Nursing Care of the Patient with Rhemuatic Disorders (SLE and Gout)

What are possible nursing problems associated with gout?

- acute pain - impaired physical mobility - altered nutrition: more than requirements - deficient knowledge

What are nonmodifiable risk factors for hyperuricemia and gout?

- age - gender - race - ethnicity

What nervous system clinical manifestations can occur due to SLE?

- difficulty concentrating, confusion - depression - headaches - seizures - "lupus cerebritis"

How is gout diagnosed?

- elevated serum uric acid - 24 hour urine for urine uric acid - aspiration of synovial fluid

What are possible nursing problems of lupus?

- fatigue - impaired skin integrity (skin rash) - impaired comfort or pain - body image disturbance - ineffective coping - deficient knowledge - ineffective self management - risk for infection (low WBCs) - risk for bleeding (low platelets) - ineffective role performance

Collaborative care during SLE exacerbations should be directed toward:

- fever - joint inflammation - limitation of movement - location/degree of discomfort - fatigue - monitor adverse effects of steroid therapy (multiple!) - monitor neuro status

What are modifiable risk factors for gout?

- hyperuricemia - obesity - HTN - hyperlipidemia - ischemic CVD - DM - CKD - dietary factors - alcohol - medications altering urate balance

What are the causes of gouty arthritis?

- inc. uric acid production - dec. uric acid excretion in the kidneys - inc. intake of foods containing purine

A patient with SLE will have psychosocial issues r/t:

- pain and fatigue - chronicity of disease - pregnancy/sexual counseling - body image disturbances

How is joint pain characterized in SLE?

- pain and stiffness tend to move from one part of body to another - does not usually affect both sides of body the same way - only a few joints are affected at any time - typical joints include fingers, wrists, and knees - joints may be swollen and warm (arthritis)

What systems does SLE typically affect?

- skin - joints - serous membranes (pleural, pericaridum) - renal, hematologic, and neurologic system

What is the time it takes for allopurinol to show improvement?

2-6 weeks

What lab value is virtually positive in all patients at some time in course of their SLE disease?

ANA +

What is a more specific indicator of SLE and why?

Anti-DNA antibody testing because these antibodies are rarely found in any other disorder

What is Raynaud's phenomenon?

Autoimmune disease where there is peripheral vasoconstriction of the fingers that is aggravated by stress and cold

How is a patient's ESR and CRP affected by lupus?

ESR and CRP increases

What is chronic tophaceous gout?

This stage eventually appears in the untreated patient (after many years) in the form of tophi in the cartilage, synovial membranes, tendons and soft tissues.

What is gout?

a disease in which defective metabolism of uric acid leads to the deposition of urate salts

When do patients with SLE get butterfly rashes? How long does it last?

after being in sun; lasts couple of days but does not return

What drug is used to treat gout prophylactically?

allopurinol (Zyloprim)

What is lupus?

an autoimmune, multisystem inflammatory disease that is chronic and has unpredictable remissions and exacerbations

What three things are SLE patients at risk of developing that occurs with the bone marrow?

anemia, thrombocytopenia, and mild leukopenia

What should the nurse teach a patient that as SLE?

avoid triggers such as UV light, abruptly stopping drug therapy, and avoiding infections

What does UpToDate recommend in terms of diet in a patient with gout?

caloric restriction, while allowing for increased proportion of protein, replacement of refined with complex CHO, and a decrease in saturated fat

What drugs are used to treat acute gout?

colchicine (usually dramatic relief within 12-24 hrs) and NSAIDs

What is the choice of drug therapy for a patient with SLE dependent on?

depending on predominant symptoms and organ involvement/severity; highly individualized

What is the primary therapy for both acute and chronic gout?

drug therapy

What is a debilitating clinical manifestation of lupus?

extreme fatigue

What are two risk factors for SLE that are non-modifiable?

female and 20-40 years old

What should the nurse focus his/her teaching on for patients that have gout?

focus teaching on modifiable risk factors, such as weight reduction

What foods should a patient with gout try to avoid?

frequent consumption of sugar-sweetened beverages and foods that individually cause flares or increase serum urate levels (e.g. fatty meals, organ-rich foods, beer, or distilled spirits)

What are the most common areas of skin affected by lupus? What about rare?

head area is most common; buttocks and groin area is rare

How can a 24 hour urine for urine uric acid be used to diagnose gout?

helps determine if disease is caused by decreased renal excretion or overproduction of uric acid

What will nearly all patient's with SLE be prescribed?

hydroxychloroquine (Plaquenil)

How does obesity affect gout?

increased adiposity/weight gain increases the gout, while weight loss decreases gout incidence

How can the pain with gout be described?

intense pain often in the great toe. At its worst in the early morning

In addition to hydroxychloroquine, what other drugs would the patient with SLE be on if they had severe/life-threatening symptoms?

intensive immunosuppressants and high-dose steroids to halt tissue injury

Why do patients with lupus have a fever?

it is unexplained

Which clinical manifestation is the earliest symptom of lupus and is the most prevalent?

joint pain

What would a patient's CBC results be if he/she has SLE?

low RBCs, platelets, and WBCs (anemia, thrombocytopenia, and leukopenia)

Where should a gout patient's protein come from?

low-fat dairy products and plant sources of protein, rather than red meat or fish

What manifestation of lupus often puts people in the hospital and occurs within 5 years of diagnosis?

lupus nephritis

How much does following a strict low-purine diet lower blood urate levels? What is the recent trend because of this?

only 15-20%. Recommend: losing weight, taking med, and eating as recommended

What should the nurse implement if a patient is admitted with a gout flare-up?

pain control and joint immobilization

What are manifestations of gout?

pain, inflammation, fever, and malaise

What are tophi?

painless subcutaneous deposits of uric acid crystals

When do gout manifestations peak? How long does it take for a flare-up to dissipate?

peaks at 24-48 hours; can take 5-10 days for flare-up to dissipate

Which clinical manifestation of lupus manifests as rash that appears after exposure?

photosensitivity

A patient with lupus nephritis is assigned to you, the nurse. What would you expect to see if a urinalysis was performed?

proteinuria, hematuria, and blood cell casts

What is gouty arthritis?

recurring acute arthritis characterized by accumulation of uric acid crystals in one or more joints

How is a patient's serum complement affected by SLE?

serum complement decreased (all used up)

In addition to hydroxychloroquine, what other drugs would the patient with SLE be on if they had moderate symptoms?

short-term therapy of 5-15 mg prednisone daily (taper off once Plaquenil takes effect) and/or steroid-sparing immunosuppressant (i.e. methotrexate)

Why should the nurse encourage fluids in a patient with gout?

to maintain an increased urine volume and to prevent precipitation of uric acid in renal tubules

What are common gout hot spots?

toes and to a lesser extent, knees and the ankles

In addition to hydroxychloroquine, what other drugs would the patient with SLE be on if they had mild symptoms?

with or without NSAIDs and/or short-term low-dose glucocorticoids (< 7.5 mg prednisone daily)