Mr. Owens is a 52 year old gentleman with a history of diabetes and hypertension who was mostly non-adherent to medication and follow-up in the community. At the facility, he is prescribed metformin 500 mg BID and lisinopril 20 mg QD. he has been incarcerated for about 10 weeks, and his blood sugars have been averaging 140 mg/DL and his blood pressures have been in the range of 140-170 systolic and 80-100 diastolic. Today he is seen in Nurse Sick Call for pain and swelling in his right great toe. He denies trauma, stating that he “just woke up like this” yesterday.
WHAT ADDITIONAL QUESTIONS WILL YOU ASK?
Has this even happened before? If yes – what happened? What was done as a treatment? Did it resolve?
Mr. Owens states that he cannot remember for sure, but he thinks that he had the same thing last winter. He was treated in the emergency department and given a pain medication and something for the “redness.” It did get better.
PHYSICAL EXAMINATION
You then conduct your nursing evaluation, including his feet.
- Vital Signs: 142/90 blood pressure; 82 beats per minute; 16 breaths per minute; oxygen saturation 98%; temperature 97.9 ℉; blood sugar 138
- Alert, oriented X 4; gait favoring right foot
- Lungs clear bilaterally without adventitious sounds
- Heart S1S2 without murmur, gallops or rubs heard
- Abdomen soft, non-tender to palpation with +bowel sounds all four quadrants
- Right great toe swollen +2, with erythema and very tender to palpation. Skin intact with no s/s of trauma and sensation is intact to foot dorsum, sole, and all toes. Left foot is unremarkable.
Why did you measure vital signs for a toe problem? Why did you obtain a blood sugar – it was done earlier in the day?
WHAT DO YOU DO NEXT?
You call the provider, who orders labs (complete metabolic panel, complete blood count and uric acid), and presumptively treats Mr. Owens for gout with indomethacin 50 mg QD and colchicine 0.6 mg BID day one, then 0.6 mg QD for 5 days. You read back the order and document all in the health record.
WHAT DO YOU DO NEXT?
You provide patient education concerning medication side effects (colchicine may cause loose stools; indomethacin is a Non-Steroidal Anti-Inflammatory medication and he must watch for gastric bleeding); expect to see resolution in 3-5 days – return to clinic if no improvement in 48 hours; and try to avoid a diet high in purines (cauliflower, spinach, and mushrooms; oatmeal; red meat, organ meat, bacon and seafood). Consuming foods high in fructose and foods high in fat may interfere with the processing of purines, increasing the risk of another gout attack.
Please share any experiences you have had in your practice with patients presenting with gout, below.
*As always, your company or facility policies, procedures and Nursing Protocols/Guidelines take precedence over any written recommendations on this website.
Leave a Reply