organs in the thorax; and the
shoulder blades.
4. Irregular bones
The irregular bones are bones, which, from their peculiar form, cannot be grouped as
long bone, short bone, flat bone, or sesamoid bone. Irregular bones serve various purposes in the
body, such as protection of nervous tissue (such as the vertebrae protect the spinal cord),
affording multiple anchor points for skeletal muscle attachment (as with the sacrum), and
maintaining pharynx and trachea support, and tongue attachment (such as the hyoid bone). The
irregular bones are the vertebræ, sacrum, coccyx, temporal, sphenoid, ethmoid, zygomatic,
maxilla, mandible, palatine, inferior nasal concha, and hyoid.
5. Sesamoid Bone
Sesamoid bones are typically found in locations where a tendon passes over a joint, such as the
hand, knee, and foot. Functionally, they act to protect the tendon and to increase its mechanical effect.
The presence of the sesamoid bone holds the tendon slightly farther away from the center of the joint and
thus increases its moment arm. Sesamoid bones also prevent the tendon from flattening into the joint as
tension increases and therefore maintain a more consistent moment arm through a variety of possible
tendon loads. This differs from menisci, which are made of cartilage and rather act to disperse the weight
of the body on joints and reduce friction during movement.
Sesamoid bones can be found on joints throughout the body, including:
 In the knee - the patella

 In the hand - two sesamoid bones are located in distal portions of the first metacarpal bone. There
is also commonly a sesamoid bone in distal portions of the second metacarpal bone. The pisiform
of the wrist is a sesamoid bone as well.
 In the foot - the first metatarsal bone has two sesamoid bones at its connection to the big toe.
PARTS OF A BONE
1. Diaphysis is the bones shaft or body- the long, cylindrical main portion of the
bone.
2. Epiphyses are the distal and proximal ends of a bone.
3. Metaphyses are the regions in a mature bone where the diaphysis joins the
epiphysis. In a growing bone, each metaphysis includes an epiphyseal plate, a
layer of hyaline cartilage that allows the diaphysis of the bone to grow in length.
When bone growth in length stops, the cartilage in the epiphyseal plateis replaced
by bone and the resulting bony structure is known as epiphyseal line.
4. Articular cartilage is a thin layer of hyaline cartilage covering the epiphysis
where the bone forms an articulation with another bone. Articular cartilage
reduces friction and absorbs shock at freely movable joints. Because articular
cartilage lacks a perichondrium, repair of damage is limited.
5. Periosteum is a tough sheath of dense irregular connective tissue that surrounds
the bone surface wherever it is not covered by articular cartilage. The periosteum
contains bone-forming cells that enable bone to grow in diameter or thickness but
not in length. It also protects the bone, assists in fracture repair, helps nourish
bone tissue and serves as an attachment point for ligaments and tendons.
6. Medullary Cavity or Marrow Cavity is the space within the diaphysis that
contains fatty yellow bone marrow in adults.
7. Endosteum is a thin membrane that lines the medullary cavity. It contains a
single layer of bone forming cells and a small amount of connective tissue.
TYPES OF BONE CELLS

Osteogenic Cells
These are unspecialized stem cells derived from mesenchyme, the tissue from which all
connective tissues are formed. They are the only bone cells to ndergo cell division; the resulting
daughter cells develop into osteoblasts. Osteogenic cells are found along the inner portion of the
periosteum, in the endosteum, and in the canals within bone that contain blood vessels.
Osteoblasts
These are bone-building cells. They synthesized and secrete collagen fibers and other
organic components needed to build the matrix of bone tissue, and they initiate calcification. As
osteoblasts surround themselves with matrix, they become trapped in their secretions and
become osteocytes.
Osteocytes
These are mature bone cells, the main cells in the bone tissue and maintain its daily
metabolism, such as the exchange of nutrients and wastes with the blood. Like osteoblasts,
osteocytes do not undergp cell division.
Osteoclasts
These are huge cells derived from the fusion of as many as 50 monocytes and are
concentrated in the endosteum. On the side of the cell that faces the bone surface, osteoclats
plasma membrane is deeply folded into a ruffled border. Here the cells release powerful
lysosomal enzymes and acids that digest the protein and mineral components of the underlying
bone matrix. This breakdown of bone matrix, termed resorption, is part of the normal
development, growth, maintenance and repair of bone.
Joints
A joint, or articulation, is the place where two bones come together. There are three types
of joints classified by the amount of movement they allow: immovable, slightly movable, and
freely movable. The joints are the places of union between skeletal elements that are more or less
moveable. Joints are commonly defined as being between bones, but joints also occur between
bones and cartilages, between cartilages, and between bones and teeth. The articular system joins
the skeleton, allows and/or restrains movement, and allows growth of the skeleton until the end
of puberty.
Classification of joints by range of movement
 Synarthroses - immoveable joints

 Amphiarthroses - "mixed" joints of limited movement
 Diarthroses - moveable joints
1. Immovable joints (synarthroses)
In this type of joint, the bones are in very close contact and are separated only by
a thin layer of fibrous connective tissue. An example of a synarthrosis is the suture in the
skull between skull bones.
Classification of joints by structure
 Fibrous joints - joints composed of dense collagenous or elastic connective tissue

 Cartilaginous joints - joints composed of hyaline cartilage or fibrocartilage
 Bony unions - fusion between two bones
 Synovial joints - joints containing a synovial cavity filled with synovial fluid
2. Slightly movable joints (amphiarthroses)
This type of joint is characterized by bones that are connected by hyaline cartilage
(fibro cartilage). The ribs that connect to the sternum are an example of an amphiarthrosis
joint.
3. Freely movable joints (diarthrosis)
Synovial (diarthrosis): Synovial joints are by far the most common classification
of joint within the human body. They are highly moveable and all have a synovial
capsule (collagenous structure) surrounding the entire joint, a synovial membrane (the
inner layer of the capsule) which secretes synovial fluid (a lubricating liquid) and
cartilage known as hyaline cartilage which pads the ends of the articulating bones. There
are 6 types of synovial joints which are classified by the shape of the joint and the
movement available.
Six types of diarthroses joints

Joint Type Movement at joint Examples Structure
A convex projection on one bone fits into

a concave depression in another
Hinge permitting only flexion and extension as
in the elbow joints.
Flexion/Extension
Elbow/Knee Hinge joint
Rounded or conical surfaces of one bone

fit into a ring of one or tendon allowing
Pivot rotation. An example is the joint between
the axis and atlas in the neck.
Rotation of one bone around another
Top of the neck
(atlas and axis Pivot Joint
bones)
The ball-shaped end of one-bone fits into

a cup shaped socket on the other bone
allowing the widest range of motion
Ball and including rotation. Examples include the
Socket shoulder and hip.
Flexion/Extension/Adduction/Abduction/
Internal & External Rotation Shoulder/Hip Ball and socket
joint
Saddle This type of joint occurs when the
touching surfaces of two bones have both
concave and convex regions with the
shapes of the two bones complementing
one other and allowing a wide range of
movement. The only saddle joint in the
body is in the thumb.
CMC joint of the
Circumduction Saddle joint
thumb
Oval shaped condyle fits into elliptical

cavity of another allowing angular motion
but not rotation. This occurs between the
metacarpals (bones in the palm of the
Condyloid hand) and phalanges (fingers) and
between the metatarsals (foot bones
excluding heel) and phalanges (toes).
Circumduction Wrist/MCP &
Condyloid joint
MTP joints
Flat or slightly flat surfaces move against

each other allowing sliding or twisting
without any circular movement. This
Gliding happens in the carpals in the wrist and the
tarsals in the ankle.
Gliding movements
Intercarpal joints Gliding joint
Big toe
The largest and innermost toe of the human foot.

Ankle
The bones which constitute the ankle are the two long bones of the lower leg (tibia and
fibula), which articulate with a short anklebone called the talus. This is a ‘uniaxial’, or hinge,
joint, which allows flexion and extension movements. In the case of the ankle these movements
are called dorsiflexion (sole of the foot up) and plantarflexion (foot down) respectively.
Plantarflexion is achieved by the calf muscles (gastrocnemius and soleus), which form a large
strong tendon (Achilles tendon) which inserts into the bone of the heel (calcaneum).
The ankle joint acts like a hinge. But it's much more than a simple hinge joint. The ankle
is actually made up of several important structures. The unique design of the ankle makes it a
very stable joint. This joint has to be stable in order to withstand 1.5 times your body weight
when you walk and up to eight times your body weight when you run.
Knee
The knee joint is functionally a hinge joint, which principally allows movements of the
lower leg forwards (extension) and backwards (flexion), although a limited degree of rotation is
also possible towards the end of extension. Extension is achieved by a group of four large
muscles at the front of the thigh (quadriceps), whilst muscles at the back of the thigh
(hamstrings) produce flexion. The lower end of the femur articulates, through two condyles, with
the top of the tibia, which is shaped rather like a plateau. In addition to the cartilage covering the
surfaces of these bone-ends, there is another piece of cartilage (meniscus) separating them on
each side. These can be torn by rotational injuries, particularly in football and rugby players, a
condition commonly referred to as torn cartilage.
Hip
The hip joint is an example of a ‘ball and socket’ (multiaxial) type of joint, with the top
(head) of the long bone of the leg (femur) being the ‘ball’ and the socket being a depression in
the bone of the pelvis known as the acetabulum. This arrangement permits movements in three
planes — forwards and backwards (extension/flexion) ; inwards and outwards
(adduction/abduction) ; and inward twist and outward twist (internal and external rotation).
Combination of these movements also gives rise to ‘circumduction’, a circular movement of the
whole leg, which describes a ‘cone’ with the foot at the base and the hip at the apex. The joint is
spanned by powerful muscles, which are required not only for postural control and movement
but also to confer stability at the hip.
Wrist and Hand
The joint between the end of the

forearm and the hand. Movements
occur in two planes — flexion/extension and adduction/abduction (inward/outward). This is a
relatively complex joint as it is an articulation between the lower end of the long bones of the
forearm (radius and ulna) and the eight small bones of the hand (carpal bones). These carpal
bones are connected to one another by ligaments so that they form an arch, concave towards the
palm, with its ends connected by a fibrous tissue band. Through this ‘tunnel’ run long tendons
which control the fingers and, more importantly, the median nerve which carries the nerve
supply to some muscles of the hand and to the skin of some of the fingers.
Elbow
The elbow is the region surrounding the elbow-join—the ginglymus or hinge joint in the
middle of the arm. Three bones form the elbow joint: the humerus of the upper arm, and the
paired radius and ulna of the forearm. An example of a hinge joint (uniaxial) with movement
essentially limited to flexion and extension. The condyles at the lower end of the humerus in the
upper arm articulate with the heads of both the radius and the ulna in the lower arm. Twisting
movements of the lower arm (pronation and supination) are possible because the top end (the
head) of the radius can rotate against the lower end of the humerus. Flexion of the elbow is
achieved by action of the biceps muscle, which shortens and bulges, a muscle often shown to
advantage in the classic pose of the body builder.
Shoulder
The flexible ball-and-socket joint formed by the junction of the humerus and the scapula.
This joint is cushioned by cartilage that covers the face of the glenoid socket and head of the
humerus. The joint is stabilized by a ring of fibrous cartilage (the labrum) around the glenoid
socket. Ligaments connect the bones of the shoulder, and tendons join these bones to
surrounding muscles. The biceps tendon attaches the biceps muscle to the shoulder and helps
stabilize the joint. Four short muscles that originate on the scapula pass around the shoulder,
where their tendons fuse together to form the rotator cuff.
Common sites of TOPHI formation
READINGS
GOUT
Gout is a complex disease of uncertain origin caused by the faulty metabolism of uric
acid produced in the body by breakdown of protein, resulting in elevated levels of uric acid in the
blood that crystallizes and deposits in joints, tendons, and surrounding tissues.
It is often characterized as an inflammatory form of arthritis. But unlike the inflammation

in RA and lupus, which is related to the immune system, joint inflammation in gout is caused by
deposits of sodium urate crystals in the joints. It can cause an attack of sudden burning pain,
stiffness, and swelling in a joint, usually a big toe. These attacks can happen over and over unless
gout is treated. Over time, they can harm your joints, tendons, and other tissues.
Incidence
Its incidence is not usually affected by climate or season; about 95 percent of sufferers
are men. The disease is rare in people under the age of 30; from 10 to 20 percent of cases have a
familial history.
Epidemiology
Gout affects 1% of the Western population at some point in their lifetime and is
increasing in prevalence. This increases to 2% in men over the age of 30 and women over the
age of 50.
Different populations have different propensities to develop gout. In the United States,
gout is twice as prevalent in African American males as it is in European-Americans. It is high
among the peoples of the Pacific Islands, and the Māori of New Zealand, but rare in Australian
aborigines despite the latter's higher mean concentration of serum uric acid.
In the United States and Italy, attacks of gout occur more frequently in the spring.
Types of Gout
 Primary gout: The cause is usually unknown. However, it is likely the result of a combination
of genetic, hormonal, and dietary factors.
 Secondary gout: Secondary gout is caused by medications or medical conditions that cause
an increase in the serum (blood) levels of uric acid.
Stages of Gout
1. Asymptomatic hyperuricemia
2. Acute gouty arthritis
3. Intercritical gout
4. Chronic tophaceous gout
Risk Factors of Gout
 Age
 Middle-Aged Adults. Gout usually occurs in middle-aged men, peaking in the mid-40s. It
is most often associated in this age group with obesity, high blood pressure, unhealthy
cholesterol levels, and heavy alcohol use.
 Elderly. Gout can also develop in older people, when it occurs equally in men and
women. In this group, gout is most often associated with kidney problems and the use of
diuretics. It is less often associated with alcohol use.
 Children. Except for rare inherited genetic disorders that cause hyperuricemia, gout in
children is rare.
 Gender
 Men. Men are significantly at higher risk for gout. In males, uric acid levels rise
substantially at puberty. In about 5 - 8% of American men, levels exceed 7 mg/dL
(indicating hyperuricemia). However, gout typically strikes after 20 - 40 years of
persistent hyperuricemia, so men who develop it usually experience their first attack
between the ages of 30 and 50.
 Women. Before menopause, women have a significantly lower risk for gout than men,
possibly because of the actions of estrogen. This female hormone appears to facilitate
uric acid excretion by the kidneys. (Only about 15% of female gout cases occur before
menopause.) After menopause the risk increases in women. At age 60 the incidence is
equal in men and women, and after 80, gout occurs more often in women.
 Family History
 A family history of gout is present in close to 20% of patients with this condition. Three
genetic locations have been associated with the body's uric acid handling and gout. Some
people with a family history of gout have a defective protein (enzyme) that interferes
with the way the body breaks down purines.
 Obesity
 Researchers report a clear link between body weight and uric acid levels. In one Japanese
study, overweight people had two to more than three times the rate of hyperuricemia as
those who maintained a healthy weight. Children who are obese may have a higher risk
for gout in adulthood.
 Medications
 Thiazide diuretics are "water pills" used to control hypertension. The drugs are strongly
linked to the development of gout. A large percentage of patients who develop gout at an
older age report the use of diuretics.
 Other medications:
 Aspirin -- low doses of aspirin reduce uric acid excretion and increase the chance for
hyperuricemia. This may be a problem for older people who take baby aspirin (81 mg) to
protect against heart disease.
 Niacin (used to treat cholesterol problems)
 Pyrazinamide (used to treat tuberculosis)
 Alcohol
 Drinking excessive amounts of alcohol can raise your risk of gout. Beer is the kind of
alcohol most strongly linked with gout, followed by spirits. Moderate wine consumption
does not appear to increase the risk of developing gout.
 Alcohol use is highly associated with gout in younger adults. Binge drinking particularly
increases uric acid levels. Alcohol appears to play less of a role among elderly patients,
especially among women with gout.
Alcohol increases uric acid levels in the following three ways:

 Providing an additional dietary source of purines (the compounds from which uric
acid is formed)
 Intensifying the body's production of uric acid
 Interfering with the kidneys' ability to excrete uric acid
 Lead Exposure
 Chronic occupational exposure to lead is associated with build-up of uric acid and a high
incidence of gout.
 Organ Transplants
 Kidney transplantation poses a high risk for renal insufficiency and gout. In addition,
other transplantation procedures, such as heart and liver, increase the risk of gout. The
procedure itself poses a risk of gout, as does the medication (cyclosporine) used to
prevent rejection of the transplanted organ. Cyclosporine also interacts with
indomethacin, a common gout treatment.
 The kidneys are responsible for removing waste from the body, regulating electrolyte
balance and blood pressure, and stimulating red blood cell production.
 Other Illnesses
Treatment of several other conditions can cause significant elevations of uric acid in the
blood, and therefore a gout attack. These conditions include:
 Leukemia
 Lymphoma
 Psoriasis
Symptoms of Gout
 Asymptomatic Hyperuricemia
Asymptomatic means there are no symptoms. Asymptomatic hyperuricemia is
considered the first stage of gout. MSU levels slowly increase in the body. This stage
lasts for an average of 30 years.
Note: Hyperuricemia does not inevitably lead to gout. In fact, less than 20% of cases
develop the full-blown arthritic gout disease.
 Acute Gouty Arthritis

Acute gouty arthritis occurs when the first symptoms of gout appear. Sometimes
the first signs of gout are brief twinges of pain (petit attacks) in an affected joint. These
attacks can precede the actual full-blown condition by several years.
MSU crystals form at normal body temperature when the concentration of uric
acid in the blood reaches 7 mg/dL. At lower temperatures, MSU crystals form at lower
concentrations of uric acid. Since blood temperature falls the further blood gets from the
heart, gout usually strikes the toes and fingers first.
Symptoms of acute gouty arthritis include:

 Severe pain at and around the joint
 May feel like "crushing" or a dislocated bone
 Physical activity and even the weight of bed sheets may be unbearable
 Usually takes 8 - 12 hours to develop
 Occurs late at night or early in the morning and may wake you up
 Swelling that may extend beyond the joint
 Red, shiny, tense skin over the affected area, which may peel after a few days
 Chills and mild fever, loss of appetite, and feelings of ill
Most often symptoms start in one joint
 Monoarticular Gout. Gout that occurs in one joint is called monoarticular gout. About
60% of all first-time monoarticular gout attacks in middle-aged adults occur in the big
toe. This occurrence is known as podagra. Symptoms can also occur in other locations,
such as the ankle or knee.
 Polyarticular Gout. If more than one joint is affected, the condition is known as
polyarticular gout. Multiple joints are affected in only 10 - 20% of first attacks. Older
people are more likely to have polyarticular gout. The most frequently affected joints are
the foot, ankle, knee, wrist, elbow, and hand. The pain usually occurs in joints on one
side of the body and it is usually, although not always, in the lower legs and the feet.
People with polyarticular gout are more likely to have a slower onset of pain and a longer
delay between attacks. People with polyarticular gout are also more likely to experience
low-grade fever, loss of appetite, and a general feeling of poor health.
o An untreated attack will typically peak 24 - 48 hours after the first appearance of
symptoms, and go away after 5 - 7 days. However, some attacks last only hours,
while others persist as long as several weeks.
 Intercritical Gout
Intercritical gout is the term used to describe the periods between attacks. The
first attack is usually followed by a complete remission of symptoms, but, if left
untreated, gout nearly always returns. Over two-thirds of patients will have at least one
further attack within 2 years of the first attack. By 10 years, over 90% of the patients are
likely to have repeat attacks.
 Chronic Tophaceous Gout

After several years, persistent gout can develop into a condition called chronic
tophaceous gout. This long-term condition often produces tophi, which are solid deposits
of MSU crystals that form in the joints, cartilage, bones, and elsewhere in the body. In
some cases, tophi break through the skin and appear as white or yellowish-white, chalky
nodules that have been described as looking like crab eyes.
Without treatment, tophi develop about 10 years after the initial onset of gout,
although the occurrence can range from 3 to 42 years. Tophi are more likely to appear
early in the course of the disease in older people. In the elderly population, women
appear to be at higher risk for tophi than men. Certain people, such as those who are
receiving cyclosporine after a transplant, have a high risk of developing tophi.
A risk for tophaceous gout

 Had more than two or three acute attacks of gout in the past
 Unusually severe attacks, or attacks that affect more than one joint
 Joint damage from gout, as shown on x-rays
 Hyperuricemia caused by an identifiable inborn metabolic deficiency
Development of Chronic Pain. When gout remains untreated, the intercritical periods typically
become shorter and shorter, and the attacks, although sometimes less intense, can last longer.
Over the long term (about 10 - 20 years) gout becomes a chronic disorder characterized by
constant low-grade pain and mild or acute inflammation. Gout may eventually affect several
joints, including those that may have been free of symptoms at the first appearance of the
disorder. In rare cases, the shoulders, hips, or spine are affected.
Location of Tophi
 Curved ridge along the edge of the outer ear
 Forearms
 Elbow or knee
 Hands or feet -- older patients, particularly women, are more likely to have gout in the
small joints of the fingers.
 Around the heart and spine (rare)
Tophi are generally painless. However, they can cause pain and stiffness in the affected
joint. Eventually, they can also erode cartilage and bone, ultimately destroying the joint.
Large tophi under the skin of the hands and feet can give rise to extreme deformities.
Hyperuricemia
Hyperuricemia is an excess of uric acid in the blood. Uric acid passes through the liver,
and enters your bloodstream. Most of it is excreted (removed from your body) in your urine, or
passes through your intestines to regulate "normal" levels.
Normal Uric acid levels are 2.4-6.0 mg/dL (female) and 3.4-7.0 mg/dL (male.
Three functional causes of Hyperurecemia:
 Increased production of uric acid

Hyperuricemia of this type is a common complication of solid organ transplant.
Apart from normal variation (with a genetic component), tumor lysis syndrome produces
extreme levels of uric acid, mainly leading to renal failure. The Lesch-Nyhan syndrome
is also associated with extremely high levels of uric acid.
 Decreased excretion of uric acid

The principal drugs that contribute to hyperuricemia by decreased excretion are
the primary antiuricosurics. Other drugs and agents include diuretics, salicylates,
pyrazinamide, ethambutol, nicotinic acid, ciclosporin, 2-ethylamino-1,3,4-thiadiazole,
and cytotoxic agents.
A ketogenic diet impairs the ability of the kidney to excrete uric acid, due to
competition for transport between uric acid and ketones.
Elevated blood lead is significantly correlated with both impaired kidney function
and hyperuricemia (although the causal relationship among these correlations is not
known).
 Mixed type
Causes of hyperuricemia that are of "mixed" ("double whammy") type have a dual
action, both increasing production and decreasing excretion of uric acid.
High intake of alcohol (ethanol), a significant cause of hyperuricemia, has a dual
action that is compounded by multiple mechanisms.
High dietary intake of fructose contributes significantly to hyperuricemia. Increased
production of uric acid is the result of interference, by a product of fructose metabolism,
in purine metabolism.
Starvation causes the body to metabolize its own (purine-rich) tissues for energy.
Thus, like a high purine diet, starvation increases the amount of purine converted to uric
acid. A very low calorie diet without carbohydrate can induce extreme hyperuricemia;
including some carbohydrate (and reducing the protein) reduces the level of
hyperuricemia. Starvation also impairs the ability of the kidney to excrete uric acid, due
to competition for transport between uric acid and ketones.
Symptoms of Hyperuricemia
 You may not have any symptoms.

 If your blood uric acid levels are significantly elevated, and you are undergoing
chemotherapy for leukemia or lymphoma, you may have symptoms kidney problems, or
gouty arthritis from high uric acid levels in your blood.
 You may have fever, chills, fatigue if you have certain forms of cancer, and your uric
acid levels are elevated (caused by tumor lysis syndrome)
 You may notice an inflammation of a joint (called "gout"), if the uric acid crystals deposit
in one of your joints. (*Note- gout may occur with normal uric acid levels, too).
 You may have kidney problems (caused by formation of kidney stones), or problems with
urination
Drugs or treatments to treat hyperuricemia:
 Non-steroidal anti-inflammatory (NSAID) agents and Tylenol®- such as naproxen

sodium and ibuprofen may provide relief of gout-related pain.
 If you are to avoid NSAID drugs, because of your type of cancer or chemotherapy you
are receiving, acetaminophen (Tylenol() up to 4000 mg per day (two extra-strength
tablets every 6 hours) may help.
 It is important not to exceed the recommended daily dose of Tylenol, as it may cause
liver damage.
 Uricosuric Drugs: These drugs work by blocking the reabsorption of urate, which can
prevent uric acid crystals from being deposited into your tissues. Examples of uricosuric
drugs include probenecid, and sulfinpyrazone.
 Xanthine oxidase inhibitors - Such as allopurinol, will prevent gout. However, it may
cause your symptoms of gout to be worse if it is taken during an episode of painful joint
inflammation.
 Allopurinol may also be given to you, if you have a certain form of leukemia or
lymphoma, to prevent complications from chemotherapy and tumor lysis syndrome - and
not necessarily to prevent gout. With high levels of uric acid in your blood, as a result of
your disease, the uric acid will collect and form crystals in your kidneys. This may occur
during chemotherapy, and may cause your kidneys to fail.
Uric Acid
Uric acid is a normal component of blood serum. It is the end product of purine
metabolism. It is catalyzed by the enzyme xanthine oxidase, which is responsible for the
production of uric acid and damaging free radicals.
Purines are generated by the body via breakdown of cells in normal cellular turnover, and
also are ingested as part of a normal diet. The kidneys are responsible for approximately two-
thirds of uric acid excretion, with the liver responsible for the rest.
Human beings have higher levels of uric acid, in part, because of a deficiency of the
hepatic enzyme, uricase, and a lower fractional excretion of uric acid. Approximately two thirds
of total body urate is produced endogenously, while the remaining one third is accounted for by
dietary purines. Approximately 70% of the urate produced daily is excreted by the kidneys, while
the rest is eliminated by the intestines. However, during renal failure, the intestinal contribution
of urate excretion increases to compensate for the decreased elimination by the kidneys.
The blood levels of uric acid are a function of the balance between the breakdown of
purines and the rate of uric acid excretion. Theoretically, alterations in this balance may account
for hyperuricemia, although clinically defective elimination accounts for most cases of
hyperuricemia.
Causes of high uric acid levels include:
 Primary hyperuricemia
 Elevated serum urate levels or manifestations of urate deposition appear to bbe
consequences of faulty uric acid metabolism. It is maybe due to severe dieting or
starvation, evcessive intake of foods that are high n purines, and heredity.
 Secondary hyperuricemia
 Gout is a clinical feature secondary to any of a number of genetic or acquired
processes, including conditions in which there is an increase in cell turnover and
an increase in cell breakdown.
Purines
Purines are natural substances found in all of the body's cells, and in virtually all foods.
Purines provide part of the chemical structure of our genes and the genes of plants and animals.
A relatively small number of foods, however, contain concentrated amounts of purines. For the
most part, these high-purine foods are also high-protein foods, and they include organ meats like
kidney, fish like mackerel, herring, sardines and mussels, and also yeast.
Foods that are high in purine include:

 All organ meats (such as liver), meat extracts and gravy
 Yeasts, and yeast extracts (such as beer, and alcoholic beverages)
 Asparagus, spinach, beans, peas, lentils, oatmeal, cauliflower and mushrooms
Foods that are low in purine include:

 Refined cereals - breads, pasta, flour, tapioca, cakes
 Milk and milk products, eggs
 Lettuce, tomatoes, green vegetables
 Cream soups without meat stock
 Water, fruit juice, carbonated drinks
 Peanut butter, fruits and nuts
Purines are metabolized into uric acid
When cells die and get recycled, the purines in their genetic material also get broken
down. Uric acid is the chemical formed when purines have been broken down completely. It's
normal and healthy for uric acid to be formed in the body from breakdown of purines. In our
blood, for example, uric acid serves as an antioxidant and helps prevent damage to our blood
vessel linings, so a continual supply of uric acid is important for protecting our blood vessels.
Uric acid levels in the blood and other parts of the body can become too high, however,
under a variety of circumstances. Since our kidneys are responsible for helping keep blood levels
of uric acid balanced, kidney problems can lead to excessive accumulation of uric acid in various
parts of the body. Excessive breakdown of cells can also cause uric acid build-up. When uric
acid accumulates, uric acid crystals (called monosodium urate crystals) can become deposited in
our tendons, joints, kidneys, and other organs. This accumulation of uric acid crystals is called
gouty arthritis, or simply "gout”.
SEPTIC ARTHRITIS
Septic arthritis, also called infectious arthritis, is caused by a bacterial infection or more
rarely by a fungal or viral infection. The condition is typically acute, causing severe joint pain,
inflammation, redness, and in some cases fever and chills but may also become chronic. Septic
arthritis may affect any joint but is most frequently found in the knee, hip, shoulder, wrist,
elbow, and finger joints. Usually only one joint will be affected but, in some cases, there may be
more than one. This condition needs to be diagnosed and treated quickly because it can destroy
joints in a short period.
Septic arthritis occurs most often in people who have had a recent traumatic injury to a
joint, have had joint surgery or joint replacement, and/or in people who currently have an
infection in their blood (bacteremia or septicemia). Microorganisms can spread from an original
site of infection into the blood and then can be carried into the joint space. Additional risk factors
for septic arthritis include age (older than 80 years), having diabetes, a weakened immune
system, and/or another condition that affects the joints, such as gout or rheumatoid arthritis.
The acute form of septic arthritis is usually caused by bacteria, such as Staphylococcus
aureus, Streptococcus pneumoniae, group B streptococci, or gonococci (which cause gonorrhea).
Sometimes the microorganisms that cause Lyme disease, HIV, hepatitis B, mumps, or rubella
can move into and infect a joint. Chronic septic arthritis is rarer and tends to be caused by
microorganisms such as Mycobacterium tuberculosis and Candida albicans.
Causes
Septic arthritis develops when bacteria spread through the bloodstream to a joint. It may
also occur when the joint is directly infected with bacteria by an injury or during surgery. The
most common sites for this type of infection are the knee and hip.
Most cases of acute septic arthritis are caused by organisms such as staphylococcus or
streptococcus.
Chronic septic arthritis (which is less common) is caused by organisms such as

Mycobacterium tuberculosis and Candida albicans.
The following increase your risk for septic arthritis:
 Artificial joint implants

 Bacterial infection elsewhere in your body
 Chronic illness or disease (such as diabetes, rheumatoid arthritis, and sickle cell disease)
 Intravenous (IV) or injection drug use
 Medications that suppress your immune system
 Recent joint trauma
 Recent joint arthroscopy or other surgery
Septic arthritis may be seen at any age. In children, it occurs most often in those younger
than 3 years. The hip is a frequent site of infection in infants.
Septic arthritis is uncommon from age 3 to adolescence. Children with septic arthritis are
more likely than adults to be infected with group B streptococcus or Haemophilus influenza., if
not immunized.
Symptoms
 Symptoms usually come on quickly, with joint swelling, intense joint pain, and low-grade
fever.
 Symptoms in newborns or infants:
 Cries when infected joint is moved (example: diaper change causes crying if hip joint is
infected)
 Irritability
 Fever
 Unable to move the limb with the infected joint (pseudoparalysis)
 Symptoms in children and adults:
 Inability to move the limb with the infected joint (pseudoparalysis)

 Intense joint pain
 Joint swelling
 Joint redness
 Low-grade fever
 Chills may occur, but are uncommon.
Testing
The goals with testing for septic arthritis are to identify the microorganism causing the
infection, to determine which antimicrobial therapy will be effective, to monitor the effectiveness
of treatment, and to evaluate the physical status of the affected joint(s).
Laboratory Tests:
 Blood culture - used to determine if a microorganism is present in the blood
 Culture of joint fluid or of other body fluids or tissues, such as sputum, urine,
cerebrospinal fluid - to detect microorganisms, to determine which antimicrobials they
are likely to be susceptible to, and to evaluate the effectiveness of treatment
 Synovial fluid analysis - to detect microorganisms and to see if there are any signs, such
as crystals in the joint fluid, that may indicate a different or co-existing cause for joint
pain (such as gout)
 Complete Blood Count (CBC) - this is a group of tests used to evaluate a patient’s red
and white blood cells and hemoglobin to help evaluate and monitor the condition
Non-Laboratory Tests:
 X-ray of joint(s) - used to help evaluate joint damage; may not show abnormalities until
significant damage exists
Treatments
The goals with treatment are to eliminate the infection, reduce inflammation and associated fluid
pressure on the joint, to minimize joint damage, and to maintain and/or recover joint mobility.
 The primary treatment is the appropriate antimicrobial therapy. The exact medication
prescribed will depend on which drugs the microorganism is susceptible to and how
effective the antimicrobials are at getting into the joint space where the infection is. In
most cases, this drug will also be effective in treating the source of the infection when it
has originated in the blood or another body organ or tissue. With some organisms, such
as a mycobacterium, multiple drugs may need to be taken for extended periods of time.
Viral infections will usually resolve on their own.
 Patients may also be treated for inflammation and pain. Fluid is usually aspirated from
the affected joint(s) to relieve pressure and to obtain material to culture the specific
microorganism. Aspiration may need to be done several times to relieve pressure. In
some cases, surgery may be needed to drain the fluid.
Outlook (Prognosis)
Recovery is good with prompt antibiotic treatment. If treatment is delayed, permanent

joint damage may result.
Possible Complications
Joint degeneration (arthritis)
Prevention
Preventive (prophylactic) antibiotics may be helpful for people at high risk.
FAMILY BACKGROUND
Name Sex Age Educational Occupation Religion Residence

Attainment
Dionisia Female 61 High School Housewife Pentecost Bacarra I.N
Graduate
Emong Male 40 High school Driver Pentecost Bacarra I.N
Graduate
Emang Female 36 High school Caregiver Pentecost Bacarra I.N
Graduate
Ago Male 15 Not applicable Not Pentecost Bacarra I.N
applicable
Bendita Female 13 Not applicable Not Pentecost Bacarra I.N
applicable
A) Family Structure
Emong, a 40-year-old male, is the head of the family, happily married with his wife Emang,
36 years old, and is a father of two children, his eldest son is Ago 15 years old, and his youngest
daughter is Bendita 13 years old, both are high school students. Living with them is his mother
Dionisia, 61 years old.
Their family is considered as an extended type and is permanently residing at Bacarra, Ilocos
Norte. Since his wife works abroad, he takes the responsibility for rearing his children with the
assistance of Aling Dionisia, his mother. The family is patriarchal because Mang Emong is the
leader of the family and is usually the decision maker, but as much as possible he let his children
participate.
All the members irrespective of their ages and economic status, where treated equally,
which is under egalitarian type. They are devout members of the Pentecost and they attend mass
every Sunday. They have a happy home where parental guidance and children’s laughter reigns,
both parents and children were harmoniously united by strong ties of affection and
understanding.
As a father, he instilled in his children’s mind a love for parents, self-respect and deeply
influenced their character to become a better and responsible individual in the future. There are
times that problems arise in their family but it does not last in a day because they resolved it
immediately as much as they can. Mang Emong’s family is an example of a happy family; they
find time to go out together, spend holidays and weekends with their relatives, and participate in
various activities of their Barangay.
B) Environmental
The family live in an up and down type of house with a combination of cement
and wood with surrounding fences, behind it were the poultry yard and vegetable garden.
They live near a high school and in front of a busy road. Typically, their toilet is water
sealed system located inside their house.
C) Socio Economic
As a provider he works hard to sustain their family’s needs, he works as a tricycle driver
earning an average monthly income of Php 5,000,his wife who is currently working in Taiwan as
caregiver gives an additional Php 5,000 allowance per month.
The total monthly income is approximately Php 10,000 per month. As a decision maker
in the family, he makes sure to spend the money wisely. The Php 10,000 monthly income was
allotted for food Php3,000 (Php 750 per week), Php 2,000 for education, approximately Php 200
for medicine, Php 500 for electricity, for water Php 5,00 and Php 1,000 for miscellaneous
expenses. All in all the total monthly expenses of the family is approximately 7,200. The
remaining monthly income of Php 2800 is being kept in the bank for future use of his children
and for emergency cases.
Sales
28% 30% Food

Education
Medicine
Electricity
Water
Miscellaneous
Savings
10%
5% 20%
5%
2%
HEALTH HISTORY
Family Health History
The family members had experienced simple ailments such as cough and colds, fever,
headache and stomachache. All were managed at home of they can, however, they also consult a
physician if they cannot treat themselves alone. For headache, they used to manage by putting a
piece of sliced ginger on to their temporal and taking OTC drug like Biogesic and Cortal.
According to him, the ginger can lessen the pain due to its cooling effect. For stomachache, they
drink a decoction of “Herba Buena”. For cough and colds, they take Asmasolon and Neozep,
drinking plenty of water and taking enough rest. For fever, they stayed at home, rest, and take
drug such as Paracetamol. For cases of fractures, the family usually consults a “manghihilot”
which is according to him, is also effective.
The family had also experienced childhood diseases such as chickenpox, mumps, and
measles. All were managed at home. They used to manage mumps through putting an “akot-
akot” (mixed with water) on to their buccal area and below their ears. According to him, the
cooling effect of the “akot-akot” can help to reduce the pain. For chickenpox, they stayed at
home and take enough rest, and when the vesicles will dry, they burn hay and add with warm
water, and they will use this as bath soap believing that this would kill the remaining bacteria in
their wounds. For measles, they just stayed at home, wore black clothes and they do not take a
bath until the rashes will gone.
The knowledge they had in treating diseases mentioned above were all based from their
beliefs and practices, from what they heard from their relatives, friends and neighbors, from the
television and also from those who are in the medical field.
However, for his daughters, it were all consulted and treated by a physician.
His father who was already dead due to gunshot way back 1979 had asthma likewise
sibling 1 and 2. His daughter 2 had weak lungs at the age of six and was confined and treated at
GRBASMH, Laoag City. A physician diagnosed all of these diseases.
He and his siblings had experienced to receive immunizations when they were child,
however, he cannot recall what these immunizations anymore. His two daughters were both fully
immunized child. They received their immunizations in the hospital and at their Barangay Health
Center.
The family is fond of drinking coffee and soft drinks. Their meal is usually comprised of
meat and vegetable most of the time. During their free time, they usually watch TV and chat with
each other.
Past Health History
During his childhood, he had experienced illnesses such as cough and colds, fever,
headache and stomachache. All were managed at home if they can, however, they also consult a
physician if they cannot treat themselves alone. For headache, they used to manage by putting a
piece of sliced ginger on to their temporal and taking OTC drug like Biogesic and Cortal.
According to him, the ginger can lessen the pain due to its cooling effect. For stomachache, they
drink a decoction of “Herba Buena” and taking OTC drug such as Diatabs. For cough and colds,
they take Asmasolon and Neozep, drinking plenty of water and taking enough rest. For fever,
they stayed at home, rest, and take drug such as Paracetamol. For cases of fractures, the family
usually consults a “manghihilot” which is according to him, is also effective.
He had also experienced childhood diseases such as chickenpox, mumps, and measles.
All were managed at home. They used to manage mumps through putting an “akot-akot” (mixed
with water) on to their buccal area and below their ears. According to him, the cooling effect of
the “akot-akot” can help to reduce the pain. For chickenpox, they stayed at home and take
enough rest, and when the vesicles will dry, they burn hay and add with warm water, and they
will use this as bath soap believing that this would kill the remaining bacteria in their wounds.
For measles, they just stayed at home, wore black clothes and they do not take a bath until the
rashes will gone.
In 1997, his abdomen particularly his LUQ was stab by a friend while they were
drinking. Fortunately, there was no vital organ involved. He was confined and treated at
GRBAMH for one week for this incident.
Five years ago, he felt pain from his RUQ, nauseated and feels like vomiting. After one
week, he decided to consult a physician here in Laoag City and was diagnosed of having liver
cirrhosis. As he can remember, one of his medications was Godecs. After a year of treatment, his
liver cirrhosis was treated.
As stated by him, before he had diagnosed to have liver cirrhosis, he used to drink
alcoholic beverages such as beer and gin every day. If it is GSM, he can consume one bottle
(bilog) and if it is beer, he can consume 1-2 bottles of beer (mL). However, when he was
diagnosed to have cirrhosis, he totally stopped drinking alcoholic beverages as advised by his
doctor. Nevertheless, after his physician declared that he was already treated, he went back to his
vices. He again drinks alcoholic beverages but with a lesser amount and frequency, which is
about one to two bottles of beer in each month.
He loves to eat foods such as organ meats except liver, meat, and vegetables. He has
allergies to egg, chicken, and shrimps. When ingest these foods, he will manifest rashes and
itchiness.
Present Health History
Ten years ago, Mr. Emong felt a severe pain at his right lower leg especially at his right
knee during late at night. However, he does not seek medical advice, nor took any drugs to
relieve the pain thinking that this was only because he was tired from work. After some weeks
(1-2 weeks), the pain subsided even without any consultation and drugs taken.
Five months ago, he observed that there was an attack of pain in his big toe. Again, he
does not give attention to this because he thought that he was only tired from work. From his big
toe, there was also an attack of pain in his ankle, knee, fingers, and wrists. After four months of
attacks of pain, his right knee began to swell that made him difficult to ambulate. His joints
particularly his fingers were deformed, nodules were prominent in his elbow, ankle, and fingers
and skin eruptions to his right foot. During this period, he just took OTC drugs such as
mefenamic acid to alleviate the pain and clean his wounds by just washing with soap and water.
Moreover, on February 4, 2010, he went to GRBAMH, Laoag City for check-up with a
complaint of swelling and severe pain on his right knee. From his check-up at the OPD
Department, he was confined directly at the said hospital.
After a week, due to absence of progression to his condition, he and his family decided to
transfer him at MMMH and MC, Batac City. He was brought to MMMH via ambulance per
stretcher with an IVF of PLR 500 cc level. He was admitted on February 11, 2010 at 8:35 pm
with an admitting diagnosis of Thopaceous Gouty Arthritis, R/O Septic Arthritis.
DEVELOPMENTAL DATA
A. Havighurst’s Theory of Developmental Task
According to Havighurst, learning is fundamental to life and in order to have a deeper

insight on growth and development, one must understand it and recognize the premise that
human being continues to learn throughout life. Happiness is being achieved when a particular
task of a certain age is achieved by the person successfully, but if not, failure occurs which is a
feeling of unhappiness and disapproval from people surrounding the client
Our patient, 40 years of age, belongs to the MIDDLE AGE, in which the following tasks
are very important to accomplish.
 ACHIEVING ADULT CIVIC AND SOCIAL RESPONSIBILTY

Mang Emong claimed that in this aspect, he was able to carry out his role as an adult and
an individual of the society. He usually participates in barangay activities such as clean and
green program as well as barangay fiestas. He greatly believes that joining in such activities is
vital since one is a part of the community and that, one should abide by it. Whenever asks his
help, he never resist helping them as long as he can.
 ASSISTING TEENAGE CHILDREN TO BECOME RESPONSIBLE AND HAPPY

ADULTS
He verbalized that from the start his children are growing up, he had taught them the
proper values and attitudes to live by in order to become better and fulfilled adults in the future.
He also considers that the most important thing that he has shared to his children is the virtue of
being God-fearing and responsible as well.
 RELATING ONESELF TO ONE’S SPOUSE AS A PERSON

His wife works abroad, but according to him, life is not easy to both of them for they
have faced the most difficult trials of their life and with determination and courage to
countenance all these things, they were able to surpass it. He also admitted that though there
were times of argument, but through proper communication, they easily resolve it. He also added
that throughout the years, they have been fulfilled because of the love and harmony they have
always shared together.
 ACCEPTING AND ADJUSTING TO THE PHYSIOLOGIC CHANGES OF

MIDDLE AGE
In this aspect, the client stated that physical and physiologic activity gradually decreases
from time to time. Somehow, he accepts that the process of aging and degenerative changes is
just but a normal toall creature.
 ESTABLISHING AND MAINTAINING AN ECONOMIC STANDARD OF

LIVING
As the head of the family and as a provider he works hard to sustain their family needs,
he works as a tricycle driver and his earnings is placed only an important matter and he
makes sure to spend the money wisely.
 DEVELOPING ADULT LEISURE TIME ACTIVITIES
Mang Emong enjoys performing some leisure activities. He loves chatting with his co-
drivers while waiting for passenger. At home, his past time is reading “bannawag magazines,
newspapers and listening to radio. He is also fond of planting vegetables in their
backyard.
ANALYSIS:
Mang Emong achieved the expected attitude and behavior at his age. His relationship
with his children is good since they maintain good closure and communication although, there
are times that conflict arises, but they believes that it’s normal to a family’s life. This implies that
he is physically, mentally, emotionally and socially prepared to whatever crisis or unexpected
event that may occur.
The client attained the developmental tasks for him, thus, he is now partially ready to go
to the next stage of his life.
B. ERIK ERIKSON’S PSYCHOLOGICAL DEVELOPMENT THEORY
Erikson considers life as composed of sequence of levels of achievement and each stage
indicates a certain task to be achieved. An achievement would mean a healthier personality while
failure would also mean that the person will not be able to go to the next level and probably will
lead to regression.
Mang Emong 40 years old, belongs to the stage of adulthood. His developmental task is
to achieve GENERATIVITY which includes creativity, productivity and concern for others.
Generativity is defined as the concern for establishing and guiding the next generation.
STAGNATION, on the contrast, is those people who are unable to expand their interests at the
time and who do not assume the responsibilities of a middle age suffer from a sense of boredom
and impoverishment, thus, people have difficulty accepting their aging bodies and become
withdrawn and isolated. Self-indulgence, self-concern, lack of interests and commitment would
mean a negative resolution.
In the case of Mang Emong, we could simply say that he was able to partially achieve the
task appropriate for his age. The idea about generativity is reflected with his family of
procreation and he does everything in order to keep his family in a stable state not only in the
economic aspect but as well as in the social, emotional, and physical aspects. He works hard to
provide the things needed by his family. He told that no matter what happens in his life, he
strongly believes that everything was planned by the Holy Father. He was able to fully realize his
worth of life when he established his own family and gifted with 2 childrens who made his feel
special.
ANALYSIS:
Mang Emong had satisfactorily achieved the initial task required at his age under
Erikson. Thereby, this means that he is ready to face any challenges and can easily adjust to any
problems that may happen. Overall, He is still struggling generativity in its optimum level.
PATTERNS OF FUNCTIONING
Eating Pattern
Before illness During Illness Analysis
Before During
hospitalization hospitalization
Mang Emong eats Mang Emong eats Mang Emong was There is a change
4 times a day. In the 4 times a day. 5:30 on Low Purine Diet. in the eating pattern of
morning, he takes his AM for his breakfast, Sometimes, he could the patient as shown
breakfast at the 12 NN for his lunch & able to eat all ration in the data given
“karinderya” at 6-6:30 PM for his but most of the times before & during his
around 5:30 AM. It is dinner. His breakfast he can only consume illness. The change is
usually composed of 1 is usually composed ½ to ¾ of the hospital brought by the
bowl paksiw or of 1 cup of rice, 1 pc. ration. Before his discomfort & pain he
sometimes ½ cup Egg/noodles, 1 pc. operation, the doctor is feeling. Likewise,
grilled meat. For his dried fish. His lunch ordered NPO in he was not used to the
lunch at 12 NN, he is composed of 2 cup preparation of his manner of serving as
eats 1½ cup of rice, of rice, ½-cup meat, surgery, & goes back well as the food
and 1-cup vegetables. & 1-cup vegetables. to Low Purine Diet served was not his
For his dinner, which For his dinner, it is when he was brought Food Preference.
is 6-6:30 PM, it is composed of 1 cup of back to the ward.
composed of 1 cup of rice and 1 bowl
rice, 1-cup vegetables vegetable. For his
& 4-5 matchbox size snack, it is comprised
of meat. His snack of 2 pcs. bread and
was comprised of 2 soft drinks.
pcs. of bread and soft
drinks.
Drinking Pattern
Before During
Mang Emong Mang Emong Mang Emong There is a change
usually consumed 8- drinks 8-10 glasses of drinks 5-6 glasses of in his drinking pattern
10 glasses of water a water a day wherein 1 water a day for since there is a
day where in 1 glass glass is about 240 ml. approximately 1200 decrease fluid intake.
is approximately 240 He also drinks soft ml-1400 ml per day. The decrease in fluid
ml, thus, 1920 mL- drinks, which is about intake is brought by
2400 ml per day. He 360 ml. And the decrease activity
also drinks soft sometimes liquor for of the patient.
drinks, 1 bottle a day, about 360 ml. Total
which is 360 ml or input each day is
sometimes juice for approximately 2700-
about 240 ml. In the 2900 ml.
afternoon he drinks
liquor, usually 3
bottles of BEER at
1500 ml or 1 bottle of
GIN (bilog) which is
about 360 ml. Total
input per day was
approximately 2520-
3780 ml.
Bladder Elimination
Before During
Mang Emong Mang Emong still He voids 2 to 3 There is a change
voids at least 6-8 voids 6 to 8 times a times a day. The in his bladder
times a day for day approximately client is wearing elimination, the
approximately 1400 to 1400 to 1500 ml/day. diaper. He changes decrease in frequency
1500 ml/day. His The color of his urine his diaper two times a and amount of
urine is usually clear is yellow. day which is partially urine/voiding is
light yellow without soaked. attributed to the
offensive odor. activity.
Bowel Elimination
Before During
Mang Emong He defecates once Mang Emong The change in the
usually defecates once a day before taking a defecates once every bowel pattern is
a day early in the bath in the morning. other day. Its brought by the
morning before taking Usually, its consistency is watery decrease food intake
a bath. His stool was consistency is soft and that appears yellow in and decrease
usually soft and semi semi formed that color. ambulation activity.
formed that appears appears brown in
brown in color. color.
Bathing Patterns
Before During
He usually takes a He usually takes a Mang Emong takes There is a change in
bath once a day, every bath once a day, every a partial bath every his bathing pattern.
early in the morning. early in the morning. morning with This is brought by the
He uses green cross as He uses green cross as assistance. patient’s inability to
his soap and sunsilk his soap and sunsilk get up and ambulate.
as his shampoo, his as his shampoo his
bathing usually lasts 5 bathing usually lasts 5
to 10 minutes. to 10 minutes.
Sleeping Patterns
Before During
Mang Emong Mang Emong Mang Emong falls There is an
sleeps early at night, sleeps at around 9PM asleep at 11pm and alteration in his
at around 7-8:00 PM. because the pain he awakes at 3am. He sleeping pattern
He wakes up at feels was irritating usually takes nap because the pain he
around 5-5:30 AM. him. He wakes up at during daytime 30 feels interrupts him.
He sleeps 9½-10 around 3am. He minutes in the am and
hours of sleep each usually takes sleep at about 45 minutes in
day. daytime, which is 1 to the pm. He has 5 to 5
1 ½ hours. He has 7 ½ ½ of sleep each day.
hours of sleep each
day.
LEVELS OF COMPETENCIES
Physical Competency

Before During
Our client was He can perform He was not able There is a change
able to do his his usual activities but to perform his usual in his physical
activities of daily with limitations and activities of daily competency due to the
living without he was not able to do living. He remains client’s inability to get
difficulty and his job as tricycle lying in bed most of up and walk alone.
assistance. He can driver because he has the time. He asks
also do his job as a difficulty of walking. assistance to his
tricycle driver and “bantay” whenever he
was able to support needs something.
the needs of his
family as a father and
head of the family.
Emotional Competency
Before During
He is happy Although he feels He feels lonely for There is no change

person, loving and lonely about his his situation that he in the emotional
responsible father. He situation, he does not cannot do anything competency of the
is an expressive type let his self to be but lie in bed. client because being
of person. He is able emotionally disturbed. However, he tries his lonely is just a normal
to verbalize whatever He understands that, best to cope up and response when one
he wants and anyone could manage the feeling. has illness.
whatever he feels. experience having a The support system he
When he gets mad, or disease and this is just has helps him a lot to
loses his temper, he is normal to all overcome to accept
able to express it but individuals. his condition.
not to the extent that
he will burst out. He
also added that when
trials or challenges
come, he face it with
full strength and
courage as well as
with prayers to be
able to surpass that
challenge.
Social Competency
Before During
Our clients claim He minimizes He still able to There was no

that he has a good going outside their socialize by merely change in the social
relationship with their house since he has talking to his inmates competency of the
neighbor. He interacts difficulty in walking. and to the health care client. His condition is
well with other However, the way he provider staff. He not a hindrance in
people. He even treats and talk to other entertains us very well dealing with other
participates in the people stays the same. when we visited him people.
activities of their and answer our
barangay like Oplan question thoroughly
Dalus. He also attends when we interviewed
occasions and parties him.
in their barangay as
well as to their places
whenever given the
opportunity and time.
INTELLECTUAL COMPETENCY
Before During
Our client claims The client can During interview, There was no
that he is the one who recognize, recall he can answer our change in the client’s
made decision in the place, person and entire questions intellectual
family. events. He can relate thoroughly. He competency.
He can recognize, things that happened understands our
recall place, person in the past and things purpose to him. He is
and events. He can that just happened. He still the decision
relate things that was still the decision maker in the family
happened in the past maker in his family. and he can relate
and things that just things that happened
happened. in the past and events
that recently took
place.
SPIRITUAL COMPETENCY

Before During
Our client and his Our client claimed The client claimed There was no
family are religiously that his faith in God that his faith in God change in the clients
affiliated Pentecost becomes stronger. He remained strong. He still spiritual competency
faith. He claimed that prayed harder and more prayed harder and more
they attend mass every often believing that often just like before
Sunday and practice what he is experience hospitalization.
their own religious and suffering right now
beliefs and practices. He is just a test to his faith
usually prays at night to and soon he will be able
ask forgiveness, to recover from that
blessings, and gratitude disease.
to the Lord and at the
same time for the
protection and guidance
of the entire family.
PHYSICAL ASSESSMENT
The physical assessment was done last February 18, 2010 at 5:00 pm. It was a
cephalocaudal physical examination.
I. General Appearance
The patient was lying in bed awake and conversant with an IVF of PNSS 1 liter at
950 cc level regulated to 27 – 28 gtts/min. He is weak in appearance, in pain, with a pain
scale of 7/10 and unable to get up.
Vital Signs taken as follows:
Body temperature – 37.10C

Blood pressure – 130/90mmHg
Pulse rate – 81bpm
Respiratory rate – 20 bpm
A. Head
 Normocephalic
 In proportion with the size of the neck and body
 Can move up to 90° (able to move to its desired position but has slightly
difficulty.
B. Hair
 Equally distributed black hair
 short, dull and dry
C. Eyes
 Both eyes are coordinated, moves in unison with parallel alignment
 Brown colored iris
 Pupils reaction to light-constrict
 With eyebags
D. Ears
 Both auricles are proportional in shape
 Tip of the ears are aligned to the outer cantus of the eye
 Able to hear words when whispered 1 – 2 feet away and responds
E. Nose
 nasal opening are symmetrical
 with patent airway
F. Mouth
 Lips - slightly dry, blackish in color
 Tongue - able to move freely
 Teeth – yellowish
- 15 teeth’s in the upper jaw, 15 teeth’s in the lower jaw
 Gums -slightly blackish in color
G. Neck
 Proportional to head and body
 Can move side to side at 900 with minimal difficulty
H. Chest
 Left and right portions are proportional
 Color of the skin is equal to other body parts
 With respiratory rate of 20 bpm
I. Abdominal
 With 15 bowel sounds per minute
 With scar noted
J. Upper extremities
 untrimmed and dirty fingernails
 pale (with poor capillary refill)
 finger at the right arm are unflexible, with limited mobility of the fingers, enlarge
joints of all fingers
 white and rough palms
 with pinkish nodules on both elbow, back of the palm and fingers
 with scar on the left deltoid (BCG vaccination)
 with tattoo at left arm
K. Lower
 Pale nail bed and thick nails

 with bandage at right knee
 right leg and ankle is swelling, shiny
 with wounds scattered at right leg
 discharges noted on the wounds
 with pinkish nodules on both feet
 poor capillary refill
I. Skin
 brown complexion
 cold skin
ON GOING APPRAISAL
February 19, 2010 @ 11:00 am
First day of appraisal
Mang Emong was lying on bed, awake and conversant with an IVF of PNSS 1L @ 500cc
level regulated to 41-42 gtts/min. He is wearing white shirt and black short with bandage at his
right knee. He is weak in appearance and unable to get up alone and ambulate. His right lower
leg is swelling and he complains of pain on his right leg with a pain scale of 6/10.
Vital signs as follows:

BP – 130/80mmHg
BT – 36.60C
RR – 20 breathe per minute
PR – 78 beats per minute
February 20, 2010 @ 12:30 pm
Second day of appraisal
Mang Emong was lying in bed awake and conversant, with an IVF of D5LRS @ 975 cc
level regulated to 41-42gtts/min. He is wearing red shirt and black short with bandages at his
right ankle and knees, He is weak in appearance and still unable to get up alone and ambulate.
His right lower leg is swelling and with minimal discharges (pus and blood) from his wound
noted. He complains of pain on his right leg with a pain scale of 5/10
BP – 120/80mmHg
BT – 36.70C
RR – 21breathe per minute
PR – 80beats per minute
February 21, 2010 @ 4 pm
Third day of appriasal
Mang Emong had just undergone debridement at his right knee and foot.He was lying in
bed, asleep, with an IVF of D5NSS 1L@ 950 cc level regulated to gtts/min., with bandages at his
right knee, ankle, and legs. He is weak in appearance and with a pain scale of 8/10

BP – 140/100mmHg
BT – 36.50C
February 22, 2010 @ 4 pm
Fourth day of appraisal
Mang Emong was lying in bed, awake and conversant with an IVF of PNSS1L@450cc
level regulated to 41-42gtts/min.With bandages at his right knee and leg. About 30-40% of the
bandage is soaked with yellowish discharges. He is weak in appearance and still unable to get up
alone and ambulate. He complains of post op pain at the operative site with a pain scale of 8/10
BP – 110/90mmHg
BT – 37.70C
MEDICAL MANAGEMENT
X-ray/UTZ
Chest AP
 No definite radiographic abnormality
 No definite active parenchymal infiltrates seen
 Pulmonary vascularity is within normal limits
 Heart is not enlarged
 Diaphragm is normal in position and contour
 Both costrophenic sulci and visualized bones are intact
KNEE APC
 No definite fracture or dislocation seen
 Knee joint space appears narrowed, suggest comparison with collateral knee.
X-ray is a radiographic examination of bones. This examination can accurately

identify fractures, tumors, bone infection, and bone destruction. Abnormalities identified
in x-ray frequently require more extensive diagnostic evaluations through radioisotope
scans or biopsy.
Analysis:
The Chest AP was done to determine the accumulation of MSU crystals in the
heart specifically in the myocardium.
The knee APC was done to determine the extent of deformity and base from the
result, it shows an abnormal finding in the knee joint space which appears to be narrowed.
Hematology
2-11-10
TEST RESULT RANGES INTERPRETATION
CBC
Hemoglobin 110.00 g/L 140-175 Low
Hematocrit 0.34 0.41-0.50 Low
RBC 4.120 10^12/L 4.5-5.9 Low
MCV 82.30 fL 80-100 Normal
MCH 26.20 pg 27-32 Low
MCHC Concentration 32.40 g/dL 31-35 Normal
WBC 25.32 10^9/L 4.50-11.00 High
DIFFERENTIAL COUNT
Segmenters 0.77 .50-.70 High
Lymphocytes 0.10 .20-.40 Low
Monocytes 0.07 .02-.08 Normal
Eosinophils 0.03 .01-.04 Normal
Basophils 0.01 0.00-0.001 Normal
Platelet count 475 10.^9/L 150-450 High
2-13-10
CBC
RBC 4.480 10^12/L 4.5-5.9 Low
MCV 79.90 fL 80-100 Low
MCH 25.9 Pg 27-32 Low
WBC 33.26 10^9/L 4.50-11.00 High
DIFFERENTIAL COUNT
2-16-10 @ 06:03 am
CBC
RBC 3.880 10^12/L 4.5-5.9 Low
MCH 26.30 pg 27-32 Low
WBC 29.75 10^9/L 4.50-11.00 High
DIFFERENTIAL COUNT
2-16-10 @ 3:57 pm
CBC
RBC 3.630 10^12/L 4.5-5.9 Low
MCH 25.90 pg 27-32 Low
WBC 29.48 10^9/L 4.50-11.00 High
DIFFERENTIAL COUNT
Eosinophils 0.05 .01-.04 High
Analysis:
The result shows that there was a decrease RBC, Hbg, Hct, MCH and lymphocyte while
WBC, Eosinophils and platelet count increased.
The decreased level of RBC due to excessive breakdown of cells. increased
WBC increases because of his inflammation likewise eosinophils. An increase in

eosinophils may indicate allergic response including asthma, food, and medication, and the
increased in platelet count indicates iron deficiency, hemorrhage, infectious and inflammatory
D/O.
The decreased in MCU may indicate iron deficiency anemia.
Chemistry and Lipid Profile

2-12-10
Chemistry
Glucose, FBS 4.65 mmol/L 4.2-6.4 Normal
BUN 4.97 mmol/L 1.7-8.3 Normal
AST 65.94 u/L Up to 35 High
ALT 49.70 u/L Up to 45 High
Lipid Profile
Cholesterol 4.43 mmol/L <5.17 Normal
Triglycerides 1.46 mmol/L <2.28 Normal
HDL 0.22 mmol/L >1.55 Low
LDL 1.63 mmol/L <3.36 Normal
Analysis:
Slightly to moderately increased levels of AST was because of his liver damage due to
liver cirrhosis.
Slightly to moderately increased levels of ALT may indicate cirrhosis, myocardial

infarction, congestive heart failure, or resolving or prodromal hepatitis.
The decreased levels of HDL were because of his lifestyle, which are inadequate exercise
and low purine diet.
Urine Analysis
2-12-10
TEST RESULT INTERPRETATION
Physical Exam
Urine Color Yellow Normal
Clarity Slightly turbid Normal
Specific Gravity 1.015 Normal
pH 6.5 Normal
Chemical Exam
Protein (-)
Glucose (-)
Hgb +2
Ketone (-)
Nitrite (-)
Bilirubin +1
Urobilinogen +1
Leukoesterase (-)
Urinary Cells
WBC 0-1 HPF
RBC 6-8 HPF
Epithelial Cells Rare Normal
Bacteria Few Normal
Mucus Threads Few Normal
Renal Cells (-)
Yeast Cells (-)
Urinary Casts (-)
Hyaline Casts -/LPF 0-1
Fine Granular Casts -/LPF 0-1
Coarse Granular Casts -/LPF 0-1
Waxy Casts -/LPF 0-1
Urinary Crystals
Amorphous Urate/phosphate Few
Calcium Oxalates (-)
Triple Phosphate (-)
Uric Acid (-)
ECG
2-12-10
 Regular Sinus Rhythm
 Within normal limits
Electrocardiogram is frequently used to diagnose abnormal heart rhythms,

conduction disturbances, hypertrophy of cardiac chambers,and myocardial infarction. It is
also used to monitor pacemaker function and the effectiveness if some medications.
Likewise, it can also help monitor clients responses to therapy.
Analysis:
The result shows normal findings.
DIET THERAPY
 Low Purine Diet

- This diet is indicated for the patient to minimize the production of uric acid, which one
of the causes hyperurecemia.
Date ordered: February 11, 2010
Nursing Responsibilities Rationale

1. Check doctor’s order. To identify what diet was ordered and to avoid
mistakes.
2. Transcribe the diet ordered to the diet list. To let the dietician know that the client is on low
purine diet.
3. Inform the watcher about the prescribe For them to be aware of the diet.
diet.
4. Emphasize the purpose of diet therapy. To gain cooperation for the client and family.
5. Remove foods on the bedside table of the To avoid temptation to eat especially if the foods
client. are attractive to him.
 NPO (Nothing per Orem)

- This was indicated for decreasing the workload of the stomach. It is a preparatory
procedure for his operation.
Date Ordered: February 20, 2010

1. Inform the client and the watcher about For the patient to be aware and gain
the prescribed diet. cooperation. And to get real results.
2. Emphasize the purpose of diet therapy. To gain cooperation from the client and
family.
3. Keep all foods or fluids out of patient’s To lessen patient’s interest and to prevent
sight. stimulation of vagal nerves.
4. Instruct the watcher to remind the client For the client not to eat and drink secretly.
about her diet.
5. Regulate IVF properly (as ordered), for To meet the nutritional supplementation of
nutritional supplementation. our client.
INTRAVENOUS THERAPY
Intravenous therapy is an efficient and effective method of giving of liquids directly into
a vein. IVF is used to administer fluids that contain water, dextrose, vitamins, electrolytes and
drugs. IVF is considered the fastest way of absorption. Intravenous therapy is an important
adjunct in the management of the seriously ill or injured patients.
1. Plain Normal Saline Solution 1000 cc x 120

Date Administered: February 11, 2010
2. D5NSS 1 liter x 120
3. PLR 1 liter x 120

4.D5LRS 1 liter x 80
Nursing Responsibilities:
Responsibilities Rationale
1. Review doctor’s order for the type of -to prevent inserting the wrong IVF
intravenous fluid to be administered.
2. Identify the client. - to prevent inserting the IVF to the wrong

patient
3. Explain the procedure to the patient. - to gain the cooperation of the client and
eliminate doubts of the patient
4. Observe aseptic technique in inserting -to prevent infection

the IVF.
5. Compute and regulate for the infusion - to prevent fluid overload

rate.
6. Check for air bubbles in the tubing. - to prevent the occurrence of air embolism
7. Change or stop the solution before it -to prevent air embolism

empties.
8. Protect the insertion site. - to prevent needle dislodgement
9. Document the procedure done. - to serve as evidence with the quality of care
given, it serves as a legal document as a basis
for the continuity of care for health care
providers.
Blood transfusion
When red and white blood cells, platelets, or blood proteins are lost because of
hemorrhage or disease or even because of an operation, it is necessary to replace these
components to restore the blood’s ability to transport oxygen and carbon dioxide, to clot, to fight
infection, and to keep extra cellular fluid within the intravascular compartment. A blood
transfusion is the introduction of whole blood components into the venous circulation.
Mr.Emong was transfused with PRBC, this was given to him to restore his blood volume,
to restore the capacity of the blood to carry oxygen and to provide plasma factors or platelet
concentrate, which prevent or treat bleeding.
DATE ORDERED DATE SERIAL NO. TYPE OF BLOOD

TRANSFUSED
2-11-2010 2-12-2010 10-0772 2 units of PRBC
2-18-2010 2-20-2010(1 unit) 2007- 630611 2 units of PRBC
Nursing Responsibilities
Nursing responsibilities Rationale
1. Check the physicians’ order for the To obtain correct blood component for the client
number of units and type of transfusion to
be given.
2. Secure consent. To secure both the patient and the health care
provider for legal purposes.
3. Check that the type and cross match has To check if there is available blood that is to be
been completed and that the blood is ready transfused to the patient.
in the blood bank.
4. Check and record the vital signs, To avoid for any blood transfusion reaction.
determine any allergies and previous
transfusion. Check also for the expiration
date of the blood.
5. Confirm client’s identity. To avoid doing the procedure to the wrong patient.
6. Do hand hygiene, observe aseptic To prevent transfer microorganism that will cause
technique. infection
7. Make sure that the only side drip is plain To prevent agglutination of blood.
normal saline solution.
8. Start the infusion slowly and stay with To prevent overload and if any abnormalities will
the patient for the first 15 minutes. occur, only a few amount of blood is being
infused. The first 15 minutes is the time that
abnormalities will show if there is any.
9. Observe the client for an hour after the To check if there are abnormalities and BT
transfusion. reactions.
10. Document the procedure done. It will serve as a legal document. It is also a basis
for the continuity of care.
Debridement
 Debridement is the process of removing nonliving tissue from pressure ulcers, burns, and
other wounds
Surgical debridement
Surgical debridement (also known as sharp debridement) uses a scalpel, scissors, or other
instrument to cut dead tissue from a wound. It is the quickest and most efficient method of
debridement. It is the preferred method if there is rapidly developing inflammation of the body's
connective tissues (cellulitis) or a more generalized infection (sepsis) that has entered the
bloodstream. The procedure can be performed at a patient's bedside. If the target tissue is deep or
close to another organ, however, or if the patient is experiencing extreme pain, the procedure
may be done in an operating room. Surgical debridement is generally performed by a physician,
but in some areas of the country an advance practice nurse or physician assistant may perform
the procedure.
Purpose
Debridement speeds the healing of pressure ulcers, burns, and other wounds. Wounds
that contain non-living (necrotic) tissue take longer to heal. The necrotic tissue may become
colonized with bacteria, producing an unpleasant odor. Though the wound is not necessarily
infected, the bacteria can cause inflammation and strain the body's ability to fight infection.
Necrotic tissue may also hide pockets of pus called abscesses. Abscesses can develop into a
general infection that may lead to amputation or death.
Preparation
The physician or nurse will begin by assessing the need for debridement. The wound will
be examined, frequently by inserting a gloved finger into the wound to estimate the depth of
dead tissue and evaluate whether it lies close to other organs, bone, or important body features.
The assessment addresses the following points:
 the nature of the necrotic or ischaemic tissue and the best debridement procedure to
follow
 the risk of spreading infection and the use of antibiotics
 the presence of underlying medical conditions causing the wound
 the extent of ischaemia in the wound tissues
 the location of the wound in the body
 the type of pain management to be used during the procedure
Before surgical or mechanical debridement, the area may be flushed with a saline
solution, and an antalgic cream or injection may be applied. If the antalgic cream is used, it is
usually applied over the exposed area some 90 minutes before the procedure.
Aftercare
After surgical debridement, the wound is usually packed with a dry dressing for a day to
control bleeding. Afterward, moist dressings are applied to promote wound healing. Moist
dressings are also used after mechanical, chemical, and autolytic debridement. Many factors
contribute to wound healing, which frequently can take considerable time. Debridement may
need to be repeated.
DRUG STUDY
1. Generic Name: Ciprofloxacin

Brand Name: Cipro
Classification: Antibiotic Fluroquinolone
Dosage, Route, Frequency: 100 mg IV q 12 hours
Mechanism of Action: Interferes with DNA gyrase and topoisomerase IV. DNA gyrase is an
enzyme needed for replication, transcription, and repair of bacterial DNA.
Topoisomerase IV plays a key role in the participation of
chromosomal DNA during bacterial cell division. Effective against both gram-
positive and gram- negative microorganism
Desired Effects: To inhibit growth of bacteria and to treat infection.
Side effect: abdominal pain, constipation, drowsiness, dizziness, blurring of vision.
Adverse effect:
CNS: headache, restlessness, tremors, dizziness, fatigue, drowsiness
CV: Thrombophlebitis, edema, chest pain
GI: nausea, diarrhea, vomiting, abdominal pain, or discomfort, oral candidiasis
Hematologic: eosinophilia, leucopenia,neutropenia, thrombocytopenia
Muscuskeletal: arthralgia, joint or back pain
Skin: rash, photosensitivity, pruritus, erythema
Other: hypersensitivity reaction

1.Check doctor's order before giving To avoid mistakes
medication
2. Observed the 10 R's in administering To prevent administering wrong drug and
medication. administering to a wrong person.
3. Administer the drug slowly. To prevent phlebitis.
4. Check patency of IV line. To avoid wastage of the drug.
5. Report tendon inflammation and pain to For immediate care.
know when to discontinue the drug.
6.Use caution with hazardous activities until Drug may cause light-headedness.
reaction to drug is known.
2. Generic Name: Clindamycin

Brand Name: Cleocin
Classification: Antibiotic Lincosamide
Dosage, Route, Frequency: 300-mg IV q 6 hours
Mechanism of Action: Suppresses protein synthesis by microorganisms by binding to
ribosomes and preventing peptide bond formation.
Desired Effect: To inhibit growth of bacteria and to treat infection.
Side effect: nausea and vomiting, super infections in the mouth
Adverse Effect:
CV: hypotension, cardiac arrest
GI: nausea, vomiting, abdominal pain, diarrhea
Hematologic: transient leucopenia, eosinophilia,
Skin: maculopapular rash, urticaria, dryness, irritation, oily skin

medication
2.Observed the 10 R's in administering To prevent administering wrong drug and
medication administering to a wrong person.
3. Monitor BP and pulse in patients receiving Because the drug may cause hypotension.
drug parenterally.
4. Be alert for signs of super infection and For immediate attention and intervention.
anaphylactic reactions.
3. Generic Name: Tramadol Hydrochloride
Brand Name: Ultram
Classification: Analgesics
Dosage, Route, Frequency: 50-mg IV q 5 hours
Mechanism of Action: A centrally acting synthetic analgesic compound not chemically related
to opiates. Thought to bind to opoid receptors and inhibit re-uptake of
norepinephrine and serotonin.
Desired Effects: To relieve the pain
Side effect: dizziness, vertigo, headache, nausea, constipation, vomiting, drowsiness, respiratory
depression, seizures
Adverse Effect:
CNS: drowsiness, dizziness, vertigo, headache, seizure
CV: palpitations, vasodilations
GI: nausea, vomiting, constipation, diarrhea, abdominal pain
Body as a whole: anaphylactic reaction, diarrhea, sweating, nausea, tremors
Skin: rash

1.Check doctor's order before giving
To avoid mistakes
medication
3. Advice client to increase intake of fluids This is necessary to prevent the constipating
unless contraindicated. effect of the drug.
4. Monitor patient for seizures. Drug may reduce seizure threshold.
4. Generic Name: Paracetamol

Brand Name: Acetaminophen
Classification: Antipyretics
Dosage, Route, Frequency: 300mg. IV q 5 hours
Mechanism of Action: Thought to produce analgesia by blocking pain impulses by inhibiting
synthesis of prostaglandin in the CNS or of other substances that
sensitize pain receptors to stimulation. The drug may relieve fever
through central action in the hypothalamic heat-regulating center.
Desired Effects: To decrease body temperature.
Side effect: nuetropenia, luekopenia, pancytopenia, hypoglycemia
Adverse Effect:
CNS: headache
CV: chest pain, dyspnea
GI: hepatic toxicity and failure
GU: Acute renal failure, renal tubular necrosis
Hematologic: pancytopenia, hypoglycemia
Hypersensitivity: rash, fever

medication
3. Administer after meals. To prevent GI upset.
4. Discontinue drugs if hypersensitivity To prevent further reactions and for immediate
reaction occurs. care.
5.Do not take other medications containing Overdosing can cause liver damage and other
acetaminophen without medical advice toxic effects.
5. Generic Name: Captopril

Brand Name: Capoten
Classification: Antihypertensive
Dosage, Route, Frequency: 25mg 1 tab.SL for Bp >160/180
Mechanism of Action: Inhibits ACE preventing conversion of angiotensin I to angiotensin II a
potent vasoconstrictor. Less angiotensin II decreases peripheral arterial
resistance, decreasing aldosterone secretion, which reduces sodium
and water retention and lowers blood pressure.
Desired Effects: To lower blood pressure
Side Effects: Hives, severe stomach pain, difficulty in breathing, and swelling of the face, lips,
tongue, or throat
Adverse Effect:
CV: Slight increase in heart rate, first dose hypotension , dizziness, fainting
GI: altered taste sensation (loss of taste perception, persistent salt or metalic
taste); weight loss, intestinal angioedema.
Hematologic: Hyperkalemia, neutropenia, agranulocytosis (rare)
Respiratory: cough
Skin: Maculopopular rash, urticaria, pruritus, angioedema, photosensitivity.
Urogenital: azotemia, impaired renal function, nephrotic, syndrome, membranous
glomerulonephritis

medication
3.Raised bedside rails To prevent falling since these drug can cause
dizziness
4.Monitor BP closely following the first A sudden exaggerated hypotensive response
dose. may occur within 1-3 hours of first dose,
especially in those with high BP or on a
diuretic and restricted salt intake.
5.Advise the patient to report any for early detection and early prevention
discomfort like cough, dizziness.
6. Generic Name: Colchicine

Brand Name: Colgout
Classification: anti-inflammatory
Dosage, Route, Frequency: one tab. TID
Mechanism of Action: As an anti-inflammatory drug,it will decrease WBC motility,

phagocytosis and lactic acid production.decreasing urate crystal
deposits and reducing inflammation. As an antiosteolytic
drug,may inhibit mitosis of osteoprogenitor cells and decrease
osteoclast activity.
Desired Effects: to reduce inflammation
Side effect: nausea and vomiting, loss of appetite, loss of hair
Adverse Effect:
GI: nausea, vomiting, abdominal pain, anorexia
Hematologic: bone marrow depression
CNS: Mental confusion, peripheral neuritis
Skin: severe irritation and tissue damage

medication
3. Monitor I&O ratio and pattern. High fluid intake promotes excretion and
reduces danger of crystal formation in kidneys
and ureters.
4.Discuss the dosage regimen with patients So that patients know when to stop the drug
who have been using colchicines. before GI aside effects occur.
7. Generic Name: Omeprazole

Brand Name: Losec
Classification: Proton Pump Inhibitor
Dosage; Route; Frequency: 40 mg x 1 dose /10 am
Mechanism of Action: Suppresses gastric secretion by specific inhibition of the hydrogen-
potassium ATPase enzyme system at the secretory surface of the gastric
parietal cells thereby it blocks the final step of acid production.
Desired Effects: This drug was given to our patient to decrease gastric irritation caused by over
secretion of hydrochloric acid.
Side effect: Headache, dizziness, diarrhea, flatulence, nausea, and vomiting
Adverse Effect:
CNS: headache, dizziness, vertigo, insomnia, apathy, anxiety,paresthesia
Skin: rash,urticaria, pruritus, dry skin
GI: diarrhea, abdominal pain, nausea, vomiting, dry mouth, constipation
Respiratory: cough and epistaxis

1. Check for the patency of the IV To avoid wastage of the drug.
line.
2. Advice patient to avoid activities Because it may cause dizziness and drowsiness.
requiring alertness.
3. In cases of rashes, advice patient Because it may lead to bruises and will increase
not to scratch the affected areas. the tendency of infection.
4. Instruct patient to avoid eating sour To prevent further irritation of gastric mucosa.
tasting foods.
5. Instruct patient to avoid eating large To avoid aggravating the condition.
meal.
8. Generic Name: Ketorolac tromethamine

Brand Name: toradol
Classification: Non-steroidal anti-inflammatory drug
Dosage, Route, Frequency: 30 mg x 6 hours x 4 doses
Mechanism of Action: It inhibits synthesis of prostaglandin by inhibiting both COX 1
and COX2 enzymes.
Desired Effects: to relieve pain
Side effect: dizziness, drowsiness, sedation, headache, nausea, vomiting, dyspepsia, constipation
Adverse Effect:
CNS: headache, dizziness, insomnia, fatigue, tinnitus
Skin: rash, pruritus, sweating, dry mucus membrane
GI: nausea, dyspepsia, pain, diarrhea, vomiting, constipation, flatulence

medication
medication administering to a wrong person
4. Caution patient to avoid activities requiring In order to prevent injury since dizziness
alertness until response to medication is known. and drowsiness may occur.
6. Advice client to increase intake of fluids. This is necessary to prevent the

constipating effect of the drug.
9. Generic Name: Celecoxib

Brand Name: Celebrex
Classification: NSAIDS
Dosage, Route, Frequency: 40 mg. Cap. OD
Mechanism of Action: Exhibit anti- inflammatory, analgesic, and anti- pyretic action due to
inhibition of COX- 2 enzyme.
Desired Effects: Non-steroidal anti-inflammatory drug
Side Effect: dizziness, headache, abdominal pain diarrhea, flatulence, nausea
Adverse Effect:
Body as a whole: back pain, peripheral edema
GI: abdominal pain, diarrhea, dyspepsia, flatulence, nausea
CNS: dizziness, headache, insomnia

medication
2.Observed the 10 R's in administering To prevent errors
medication
3 .Instruct patient to take drug with food or
For better absorption thus maximum therapeutic
milk effect of the drug will be achieved and to
prevent GI upset
4. Tell patient to avoid aspirin or other Because it can cause GI bleeding.
NSAIDS during therapy.
NURSING CARE PLAN
1. NURSING DIAGNOSIS: Pain related to inflammation of joints as evidenced by

verbal reports, guarding behavior and a pain scale 6/10.
NURSING INFERENCE: Excessive accumulation of uric acid in the joints causes acute
gouty arthriris which if left untreated will lead to repeated attacks and this may cause tophi
formation. Tophi can cause pain and stiffness in the affected joint.
NURSING GOAL: After 2-3 days of rendering of nursing intervention, the client will be
able to verbalize relief of pain, displayed relaxed manner as well as rest/ sleep appropriately.
NURSING INTERVENTIONS RATIONALE

1. Perform a comprehensive assessment of 1. To provide a base line data and monitors
pain to include location, characteristics, effectiveness of interventions.
onset/duration, frequency and quality.
2. Maintain immobilization of affected part by 2. Relieves pain.
means of bed rest.
3. Perform and supervise active/ passive ROM 3. Maintains strength/ mobility of unaffected
exercises. muscles and facilitates resolution of
inflammation in injured tissues.
4. Provide alternative comfort measures. 4. Improves general circulation; reduces areas
of local pressure and muscle fatigue.
5. Investigate any reports of unusual/ sudden 5. May signal developing complications.
pain or deep, progressive, and poorly localized
pain unrelieved by analgesics.
6. Provide emotional support and encourage 6. Refocuses attention, promotes sense of
use of stress management techniques. control and enhances coping abilities.
7. Administer medication as ordered (toradol) 7. To relieve pain.
NURSING EVALUATION:
After 3 days of rendering of nursing intervention, the client was able to verbalize relief of
pain, displayed relaxed manner as well as rest/ sleep appropriately.
2. NURSING DIAGNOSIS: Impaired physical immobility related to joint pain

evidenced by reluctance to attempt movement, limited range of motion and therapeutic
restriction movement.
NURSING INFERENCE: Acute attacks are characterized by severe pain in the joints,
often in the big toe radiating in the ankle, knee, hip, shoulders, wrist, or elbow that leads the
client to limit or restricted movement as well as alteration in physical capacity.
NURSING GOAL: After 2-3 hours of rendering of appropriate nursing interventions,

the client will be able to maintain position of function and demonstrate techniques that enable
resumption of activities, especially ADLs.
NURSING INTERVENTION RATIONALE

1. Assess degree of immobility/ treatment and 1. Client may be restricted by self- view/ self-
note client’s perception of immobility. perception out of proportion with actual
physical limitations, requiring interventions to
promote progress toward wellness.
2. Encourage participation in diversional / 2. Refocuses attention, enhances client’s sense
recreational activities. Maintain stimulating of control and aids in reducing social isolation.
environment.
3. Instruct/ Assist client in active/passive ROM 3. Increases blood flow to muscles and bone to
exercises of affected and unaffected improve muscle tone, maintain joint mobility.
extremities.
4. Encourage use of isometric exercises 4. Isometrics contract muscles without bending
starting with unaffected limb. joints or moving limbs and help maintain
muscle strength and mass.
5. Assist or encourage self- care activities. 5. Improves muscle strength and circulation,
enhances client control in situation and
promotes self- directed wellness.
6. Monitor BP with resumption of activity. 6. Postural hypertension is a common a
problem following prolonged bed rest
7. Encourage increased fluid intake to 2000- 7. Keeps the body well hydrated, decreasing
3000 mL/day. risk of urinary infection, stone formation, ands
helps to prevent constipation.
8. initiate bowel program(stool softener, 8. to promote regular bowel evacuation and
enema, laxative) as indicated. prevent constipation.
NURSING EVALUATION:
After 3 hours of rendering appropriate nursing interventions, the client was able to
maintain position of function and demonstrate techniques that enable resumption of activities,
especially ADLs.
3. NURSING DIAGNOSIS: Ineffective peripheral tissue perfusion related to

reduction/interruption of blood flow as manifested by poor capillary refill and cold skin.
NURSING INFERENCE: The decrease of RBC in the body leads to decrease oxygen
carrying capacity, hence oxygen supply also decreases, and this will cause decrease tissue
perfusion.
NURSING GOAL: After 2-3 hours of rendering nursing interventions, the client will be
able to demonstrate behaviors/ lifestyle changes to improve circulation and increased perfusion
as individually appropriate.
NURSING INTERVENTIONS RATIONALE

1. Assess capillary return, skin color and 1. Return of color should be rapid (3-5
warmth distal to affected area. seconds). White, cool skin indicates arterial
impairment. Cyanosis suggests venous
impairment.
2. Perform neurovascular assessment, noting 2. Impaired feeling, numbness, tingling,
changes in motor/ Sensory function. Ask increased/diffuse rain occurs when there is
patient to localize pain/ discomfort. inadequate circulation to nerves or nerve
damage.
3. Monitor vital signs. Note signs of general 3. Inadequate circulating volume compromises
pallor/ cyanosis, cool skin, changes in systemic tissue perfusion.
mentation.
4. Encourage client to routinely the exercise 4. Enhances circulation and reduces pooling of
digits/ joints distal to affected area. blood, especially in the lower extremities.
5. Demonstrate or encourage use of relaxation 5. To decrease tension level.
techniques.
6. Assess entire length of affected extremity for 6. Increasing circumference of affected
swelling. Measure affected extremity and extremity may suggest general tissue swelling.
compare with unaffected extremity.
7.Monitor Hgb/hct and prothrombin time 7. Assist in calculation of blood loss and
levels. effectiveness of replacement therapy.
8. Blood transfusion as prescribed. 8. To maintain circulating volume, enhancing
tissue perfusion.
NURSING EVALUATION: After 3 hours of rendering nursing interventions, the client

was able to demonstrate behaviors/ lifestyle changes to improve circulation and increased
perfusion as individually approach.
4. NURSING DIAGNOSIS: Impaired skin integrity related to tophi break through the
skin as evidenced of disruption of skin surface and presence of discharges.
NURSING INFERENCE: In tophaceous gout arthritis, it often produces tophi, which

are solid deposits of Mono Sodium Urate crystals that form in the cartilage, joints, bones, and
elsewhere in the body. In some cases, tophi break through the skin and appear as white or
yellowish –white and this may cause disruption of skin integrity.
NURSING GOAL: After 1-2 weeks of appropriate nursing interventions, the client will
verbalize relief of discomfort and achieve timely wound/ lesion healing.

1. Examine the skin for open wounds and its 1. Provides information regarding skin
discharges. circulation and problems that may require
further medical intervention.
2. Keeps the bed linens dry and free wrinkles. 2. Reduces pressure on susceptible areas and
Place water pads/ other padding under elbows/ risk of abrasions / skin breakdown.
heels as indicated.
3. Keep the area clean/ dry, carefully dress 3. To assists body’s natural process of repair.
wounds.
4. Obtain specimen from draining wounds. 4. To determine appropriate therapy.
5. Refer to dietitian and adhere to prescribed 5. To enhance healing, reduce risk of
diet. recurrence of tophi formation.
NURSING EVALUATION: After 1 week of appropriate nursing interventions, the client will
verbalize relief of discomfort and achieve timely wound/ lesion healing.
5. NURSING DIAGNOSIS: Self-care deficit related to pain and discomfort as

evidenced by impaired ability to perform ADLs.
NURSING INFERENCE: Our patient wasn’t able to get up and walk alone that leads
him to have a deficit in self care activities as well as because of severe pain at and around the
affected joint as characterized like “crushing” or a dislocated bone.
NURSING GOAL: After 2-3 days of rendering nursing interventions, the client will be
able to perform self care activities within level of own ability.
NUSING INTERVENTIONS RATIONALE

1. Determine hygiene needs and provide 1. As the disease progresses, basic hygienic
assistance as needed with in activities, needs may be forgotten.
including care of hair/nails/ skin, brushing
teeth, etc.
2. Inspect skin regularly 2. Presence of such lesions as ecchymoses,
lacerations, and rashes may require treatment,
as well as signal need for closer monitoring/
protective interventions.
3. Supervise but allow as autonomy as 3. Eases the frustration over lost independence.
possible.
4. Be attentive to nonverbal physiologic 4. Sensory loss and language dysfunction may
symptoms. cause client to express self are needs in non
verbal manner.
5. Provide reminders for elimination needs. 5. Loss of control/ independence in this self
Involve in bowel/ bladder program as care activity can have a great impact on self
appropriate. esteem and may limit socialization.
6. Assist with and provide reminders for 6. Good hygiene promotes cleanliness and
pericare after toileting/ incontinence. reduces risk of skin irritation and infection.
7. Incorporate usual routine into activity 7. Maintaining routine may prevent worsening
schedule as possible. of confusion and enhance cooperation.
NURSING EVALUATION: After 2 days of rendering nursing interventions, the client

was able to perform self care activities within level of own ability.
6. NURSING DIAGNOSIS: Sleep pattern disturbance related to pain as manifested by

verbal complaints of difficulty falling asleep, “Han nak unay makaturog ta sumro iti sakit ti
sakak nu rabii ” and presence of eye bag.
NURSING INFERENCE: The abrupt onset of pain of gout arthritis occurs at night,
awakening the patient with severe pain, redness, swelling, and warmth of the affected joint.
NURSING GOAL: After 2-3 days of rendering nursing intervention, the client will be
able to establish adequate sleep pattern and report rested.

1. Assess sleep pattern disturbances that are 1. To identify the most appropriate
associated with specific underlying illnesses. interventions to that specific disease.
2. Observe and obtain feedback from patient 2. To determine usual sleep pattern and provide
regarding usual bedtime, routines, number of comparative baseline data.
hour of sleep, time arising of pain and
environmental factors.
3. Determine patient’s/ SO’s expectations of 3. Provides opportunity to address
adequate sleep. misconceptions/unrealistic expectations as well
as occurrence of pain.
4. Administer pain medication one hour before 4. To relieve discomfort and take maximum
sleep as ordered. advantage of sedative effect.
NURSING EVALUATION: After 3 days of rendering nursing intervention, the client

will be able to establish adequate sleep pattern and report rested.
GENERAL EVALUATION:
Mr. Emong Aguilla, 40 years old, currently residing at Bacarra, Ilocos Norte was
admitted by Dr. Gout at the Mariano Marcos Memorial Hospital and Medical Center, Batac City
on February 11, 2010 at 8:35 in the evening with a chief complaint of swelling of right lower
extremities and with diffuse tophi. His admitting diagnosis was Thopaceous Gouty Arthritis, R/O
Septic Arthritis.
During his stay in the hospital, he had received intravenous therapies, blood transfusion,
medications and surgical debridement. His diet was low purine diet, however, he was also placed
on NPO in preparation for is operation. He had rendered total nursing care at the hospital.

FINAL CASE-GOUT... Print

Uploaded by

Document Information

Original Title

Copyright

Available Formats

Share this document

Share or Embed Document

Sharing Options

Did you find this document useful?

Is this content inappropriate?

Copyright:

Available Formats

FINAL CASE-GOUT... Print

Uploaded by

Copyright:

Available Formats

Divine Word College of Laoag

A case study presented to the

Thopaceous Gouty Arthritis, septic arthritis

Name of Patient: Mr. Emong Aguilla

Address: Bacarra, Ilocos Norte

Hospital number: 438633

Date of Birth: December 11, 1969

Civil Status: Married

Educational Attainment: High School Graduate

Occupation: Tricycle Driver

Chief of complaint: Swelling of the right lower extrimities

Admitting Diagnosis: Thopaceous Gouty Arthritis, R/O Septic Arthritis

Final Diagnosis: Thopaceous Gouty Arthritis, Septic Arthritis

Date and time of admission: February 11, 2010

Attending Physician: Dr. Gout

ANATOMY AND PHYSIOLOGY

Sesamoid bones can be found on joints throughout the body, including:

 In the knee - the patella

TYPES OF BONE CELLS

Classification of joints by range of movement

 Synarthroses - immoveable joints

1. Immovable joints (synarthroses)

Classification of joints by structure

 Fibrous joints - joints composed of dense collagenous or elastic connective tissue

3. Freely movable joints (diarthrosis)

Six types of diarthroses joints

A convex projection on one bone fits into

Elbow/Knee Hinge joint

Rounded or conical surfaces of one bone

The ball-shaped end of one-bone fits into

Oval shaped condyle fits into elliptical

Flat or slightly flat surfaces move against

Intercarpal joints Gliding joint

The largest and innermost toe of the human foot.

Wrist and Hand

The joint between the end of the

It is often characterized as an inflammatory form of arthritis. But unlike the inflammation

Alcohol increases uric acid levels in the following three ways:

 Acute Gouty Arthritis

Symptoms of acute gouty arthritis include:

 Chronic Tophaceous Gout

A risk for tophaceous gout

Three functional causes of Hyperurecemia:

 Increased production of uric acid

 Decreased excretion of uric acid

 You may not have any symptoms.

Drugs or treatments to treat hyperuricemia:

 Non-steroidal anti-inflammatory (NSAID) agents and Tylenol®- such as naproxen

Causes of high uric acid levels include:

Foods that are high in purine include:

Foods that are low in purine include:

Purines are metabolized into uric acid

Chronic septic arthritis (which is less common) is caused by organisms such as

The following increase your risk for septic arthritis:

 Artificial joint implants

 Symptoms in children and adults:

 Inability to move the limb with the infected joint (pseudoparalysis)

 Chills may occur, but are uncommon.

 Blood culture - used to determine if a microorganism is present in the blood

Recovery is good with prompt antibiotic treatment. If treatment is delayed, permanent

Joint degeneration (arthritis)

Preventive (prophylactic) antibiotics may be helpful for people at high risk.

Name Sex Age Educational Occupation Religion Residence