GOUTY ARTHRITIS

1. Arthrocentesis - Synovial fluid aspiration - Fluid specimen obtained by insertion of a needle into a joint space, most commonly the knee, under sterile conditions. - Indicated in undiagnosed articular disease and symptomatic joint effusion.

Purpose: To analyze synovial fluid. To aid in the differential diagnosis of arthritis, especially septic or crystal-induced arthritis To identify the cause or nature of joint effusion To relieve pain and distention form joint effusion To give local drug such as corticosteroids.

Procedure: Preparation: 1. Explain the purpose of the procedure, describing how its done, who will perform it, and who will perform it, and where it will occur. Tell the patient that the test takes less than 15 minutes. 2. Make sure the patient has signed a consent form. 3. Note and report allergies. 4. If glucose testing of synovial fluid is ordered, advise fasting for 6 to 12 hours before the test; otherwise, theres no need to restrict food and fluids before the test. 5. Inform the patient that failure to adhere to dietary restrictions can affect glucose level. 6. Warm the patient that transient pain may occur when the needle penetrates the joint capsule. 7. Give the patient a sedative. Implementation: 1. Test shouldnt be performed nears skin or wound infections. 2. Strict sterile technique used during aspiration prevents contamination of joint space or synovial fluid specimen. 3. The patient is positioned properly and told to maintain this position during the procedure. 4. Skin over puncture site is cleaned and prepared. 5. A local anesthetic is given. 6. As much fluid as possible, preferably at least 15 mL, is aspirated into the syringe. 7. The joint (except the area around the puncture site) is bandaged to compress the free fluid into this portion of the sac, ensuring maximal collection of fluid.

8. If a corticosteroid is injected, the syringe is detached, leaving the needle in the joint. The syringe containing the steroid is attached to the needle, and the steroid is injected. 9. The needle is withdrawn and pressure applied to the puncture site until bleeding stops. 10. The puncture site is cleaned and sterile dressing applied. 11. If measuring synovial fluid glucose, a venipuncture is performed to get a blood glucose analysis specimen. 12. Send the properly labeled specimen to the laboratory immediately. If a white blood cell count is ordered, clearly label the specimen Synovial Fluid and Caution: Dont use acid diluent, because these can alter the count. Patient Care: 1. Apply cold to the affected joint for24 to 36 hours after aspiration to decrease pain and swelling. 2. Use pillows to support the joint. 3. If a large quantity of fluid was aspirated, apply an elastic bandage to prevent fluid from accumulating again. 4. If the patients condition permits, resume the patients normal activities and diet immediately after the procedure. 5. Warn the patient to avoid excessive use of the joint for a few days after the test, even if pain and swelling have subsided. 6. Excessive use can cause transient pain, swelling, and stiffness. 7. Watch for and immediately report increased pain and fever, which could indicate joint infection.

Complications: Joint infection Hemorrhage

Interpretation: Normal results o o o o o Abnormal result o Inflammatory disease (systemic lupus erythematosus, rheumatic fever, pseudogout, gout, and rheumatoid arthritis), noninflammatory disease (traumatic arthritis and osteoarthritis), and septic disease (tuberculous and septic arthritis) Color: colorless to pale yellow Clarity: clear Quantity (in knee): 0.3 to 3.5 ml pH: 7.2 to 7.4 Mucin clot: good

2. Uric acid, serum - Measures serum levels of uric acid, the major and metabolic of purine. - Helps detect disorders of purine metabolism, rapid destruction of nucleic acids, and conditions marked by impaired renal excretion, which typically raise serum uric acid levels. Purpose: To confirm the diagnosis of gout to help detect renal dysfunction

Procedure: Preparation 1. Explain to the patient that the uric acid test detects gout and kidney dysfunction. 2. Tell the patient that the test requires a blood sample. Explain who will perform the venipuncture and when. 3. Notify the laboratory and physician of drugs the patient is taking that may affect test results; it may be necessary to restrict them. 4. Instruct the patient to fast for 8 hours before the test. 5. Explain to the patient that he may experience slight discomfort from the tourniquet and the needle puncture. Implementation 1. Perform a venipuncture and collect the sample in a 3- or 4-ml clot-activator tube. Patient care 1. Apply direct pressure to the venipuncture site until bleeding stops. 2. Inform the patient that he may resume his usual diet and medications stopped before the test.

Complication: Hematoma at the venipuncture site

Interpretation Normal results In men, 3.4 to 7 mg/dl In women, 2.3 to 6 mg/dl

Abnormal results Increased uric acid levels may indicate gout or impaired kidney function.

Levels may also rise in heart failure, glycogen storage disease (type I, von Gierkes disease), infections, hemolytic and sickle cell anemia, polycythemia, neoplasma, and psoriasis. Low uric acid levels may indicate defective tubular absorption (such as Fanconis syndrome) or acute hepatic atrophy.

3. Uric acid, urine - A quantitative analysis of uric acid levels that may supplement serum uric acid levels that may supplement serum uric acid and testing to identify disorders that alter production or excretion of uric acid (such as leukemia, gout, and renal dysfunction) - The most specific laboratory method is spectrophotometric absorption after treatment of the specimen with the enzyme uricase. Purpose: To detect enzyme deficiencies and metabolic disturbances (such as gout) that affect uric acid production To help measure the efficiency of renal clearance and to determine the risk of stone formation.

Procedure: Preparation: 1. Explain to the patient that this test measures the bodys production and excretion of a waste product known as uric acid. 2. Notify the laboratory and physician of drugs the patient is taking that may affect test results; it may be necessary to restrict them. 3. It may be necessary to change the patients diet to one that is low or high in purines before or during urine collection. 4. Tell the patient that the test requires urine collection over a 24hour period, and teach him the proper collection technique.

Implementation: 1. Collect the patients urine over a 24hour period, discarding the first specimen and retaining the last. 2. Send the specimen to the laboratory immediately after the collection is complete.

Patient care: 1. Instruct the patient that he may resume his usual diet and medications.

Complications: None known

Interpretation Normal results: o 250 to 750 mg/24 hours, depending on patients diet.

Abnormal results o Increased levels may result from chronic myeloid leukemia, polycythemia vera, multiple myeloma, early remission in pernicious anemia, lymphosarcoma and lymphatic leukemiaduring radiotherapy, or tubular reabsorption defects, such as Fanconis syndrome and hepatolenticular degeneration (Wilsons disease). Decreased levels occur in gout (when uric acid production is removal but excretion inadequate) and in severe renal damage such as that resulting from chronic glomerulonephritis, diabetic glomerulosclerosis, and collagen disorders

3. X-ray - Skeletal x-rays are used to evaluate extremity pain or discomfort due to trauma, bone abnormalities, or fluid within a joint. Serial skeletal-rays are used to evaluate growth pattern.

Purpose: Procedure: Pretest: 1. Positively identify the patient using at least two unique identifiers before providing care, treatment, or services. 2. Inform the patient that the procedure assesses bone structure of the area examined. 3. Obtain a history of the patients complaints, including a list of known allergens, especially allergies or sensitivities to latex, iodine, seafood, anesthetics, or contrast medium. 4. Obtain a history of the patients musculoskeletal system, symptoms, and results of previously performed laboratory tests and diagnostic and surgical procedures. Assist in detecting bone fracture, dislocation, deformity, and degeneration Evaluate for child abuse Evaluate growth pattern Identify abnormalities of bones, joints, and surrounding tissues Monitor fracture healing process

5. Record the date of the last menstrual period and determine the possibility of pregnancy in premenopausal women. 6. Obtain a list of the patients current medications, including herbs, nutritional supplements. 7. Instruct the patient to inhale deeply and hold his or her breath while the image is taken. Warn the patient that the extremitys position during the procedure may be uncomfortable, but ask the patient to hold very still during the procedure because movement will produce unclear images. 8. Instruct the patient to remove jewelry and other metallic objects from the area to be examined prior to the procedure. 9. There are no food, fluid, or medication restrictions, unless by medical direction. Intra test: 1. Ensure that the patient has removed all external metallic objects from the area to be examined prior to the procedure. 2. Have emergency equipment readily available. Instruct the patient to void prior to the procedure and to change into the gown, robe, and foot coverings provided. 3. Place patient in a standing, sitting, or recumbent position in front of the image holder or electronic receiver. 4. Ask the patient to inhale deeply and hold his or her breath while the x-ray images are taken. 5. Instruct the patient to cooperate fully and to follow directions. Ask the patient to remain still throughout the procedure because movement produces unreliable results. 6. A report of the examination will be sent to the requesting HCP, who will discuss the results with the patient. 7. Recognize anxiety related to test results, and be supportive of impaired activity related to the perceived loss of daily function. Discuss the implications of abnormal test results on the patients lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. 8. Reinforce information given by the patients HCP regarding further testing, treatment, or referral to another HCP. Explain the importance of adhering to the therapy regimen. Answer any questions or address any concerns by the patient or family. 9. Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. 10. Evaluate test results in relation to the patients symptoms and other tests Posttest: 1. A report of the examination will be sent to the requesting HCP, who will discuss the results with the patient.

2. Recognize anxiety related to test results, and be supportive of impaired activity related to the perceived loss of daily function. 3. Discuss the implications of abnormal test results on the patients lifestyle. Provide teaching and information regarding the clinical implications of the test results, as appropriate. 4. Reinforce information given by the patients HCP regarding further testing, treatment, or referral to another HCP. Explain the importance of adhering to the therapy regimen. Answer any questions or address any concerns voiced by the patient or family. 5. Depending on the results of this procedure, additional testing may be performed to evaluate or monitor progression of the disease process and determine the need for a change in therapy. Evaluate test results in relation to the patients symptoms and other tests performed. INTERPRETATION: Normal findings in: o o Infants and children: Thin plate of cartilage, known as growth plate or epiphyseal plate, between the shaft and both ends Adolescents and adults: By age 17, calcification of cartilage plate; no evidence of fracture, congenital abnormalities, tumors, or infection

Abnormal findings in: o o o o o o o o o o o o o o Arthritis Bone degeneration Bone spurs Foreign bodies Fracture Genetic disturbance (achondroplasia, dysplasia, dyostosis) Hormonal disturbance Infection, including osteomyelitis Injury Joint dislocation or effusion Nutritional or metabolic disturbances Osteoporosis or osteopenia Soft-tissue abnormalities Tumor or neoplastic disease (osteogenic sarcoma, Pagets disease, myeloma)