Nursing II Kathleen C. Ashton

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Nursing IIKathleen C. Ashton

• The Client With Alterations in Integrative And
  Regulatory Patterns

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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

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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

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Jaundice - indicates high billirubin

• Types
• Hepatocellular caused by livers 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.

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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

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Diagnostic Tests

• Liver Function Studies
• Billirubin measures livers 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 (gt15 seconds). Vitamin
  K will not return it to normal if severe liver
  damage

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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

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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

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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.

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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

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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

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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.

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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-pancreatogra
  phy - provides direct visualization with removal
  of stone if low enough

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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.

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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.

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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

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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 gt,
  waist gt35in, triglyceride gt150mg, HDL lt 50mg, BP
  gt130/85mmHg.

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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

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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) gt140, 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

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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

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Exercise

• May call for readjustment of dose
• Exercise reduces blood glucose, may reduce need
  for insulin
• Oral anti-diabetic agents used when diet alone
  isnt 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

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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

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Insulin, contd

• 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

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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.
• SS 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

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Complications, contd

• 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
• SS polyuria, polyphagia, polydipsia,
  dehydration followed by oliguria, malaise, visual
  changes, aches, ketone (sweet) breath, Kussmaul
  respirations.
• Give low dose insulin, IVs of NSS and correct
  electrolyte imbalances.

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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

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Complications cont

• 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

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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 Hgb120 days) A1C
  should be lt6.5 for glycemic control

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Neuroendocrine Regulation

• Pituitary Master Gland
• Diabetes Insipidus - disorder of water metabolism
  due to lack of vasopressin (ADH). From trauma,
  tumors
• SS 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.

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Neuroendocrine Regulation

• Thyroid straddles larynx. Good assessment
• Diet 1 mg iodine/week. Needed for hormone
  formation
• Hypofunction BMR decreased to about 40 of
  normal childcretinism, adult Hashimotos
  disease
• SS 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

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Thyroid, cont

• Hyper - Graves Disease most common type
• Affects women 8x more than men.
• SS 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.

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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.
• SS apathy, fatigue, demineralization,
  pathological fractures, constipation, NV,
  psychosis, cardiac disturbances.
• Treatment surgery

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Parathyroids, cont

• Hypoparathyroidism from atrophy or too
  aggressive removal in surgery
• SS hyperphosphotemia, hypocalcemia, tetany
  (stiffness, numbness, tremor), convulsions
• Treatment Give calcium gluconate in emergency,
  OsCal or Tums (calcium carbonate) orally

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Adrenal conditions

• Addisons Disease decreased cortical activity
  from atrophy, TB, or virus (histoplasmosis)
• SS 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

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Cushings Syndrome

• From excessive ACTH or cortisone, hyperplasia of
  cortex or pituitary tumor
• SS 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.

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Considerations with corticosteriods

• Produce same effects as Cushings Syndrome
• Uses
• adrenal insufficiency (eg, Addisons)
• 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!