Nursing II Kathleen C. Ashton The Client With Alterations in Integrative And Regulatory Patterns.

Nursing IIKathleen C. Ashton

The Client With Alterations in Integrative And Regulatory Patterns

The Liver Largest organ of the body (with exception of

skin) Divided into 4 lobes: right and left caudate and

right and left quadrate Two blood supply sources:

portal vein from gi tract brings nutrients, and toxins for processing

hepatic artery is source of oxygen Drained by hepatic vein Responsible for regulation of glucose and protein

metabolism, bile production, and circulatory blood reserve

Assessment

Inspection: look for jaundice Ascites vs. anasarca Palpation: liver edge may be palpable in

right upper quadrant on inspiration. Tenderness indicates enlargement

Percussion: dullness delineates borders

Jaundice - indicates high billirubin

Types: Hepatocellular: caused by liver’s inability to

remove billirubin from the blood. Liver damage may be result of infection (hepatitis A, B, or C) or drug or chemical toxicity. May be result of cirrhosis.

Obstructive: bile duct is plugged by tumor, gallstone, or inflammation.

Effects of Jaundice Excess bile in blood carried throughout

body. Stains skin, mucous membranes and sclera.

Urine turns deep orange and foamy. No bile in gi tract, so stools become clay

colored or light brown. Pruritis: may be relieved by oil baths Fatty food intolerance may accompany

jaundice

Diagnostic Tests Liver Function Studies:

Billirubin: measures liver’s ability to conjugate and excrete billirubin. Levels increase with impaired excretion. Measured in blood and urine.

Prothrombin time: Pro time or PT will be prolonged in liver disease (>15 seconds). Vitamin K will not return it to normal if severe liver damage

Serum enzymes

AST - aspartate aminotranferase ALT - alanine aminotransferase LDH - lactic dehydrogenase These enzymes are released into the blood stream

with parenchymal damage. May also indicate other organ damage.

Ammonia increases with liver disease Cholesterol increases with biliary obstruction,

decreases with parenchymal disease

Other tests Liver scan: to detect tumors, show size and shape

of liver. May use Technetium Barium swallow (upper gi) shows esophageal

varices which indicate increased portal pressure Angiography looks at vessels Liver biopsy: invasively samples tissue for

histologic study. Nursing implications: Check pro time first to ascertain bleeding

abnormalities Needle is inserted as patient holds breath after

expiration to bring liver against chest wall Afterwards, position on right side to prevent bleeding Bedrest for 1-2 hours

Results of Liver Dysfunction Portal hypertension: elevated blood pressure

reflected throughout the portal venous system. Results in:

Esophageal, gastric, & hemorrhoidal varices from high BP in all veins that drain into the portal system.

Likely to rupture and bleed. Worsened by blood clotting abnormalities

Surgical interventions: portacaval shunt - directs some blood into vena cava, bypasses liver. Various types.

Other Complications Ascites - assessed by:

percussion for fluid wave bulging flanks when lying supine Management:

record abdominal girth daily weight low salt intake diuretics salt-poor albumin helps increase serum osmotic pressure and

draw fluid back into the bloodstream for excretion by the kidneys

paracentesis may be used to remove up to 2-3 liters of fluid from the abdomen

More complications

Nutritional deficiencies: more pronounced when alcohol is involved. Need ample quantities of vitamins A, B complex, C, K, and folic acid

Bleeding abnormalities: bruising, nosebleeds, gi bleeds

Altered glucose metabolism Increased sensitivity to drugs - reduced dosages

required

Biliary conditions Cholecystitis: inflammation or infection of the

gall bladder Cholelithiasis: gallstones composed of either

cholesterol or pigment 95% of people with cholecystitis have gall stones Assessment: “Fair, fat, female and forty”

may have symptoms related to diseased gall bladder or symptoms related to blocked bile ducts

fried or fatty food ingestion typically causes bloating, fullness, pain. May have fever if gall bladder infected.

Pain: severe, colicky, & may radiate to shoulders or back.

Signs and Symptoms

Obstruction may produce jaundice in some people.

Nausea and vomiting common Dark urine, clay colored stools Diagnosis:

Ultrasound to detect obstruction or stones ERCP: endoscopic retrograde cholangio-

pancreatography - provides direct visualization with removal of stone if low enough

Management

Diet: low fat, fluids Actigall: dissolves cholesterol stones, takes

months up to 5 years Lithotripsy shatters stones via shock waves Surgery: cholecystectomy: removal of gall

bladder. Laproscopic if first attack. Faster recovery, can be up in 4 hours. Traditional surgery requires incision, T-tube which drains bile until swelling subsides (up to 500 ml. in first 24 hours) and Jackson-Pratt drain. T-tube clamped for 2 hours before meals to add bile. Unclamp if emesis.

Discharge Planning Tubes removed in 1-2 weeks post op Morphine used with caution – can cause spasms

of sphincter of Oddi Diet: Low fat, high protein and high carbohydrate Fat restriction lifted 4-6 weeks post op when

biliary ducts able to accommodate the bile previously stored by gall bladder.

Care of skin, incision, and drainage tubes - bile is corrosive to skin.

Diabetes A chronic disease involving the inability to

synthesize insulin Prevalence felt to be related to longevity,

obesity and increased standard of living Etiology is unclear Involves genetics, auto-immune response,

virus, obesity, infection Affects over 18 million Americans with 1.3

new cases/year – an epidemic

Types Type 1 - Insulin-dependent, pancreas does not

produce sufficient insulin. Requires injections. Type 2 - Non-insulin dependent, insufficient insulin

used or cells are not sensitive to insulin. Increase among adolescents.

Gestational - diabetes developed during pregnancy Individuals may move from one category to

another. Metabolic Syndrome – predictive – FBS 110mg or

>, waist >35in, triglyceride >150mg, HDL < 50mg, BP >130/85mmHg.

Type 1 (formerly IDDM) Usually begins in childhood, may occur in adults Weight loss, polydipsia, polyuria, polyphagia,

weakness Ketosis leads to ketoacidosis (DKA), from

protein breakdown Kussmaul respirations - fast and deep Insulin needed for life Maintenance of glucose levels below 150 may

forestall retinopathy, neuropathy, nephropathy, sexual concerns and cardiovascular effects

Type 2 (Formerly NIDDM) Usually occurs after age 40, associated with

obesity Frequently discovered when complications

develop: vision problems, leg pain, impotence Prone to vascular complications Diagnosis:

glucose tolerance test (GTT) >140, tests for high glucose levels after ingestion of high carbohydrates. Necessary for accurate diagnosis. FBS may be normal. May only have elevated GTT and signs and symptoms.

Blood samples more reliable than urine samples

Management - Diet and Exercise Diet:

meet nutritional and energy needs maintain ideal weight reduce blood lipid levels maintain normal blood glucose levels High protein, high fiber to assist in glucose

absorption 55-60% protein, 30% or less fat, 12-15%

carbohydrate Patient teaching aimed at variety and

acceptability Complex carbohydrates gaining approval over

simple carbohydrates

Exercise

May call for readjustment of dose Exercise reduces blood glucose, may

reduce need for insulin Oral anti-diabetic agents used when diet

alone isn’t enough; these directly stimulate pancreas to secrete insulin

Used with diet to achieve lower glucose When oral agents no longer work, may

need insulin injections

Insulin An interdependent function - nurse and physician

work together to determine proper dosage Regular insulin given with intermediate and

increased until urine free of glucose and the pre-prandial glucose level near normal

Teaching: technique for administration aspiration not necessary and no need to rotate sites

with Humelin complications

Insulin, cont’d Glucose monitoring mostly a client function

using a variety of devices Teach: importance, accuracy, and recording Blood monitoring more accurate than urine which

depends on kidney function Insulin delivery pumps deliver dosage over a 24

hour period. Size of a beeper. Cost: $1500 to $3000. Must be used with a monitoring system. May alter body image and be a reminder of diabetes.

Types of insulin: Regular, long-acting, 70/30

Complications Insulin reaction - hypoglycemia - usually before

meals but can be at any time. Glucose below 50 or 60 mg. From increased exercise, increased insulin, or lack of food. May be from NPH or lente insulin peaking.

S&S: weakness, headache, sweating, tremor, palpitations, mental changes. Will lead to coma.

Give juice with sugar Memory aid: Symptom Implication Cold and clammy… give hard candy Hot and dry... glucose is high

Complications, cont’d Ketoacidosis (DKA) - lack of insulin from

abnormal metabolism of protein, fat & carbohydrates

Three main clinical features: dehydration, electrolyte loss & acidosis

May be triggered by an infection S&S: polyuria, polyphagia, polydipsia,

dehydration followed by oliguria, malaise, visual changes, aches, ketone (sweet) breath, & Kussmaul respirations.

Give low dose insulin, IV’s of NSS and correct electrolyte imbalances.

Other complications Vascular complications: blood vessels lose

elasticity legs and peripheral circulation affected most kidney failure common with Type I - may be

from diabetes or from insulin administration Eye disorders: vessels become fragile hemorrhaging in fundus Neuropathy: widespread throughout body Results in sexual dysfunction, impotence Research on women lacking

Complications con’t Foot and leg problems: teach about care Trim toenails slightly rounded Well-fitting shoes, clean socks, avoid cold Infections: can be fatal. Adjust insulin

doses Encourage vaccines for prevention Prevent injury Good teaching Involve the family

Newer Developments New drugs coming out almost daily For Type 2:

Glucotrol: stimulates release of insulin from pancreas Glucophage: reduces hepatic production of glucose Avandia: reduces or ends dependence on insulin

injections. Resensitizes the body to insulin, makes better use of insulin.

HbA1C determines average blood glucose over previous 3 months (life of Hgb=120 days) A1C should be <6.5% for glycemic control

Neuroendocrine Regulation Pituitary: “Master Gland”

Diabetes Insipidus - disorder of water metabolism due to lack of vasopressin (ADH). From trauma, tumors

S&S: increased thirst, increased output of dilute, water-like urine (10-20 liters/day). ADH given for life.

Giantism - from excessive growth hormone in child before closure of epiphyses. May grow to 8 or 9 feet. Results in HBP, cardiomegaly, osteoporosis, and muscle weakness

Acromegaly - Tumor which secretes growth hormone. Occurs after puberty. Hands, feet, and jaw enlarge. Abe Lincoln.

Neuroendocrine Regulation Thyroid: straddles larynx. Good assessment Diet: 1 mg iodine/week. Needed for hormone

formation Hypofunction: BMR decreased to about 40% of

normal: child:cretinism, adult: Hashimoto’s disease S&S: tired, menstrual disturbances, dry skin, brittle

nails, hair loss, loss of libido, numbness Severe - Myxedema - weight gain, subnormal

temperature, apathetic, slow speech, pale, menstrual disturbances

Occurs 5x more often in women, usually between age 30 & 60. Synthroid given as replacement

Thyroid, con’t Hyper - Graves’ Disease – most common type Affects women 8x more than men. S&S: rapid pulse, weight loss, weakness, HBP,

palpitations, diaphoresis, amenorrhea, thyroid enlargement, exophthalmos

If untreated, results in death from tachycardia Treatment: radiation, surgery, drugs to block

hormones. Tapazole commonly used. Goiter: a tumor that is large enough to produce

swelling. From lack of iodine or excess lithium Thyroid Storm: crisis. Fever, tachycardia, coma.

Parathyroid Glands Usually 4, may be 6 or 8. Lie behind thyroid. Produce parathormone, maintain calcium level,

help excrete phosphorus Hyperparathyroidism:

1o - increased growth of glands leads to bony calcifications and renal stones

2o - from renal problems - phosphorus elevates, so parathyroids overwork.

S&S: apathy, fatigue, demineralization, pathological fractures, constipation, N&V, psychosis, cardiac disturbances.

Treatment: surgery

Parathyroids, con’t

Hypoparathyroidism: from atrophy or too aggressive removal in surgery

S&S: hyperphosphotemia, hypocalcemia, tetany (stiffness, numbness, tremor), convulsions

Treatment: Give calcium gluconate in emergency, OsCal or Tums (calcium carbonate) orally

Adrenal conditions Addison’s Disease: decreased cortical

activity from atrophy, TB, or virus (histoplasmosis)

S&S: weakness, fatigue, emaciation, dark pigmentation, low BP, low glucose and sodium, reduced BMR, high potassium, dehydration

Treatment: correct electrolyte imbalance, give cortisol for life. May be exacerbated by stress

Cushing’s Syndrome From excessive ACTH or cortisone, hyperplasia of

cortex or pituitary tumor S&S: high sodium & glucose, low K, increased

cortisol, increased bone age, stunted growth, hirsuitism, amenorrhea, breast atrophy, “buffalo hump”, masculinization, thin ecchymotic skin, round face with increased oil and hair, decreased libido, osteoporosis, HBP, “moon face”.

Treatment: Diet: High protein and potassium, low carbohydrate and sodium. Surgery for pituitary tumor.

Considerations with corticosteriods Produce same effects as Cushing’s Syndrome Uses:

adrenal insufficiency (eg, Addison’s) anti-inflammatory anti-allergy

Higher doses result in more effects & more danger: moon face, buffalo hump, abnormal distribution of

body fat, peptic ulcer, osteoporosis, infections from lack of defenses

CNS effects: euphoria, gregariousness, mood swings, depression. May stunt growth in children.

Give early morning and withdraw gradually!