NAME: J.

A CHIEF COMPLAINT: Generalized pain R foot – sole, lateral ankle and dorsum, worse at night
AGE: 51 y.o. DIAGNOSIS: Gout / Septic Arthritis
SEX: F

Nursing Care Plan:

NURSING
CUES OUTCOME CRITERIA INTERVENTION RATIONALE EVALUATION DISCHARGE PLANNING
DIAGNOSIS
Subjective -Acute pain related Short term: Independent Short Term: M – Educate the patient the
to injuring agents After 8 hours of Perform a comprehensive Thorough assessment of 1. Met. The patient was importance of meticulous
Patient complained of secondary to Gout effective nursing assessment of pain include pain will help the health able to verbalize a compliance with prescribed drug
generalized pain in right as evidenced by intervention, the patient location, characteristic, care provider understand reduced severity in therapy. Drugs must be taken in the
foot in the sole, lateral Pain in right foot, will be able to: onset, duration, frequency, and manage the pain the right foot (5/10 right dose, time, and route. Also
ankle and dorsum (with Tenderness, quality, intensity or better as it provides more pain rating scale) advise patient to follow the
a pain rating scale of Swelling over lateral 1. Verbalize a severity, and precipitating specific data regarding and displays a instructions of his physician.
7/10) that becomes ankle malleolus and reduce severity factors. the pain relaxed manner.
worse at night. hot erythema over of pain in the Monitor vital signs of This will provide basis of E – Instruct patient and folks that a
lateral aspect. right foot from patient. the client’s status. safe must be ensured. In addition, a
Objective 7/10 to 5/10. Eliminate additional Patient who are 2. Met. The patient quiet and peaceful environment is
Clinical Examination stressors or other sources experiencing pain have exhibit decreased needed for adequate rest to regain
Revealed 2. Exhibit a of discomfort. decreased ability to redness and strength and aid in recuperation.
decrease tolerate painful stimuli. A inflammation of the Stressors or sources of discomfort
 Pain in right foot redness and stressful environmental, right foot should be avoided and encourage
inflammation of interpersonal, or rest periods in between ADL
 Tender, Swelling
the right foot. intrapsychic factors are 3. Met. The patient
over lateral ankle
further stresses. demonstrate use of T – Teach the patient effective
malleolus
3. Demonstrate Encourage frequent Prevents general fatigue pain coping timing of the medication dose in
 Hot, erythema
pain coping changes of position. Assist and joint stiffness. techniques such as relation to potentially uncomfortable
over lateral
techniques the patient to move in bed, Stabilizes joint, repositioning, activities and the prevention of peak
aspect.
supporting affected joints decreasing joint imagery, and pain periods in order to minimize
Long Term: above and below, avoiding movement and breathing exercises pain experiences.
Medical History
After 2 weeks of jerky movements. associated pain.
revealed: Educate patient on non- Non-pharmacologic
effective nursing Long Term: H – Advise patient or folks that
pharmacologic measures measures show evidence
 Left foot stress intervention, the patient when doing activities, have rest
such relaxation techniques, of improving pain
fracture 4th will be able to: 1. Met. The patient periods to avoid straining the
and deep breathing experience. They can
metatarsal demonstrates proper recovering joint.
exercises. further help the patient use of adaptive
 Pt been relax.
1. Demonstrate device (crutches) to Avoid doing strenuous activities and
weightbearing on Provide Rest Periods to Patient’s experiences of
 NURSING
CUES OUTCOME CRITERIA INTERVENTION RATIONALE EVALUATION DISCHARGE PLANNING
DIAGNOSIS
right foot for 1/12 an increased facilitate comfort, sleep, pain may become assist in Mobility. use an icepack if the injury feels
years strength or and relaxation exaggerated as the result painful or if swelling occurs
 Hypertension endurance of of fatigue and exhaustion.
2. Met. The patient
due Cholesterol injured limb. A quite environment, a O – Instruct the Patient to follow the
exhibits an
 Left shoulder darkened room, are schedule of his physician for follow-
increased strength
replacement and 2. Demonstrate measures toward up check-up (a week after) or
and endurance of
bone graft proper use of facilitating rest contact immediately if any
injured limb by
 Left knee adaptive device Promote measures to Providing measures that underlying signs and symptoms
executing ADLs with
arthroscopy (3 to improve prevent exacerbations prevents exacerbation will occur.
no problem.
times) mobility lessen the risk of the
 (+) Allergy to patient worsening his D – Teach the client about dietary
Iodine condition. This includes modifications to limit foods high in
Urging the patient to drink purine (e.g. organ meats,
Laboratory Tests 2 to 3 L of fluid daily if not anchovies, sardines, shellfish,
Revealed: contraindicated and to chocolate, meat extracts).also,
report any decrease in avoid or limit the consumption of
 C-Reactive urine output. alcohol.
Protein: 37.6
Dependent S – Support from family members or
(elevated) Administer NSAIDs NSAID under the significant others is vital in the
(Aspirin) as ordered. Pharmacologic Class patient’s recuperation. Encourage
Salicylate. Thought to family members and friends to
produce analgesia and provide emotional support for the
exert its anti-inflammatory patient. (support groups)
effect by inhibiting
prostaglandin and other S – Encourage patient to coordinate
substances that sensitize with respective spiritual leaders to
pain receptors. promote spiritual upliftment. Pray
Administer Colchicine -Antigout drug under the
with the whole family.
1mg TID as ordered by the pharmacologic class
physician. colchicum autumnale
alkaloids. Involves a
reduction in lactic acid
produced by leukocytes,
reducing uric acid
deposits and
phagocytosis thereby
 NURSING
CUES OUTCOME CRITERIA INTERVENTION RATIONALE EVALUATION DISCHARGE PLANNING
DIAGNOSIS
decreasing the
inflammatory process
Continue Allopurinol as -Antigout drug under the
ordered by the physician. pharmacologic class
Xantine Oxidase
Inhibitors. Reduces uric
acid production by
inhibiting xanthine
oxidase

Collaborative
Collaborate with the Surgical interventions
Operating Room (OR) may be needed if
Department for the medications may not work
possible surgery as for the patient. This is to
ordered by the physician. prevent further loss of
vision.

Refer patient to Physical The use of an adaptive

REFERENCES

https://www.rnpedia.com/nursing-notes/medical-surgical-nursing-notes/gouty-arthritis-nursing-management/
-2017, Nursing Drug Handbook –An evidence based guide to planning care, 11th Edition, Elsevier.
-2013, Lyndia Carpenito, Nursing Diagnosis-Application to clinical practice, 14th edition, Wolters Kluwer
-Vera, M. (2019) “Rheumatoid Arthritis Nursing Care Plans” NurseLabs retrieved on May 10, 2021 from: https://nurseslabs.com/6-rheumatoid-arthritis-nursing-care-plans/?fbclid=IwAR1-
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