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N107 University of the Philippines College of Nursing, Class 2010 Nursing Care of Clients with Alterations in Nutrition and Metabolism LAN Cajucom Liver, pancreas, gallbladder bile problem; cholelithiasis is an emergency because it is Diabetes and thyroid problems, pituitary disorders only detected in the late stage; PU – heartburn and regurgitation; high fat intake; do medications diminish the pain or discomfort?; duodenal/gastric ulcer is not Application of the Nursing Process to the overproduction of acid and will therefore not be relieved Clients with Nutritional and Metabolic by antacids and eating, antacids are only given to Alterations adequately control the pain) Focused Assessment of Patient with Hypertension and g. Difficulty in swallowing (dysphagia): onset (i.e. GERD; Nephropathy secondary to Diabetes may be neurologic problem) Gordon’s patterns indicate specific areas which makes h. Difficulty tolerating certain foods: allergies, malabsorption person at risk syndromes (note lactose intolerance so that care and Chief complaint (Is this a sign of metabolic or nutritional advice given will be appropriate) alteration or is it already a complication?) i. Vomiting or Nausea: character of vomiting; amount, History of present illness (Events leading to chief characteristics, pattern of nausea, relationship to intake or complaint) other events (liver, endocrine diseases manifest with Past medical history (Examine conditions that may have vomiting and nausea; projectile vomiting is manifestation contributed to current problem i.e. liver disease – did of neuro problem; other event: smelled something foul or client have abdominal pain or jaundice?) rode a vehicle) Family history (Non-communicable/Genetic diseases; TB is j. Abdominal distention, flatus, belching, fullness (manifests included because it has high communicability) even with liver disease) Health maintenance and management k. History of abdominal surgery or trauma (Past medical Lifestyle (risk factor assessment) history: do you have any operations? Where? Any medical Does not eat on time (peptic ulcer disease, GERD) surgery predisposes the patient to adhesions, especially if Picky on foods eaten abdominal; abdominal pain with constipation may be Takes supplements which may have contraindications related to a possible adhesion; surgery is assessment cue to the medications the patient is taking i.e. TB meds for adhesion) with herbal meds l. Bleeding: onset, duration and extent (liver disease Patients who smoke have a high probability of predisposes patient to bleeding tendency) developing cancer i.e. lungs and GIT m. Alcohol intake n. Assessment a. b. c. d. e. f. Health History Physical Examination Dietary pattern; changes in appetite (other than the Inspection: Skin: color (jaundice), bruises, hemaotmas (absorption intake, examiner looks at the appetite and body composition – appropriateness of the pattern to the physical appearance seen and physical exam conducted i.e. small intake, fat body and/or large intake, thin physique; drinking pattern because diabetes insipidus produces thirst) - Weight compared to IBW, changes in weight (how much, time period, planned vs. unplanned) (sudden weight changes or clothes that fit before do not fit now; how much weight loss, measure if possible; it is normal to lose 2 lbs in 1 week) - Changes in energy level: weakness, fatigue and general malaise (Activity and Exercise Pattern; Do you do activities (i.e. bathing, shopping) without any effort/difficulty or Are you able to do it the same way you did it prior to manifestations of your illness?) Stool: changes in frequency, consistency, color, character (Elimination Pattern; changes in frequency of elimination with no changes in intake may be sign of a metabolic or electrolyte problem; increase and absence of bile changes color of stool) Urine: color, frequency, amount (Cushing’s and Addison’s disease, SIADH, Diabetes alter urine frequency and specific gravity) - problem – pernicious and megaloblastic anemia; pallor – iron-deficiency anemia; jaundice – liver disease; bruises – bleeding tendencies; also check the conjunctiva) Oral assessment: teeth, gums, tongue, tonsils and mucous membranes; note use of mechanical devices (braces, dentures, oral suction) (color and integrity of mucous membranes; dry and cracked mucous membranes if patient is malnourished; ET tube can alter mucous membranes because of oral suction) Abdomen: visible peristalsis, pulsations or masses, contour: rounded, protuberant, concave, asymmetry; striae, spider angiomas, engorged veins (Small bowel obstruction manifests with visible peristalsis in the opposite direction/going up, also manifests with foulsmelling breath (smells like feces); be careful with the masses; visible pulsations may be a mass that is pushing over a vessel or aneurysm; visible veins or arteries; striae gravidarum for pregnant women; striae present in hepatomegaly or ascites) Anorectal area: rash, hemorrhoids (inform physician if hemorrhoids is present in patient with constipation) Auscultation: listen to all four quadrants of the abdomen Bowel sounds: location, frequency, characteristics; take note of: hyperperistalsis, paralytic ileus, borborygmi (prior Indigestion, heartburn/regurgitation: pattern, frequency – drugs used, effectiveness (fat malabsorption occurs with 6/27/2017 Family history (cancer in the GIT, peptic ulcer, Hirschsprung’s disease), lifestyle pattern (preferred food, frequency of food intake, etc.) 1 T&E by: Nel, Lea, Gela, Niq, Dous, Gwen, Talz N107 University of the Philippines College of Nursing, Class 2010 - Nursing Care of Clients with Alterations in Nutrition and Metabolism LAN Cajucom to obstruction has bowel sound while distal to it has If you identify a mass, first distinguish it from a absent bowel sound; prior to obstruction may be normally palpable structure or enlarged organ. Then hyperperistaltic, distal not) note its: Sites to auscultate for bruits (if pulsation is noted in other Location areas other than those mentioned, there may be masses Size pushing on the vessels) Shape Aorta Right and left renal artery Right and left iliac artery Right and left femoral artery Percussion Stomach: tympany Liver: dull (assess borders; feces in the stomach may - manifest with dullness) Large intestine: check for gaseous distention – increased tympany Six F’s of Abdominal Distention Fat Flatus (hypertympanitic when percussed) Fluid (fluid wave is felt, not seen; dull when - percussed) Fetus (dull when percussed) - - - Feces Fatal growth (myoma is usually non-fatal) Systematic Route for Abdominal Percussion General tympany – percuss lightly in all four quadrants. Tympany should predominate because air in the intestines rises to the surface when the person is supine. Abnormal findings: dullness occurs over Do not percuss or palpate in clients with suspected abdominal aneurysm or those who have received abdominal organ transplants Perform these techniques cautiously in clients with suspected appendicitis - - If cancer, minimal percussion and palpation only because lesions may metastasize. Spleenic Dullness Locate it by a dull note from the 9th-11th intercostal space just behind the left midaxillary line The area of spleenic dullness is normally not wider than 7 cm in the adult and should not encroach on the normal tympany over the gastric air bubble (wider - than 7 cm indicates splenomegaly) - - with pain, do not do deep palpation, only superficial) Masses (Locate properly using the 4 quadrants and 9 regions) Skin: skin turgor, moisture (if abdomen is overdistended, it usually dries up; skin turgor is assessed in the abdomen for children) In some cases, DRE may be done (manual evacuation of the rectum; DRE is done for prostate cancer and for internal hemorrhoids (when patient has fresh bleeding; ask patient to cough and hemorrhoids will come it)) Tenderness compressed by mass) *Cancer nodules/cells are not localized or has diffused boundaries with irregular shape Abdominal Structures Frequently Mistaken as Masses Fecal material Uterus Palpation of the Liver Differentiation of enlarged spleen with enlarged left kidney (if kidney, usually at the bottom; if spleen usually above) Normal venous pattern: half upwards, half downwards; Portal Hypertension: all directions: esophageal varices when venous pattern is going up and hemorrhoids when venous pattern is going down Assessment of Ascites Fluid wave Shifting dullness (opposite from side where dullness is felt, percuss; fluid pools in one side with the other side tympanitic) Palpation to elicit rebound tenderness General Nursing Interventions for patients undergoing diagnostic tests: a. Provide general information about the test and the activities involved b. Instructions about pre and post procedure care including activity restrictions (KUB ultrasound – drink c. d. e. f. lots of water and do not urinate, especially for pre and post void ultrasound. Inform client about the purpose) Alleviate anxiety (especially for invasive procedures) Help patient cope with discomfort Encourage family members to offer emotional support Assess adequate hydration, before, during and after tests (especially for those tests with dye) Hematologic Studies CBC Serum electrolytes Liver function tests: AST (SGOT), ALT (SGPT), Alkaline phosphatase, Ammonia, Albumin, Globulin, Total protein Moderate Palpation Deep Palpation Description of masses 6/27/2017 Consistency (soft, firm, hard) Surface (smooth, nodular) Mobility (movement with respirations) Pulsatility (vessel is involved – has mass or Diagnostic Examinations (Significance of findings: interpretation (decreased/increased), relation to the sickness (normal (area has not yet been affected i.e. although patient is diabetic, the kidney is still able to function based on normal values of crea and BUN), alteration), implications to care (what do you need to do as a nurse, what do you watch out for based on lab values)) Palpation Note areas of pain, tenderness; organ size and position (If - 2 T&E by: Nel, Lea, Gela, Niq, Dous, Gwen, Talz University of the Philippines College of Nursing, Class 2010 - N107 Nursing Care of Clients with Alterations in Nutrition and Metabolism LAN Cajucom Hepatobiliary Function Test: Total bilirubin, Direct and indirect bilirubin, Cholesterol, Triglyceride, Prothrombin time GI function: Gastrin Pancreatic function: Serum glucose, Lipase, Amylase - Catch early on so that complications may not arise i.e. gas exchange problem, decreased CO General Nursing Planning, Implementation and Evaluation Urine and Stool Exams Urine tests: glucose, acetone, urobilinogen Stool tests: ova and parasites (stool must be warm); occult blood (guaic); fecal fat (after a 24-72 hour collection; stool culture (liver problem due to parasite) Goal 1: Client will eat diet that conforms to prescribed restrictions yet contains all needed nutrients (i.e. At end of 1 week, client will have balanced nutrition or have adequate nutrition.) - Special Tests Breath test Flat plate of abdomen Upper GI series (barium swallow) Lower GI series (barium enema) Cholecystography IV Cholangiography Percutaneous transhepatic cholangiography HBT ultrasound (fasting) Endoscopy (upper GI – anesthetic agent; pre: NPO, meds - to suppress regurgitation; post: gag reflex) Schilling test (pernicious anemia) Identify reason for vitamin B12 deficits Nursing care: keep NPO 8-12 hours before exam; follow administration of radioactive Vit B12, administer Vit B12 IM as directed (usually 1-2 hours after); start 24 hour urine collection after IM injection to assess level of radioactive Vit B12 excreted (normal is 8-40% excretion within 24 hrs); allow client to resume eating after IM injection Biopsies Precutaneous liver biopsy Blind needle biopsy of liver tissue to establish a microscopic picture of the liver Nursing care pre-test: check prothrombin time (if less than 40%, it should not be done); check platelet count (defer if less than 100,000); instruct client to exhale and hold breath for 1-2 seconds while biopsy is being done and not to move during procedure (diaphragm/lungs may be punctured or needle may deviate); client may be placed on supine position with right arm under the head during procedure Nursing care post test: have client lie on right side with pillow or sandbag over the insertion point under costal margin for 1-2 hours Closely monitor vital signs as ordered for 24 hours (internal bleeding) Assess for pain or respiratory distress (punctured Common Nursing Diagnoses Imbalanced Nutrition: Less/More than Body Requirements Acute pain Risk for deficient/excess fluid volume Risk for imbalanced fluid volume (relative excess for liver problem since fluid shifting – imbalanced fluid volume; SIADH, diabetes insipidus are actual excess or deficits) 6/27/2017 Cushing’s disease because it increases salt retention) Teach client rationale for dietary restrictions Help client identify factors in the lifestyle that may interfere with compliance 4. Provide needed support and encouragement by involving the family Evaluation: Client selects appropriate diet from sample menus; verbalize rationale of diet restriction; identifies lifestyle factors that may interfere with compliance and express willingness to change such factors to comply with dietary regimen Goal 2: Client will express comfort and have reduced if not completely without pain Implementation: 1. Administer pain medication as ordered 2. Teach client non-pharmacologic methods for pain management such as massage, imagery, distraction techniques, and other relaxation techniques 3. Position client to the position of comfort and provide a restful environment 4. Teach client what foods, activity to avoid to prevent triggering the pain experience Evaluation: Client’s pain rating is reduced/lowered or nonexistent; demonstrates use of non pharmacologic measures to reduce pain; verbalizes measures to prevent recurrence of pain Goal 3: Client fluid and electrolyte levels will return to normal Implementation: 1. Institute replacement therapy or restrictions as ordered 2. Instruct patient on importance of increasing or decreasing fluid intake in relation to illness 3. Monitor I&O accurately 4. Monitor daily weight Evaluation: Clients fluid and electrolyte levels are within normal limits Goal 4: Client will be knowledgeable about disease process, treatment regimen, and prevention of complications Implications 1. Explain disease process including possible complications 2. Discuss rationale for ordered treatment regimen 3. Provide information regarding the administration and side effects of all medications lung) - Implementation: 1. Increase or decrease dietary intake of specific food as ordered (intake depends on restriction i.e. low salt for 2. 3. - Risk for Infection Deficient Knowledge 3 T&E by: Nel, Lea, Gela, Niq, Dous, Gwen, Talz University of the Philippines College of Nursing, Class 2010 4. - N107 Nursing Care of Clients with Alterations in Nutrition and Metabolism LAN Cajucom Discuss factors that might trigger complications of the disease (Nursing: if constipated, increase fiber and - fluid) Evaluation: Client discuss in simple terms what his/her illness is, possible complications and the treatment regimen including medications; discusses ways to prevent complications - Imbalanced nutrition: less than body requirements r/t decreased absorption of nutrients(fat soluble vitamins: ADEK) Risk for imbalanced fluid volume r/t excessive loss Anxiety r/t course of illness Deficient knowledge about management of condition r/t lack of exposure to information Elective surgery: explore laparotomy to clean out because of increased risk for infection due to bile; CI for severe acute pain Open cholecystectomy: major surgery Develops vomiting d/t severe pain NOTE: Goal addresses the nursing diagnosis. Objectives address the etiology (related to). Nursing interventions encompasses both the goal and objectives. Medical Management: Cholecystectomy Low fat diet, weight reduction, dissolution therapy (chenodeoxycholic acid), lithotripsy Principles of a low fat diet: Trim all visible fats from foods Use only lean meats: remove skin from poultry Restrict use of eggs (2-3 times/week –Cajucom age; our Problems in the Accessory Organs Cholecystitis with Cholelithiasis age – daily; once a week for patient) Do not use fat for food preparation: no frying Use skim milk and low-fat cottage cheese Avoid use of sauces, gravies and rich desserts Increase intake of fish and seafood minus the fats Nursing Interventions Relieve pain with analgesics as ordered Relieve reflex spasms with antispasmodics Relieve vomiting and decrease gastric stimulation with NG tube to suction Give antibiotics as ordered and monitor fever Teach client non-pharmacologic means to relieve pain which he can use even postoperatively Monitor I and O and IV therapy Provide adequate information and support Provide peri-op care - Acute Pancreatitis Occurs when something irritates the gallbladder and triggers an inflammatory reaction i.e. polyps May be due to high fat intake and decreased fluid intake. There is a frequent occurrence of fat indigestion. Stones are liberated which obstruct the hepatic duct and intrahepatic duct (faster jaundice if intrahepatic. Gallbladder may burst due to obstruction. Assessment Risk Factors: gallbladder disease (40%), alcohol abuse (40%), abdominal trauma, infection (specially viral) (targets glands), idiopathic (sudden changes in diet) (15%) Assessment: Predisposing factors: More common in women Obese individuals Presence of diabetes Clinical Manifestations: Abdominal pain and acute tenderness in the right upper quadrant that may radiate to back Fullness, dyspepsia following fat ingestion Nausea and vomiting, low grade fever, may have signs of obstructed bile flow such as mild jaundice, clay colored stools, dark amber urine (dark amber because bile levels increase in the blood, goes to kidney and is filtered out) Diagnostics: Ultrasound, cholecystography, cholescintigraphy Nursing Diagnosis: Acute pain r/t inflammation and obstruction of gallbladder 6/27/2017 4 T&E by: Nel, Lea, Gela, Niq, Dous, Gwen, Talz N107 University of the Philippines College of Nursing, Class 2010 Nursing Care of Clients with Alterations in Nutrition and Metabolism LAN Cajucom Clinical Manifestations: Administer TPN as ordered and provide TPN care (GIVEN Extreme abdominal pain usually epigastric or left upper IN CENTRAL LINE ONLY) quadrant Teach to avoid stimulants, alcohol, cigarettes - - Vomiting, abdominal distention and severe tenderness, low grade fever, s/sx of shock (chemotrypsin causes irritation and vasodilation), hyperglycemia (do not release insulin), chronic steatorrhea (fat in the stools) Cullen’s sign – periumbilical hemorrhage (umbilicus has - Gray turner’s sign – flank hemorrhages Colon cut off (No blood supply to colon due to bleeding) - Monitor blood glucose, urine glucose and acetone levels (insulin may be needed) May give pancreatic enzymes with meals to aid fat digestion Monitor for s/sx of shock and intervene accordingly Nursing Interventions in Giving TPN Monitor insertion site; provide site care and dressing changes Administer TPN solutions through inline filters; lipids do not require filters (lipids will occlude line; Pulmonary black area due to hemorrhage) - Diagnostics: Serum amylase (most accurate) and lipase, urinary amylase (elevated) Nursing Diagnosis: Acute pain r/t inflammation of pancreas secondary to autoingestion Imbalanced nutrition: less than body requirements r/t decreased absorption of nutrients Risk for imbalanced fluid volume r/t excessive loss Anxiety/t course of illness Deficient knowledge about management of condition r/t lack of exposure to information (patient can eat when - late sign) Later signs: Enlargement of the liver, abnormal liver function tests, intermittent jaundice and pruritus Edema and ascites (drop in plasma oncotic pressure Nursing Interventions: Keep NPO until inflammation subsides and amylase level falls Give Meperidine for pain (NEVER morphine) (cause spasm prominent abdominal wall veins, decreased serum albumin Bleeding tendencies (no clotting factors), prolonged PTT, decreased platelet count No protein: anemia secondary to folic acid deficiency, decreased RBC production, increased RBC destruction (fragile RBC leading to splenomegaly) of sphincter of OD) Put NG tube to suction if vomiting is severe or ileus is present (no bowel sounds for paraltytic ileus) Provide mouth care (PNSS with pledgets; nistatin or bactidol for those with fungal infections) Frequent infections, decreased WBC production Enzymes produced in liver are essential in production of hormones; female hormone is more prominent than the male; due to elevated estrogen, no feedback, leading to amenorrhea: hormonal abnormalities – elevated estrogen levels, testicular atrophy, gynecomastia, impotence, amenorrhea Give anticholinergics or H2 receptor antagonists as ordered to decrease secretions and relax the sphincter 6/27/2017 Monitor blood glucose levels throughout therapy; provide sliding scale insulin coverage as ordered Encourage active exercise as tolerated to support production of muscle Monitor respiratory rate; excess CHO increase CO2 production leading to tachypnea/hyperventilation Instruct client to use valsalva maneuver and clamp tube during tubing changes to prevent air emboli Carefully monitor infusion times leads to fluid shift; many electrolyte imbalances due to fluid shifting: hyponatremia, hypokalemia), PC (anticipate possible problems): Hemorrhage (Collaborative Problem) - draw blood because all will be elevated; insulin only med that can be put in TPN) Liver Cirrhosis amylase levels have normalized) - Weight client daily Assess for fluid volume overload (pulmonary edema, etc) Monitor laboratory values daily (electrolytes, proteins, etc) Avoid drawing blood, administering meds through TPN catheter (there may be food and drug interaction; do not Assessment Predisposing/precipitating factors: malnutrition, alcohol and drug abuse, chronic impairment of bile excretion, hepatitis, chronic CHF (portal circulation is congested) Clinical Manifestations: Early signs: anorexia, nausea, indigestion, aching or heaviness in RUQ, weakness, fatigue, malaise (Jaundice is Medical Management: Generally conservative: control pain, rest pancreas, support nutrition and hydration; seldom done – surgical intervention - emboli is problem; do valsalva while inserting line) 5 T&E by: Nel, Lea, Gela, Niq, Dous, Gwen, Talz University of the Philippines College of Nursing, Class 2010 N107 Nursing Care of Clients with Alterations in Nutrition and Metabolism LAN Cajucom Palmar erythema, spider angiomas Chronic dyspepsia (stomach is compressed), constipation or diarrhea, spleenomegaly (pruritus is Ascites: Decrease in plasma oncotic pressure and increased hydrostatic pressure in abdominal vessels due to bile salts and excess ammonia) Diagnostics: Liver function tests ABG, laparoscopy with biopsy, bleeding tests, ultrasound, CT scan, MRI Nursing Diagnosis: Imbalanced nutrition: less than body requirements r/t decreased intake secondary to decreased GI motility and anorexia Activity intolerance r/t loss of muscle mass Collaborative Problems: Potential Complications: Bleeding/hemorrhage Hepatic encephalopathy Nursing Interventions Improving nutritional status Provide a nutritious, high protein diet, supplemented by vitamins; temporary low protein diet for patient in coma Provide small, frequent meals considering patient preference (compartment of stomach lessens due to Portal HPN compression) - - - 6/27/2017 6 Use feeding tubes or parenteral nutrition as necessary Providing rest Promotion for maximal respiratory efficiency (upright) Provide a restful environment Increase activity gradually Reducing risk for infection Ensure protection from possible contact with infectious persons Ensure sterile procedures are kept sterile Reducing risk for injury Use padded side rails if patient becomes restless or agitated Provide assistance when mobilizing out of bed Provide safety measures T&E by: Nel, Lea, Gela, Niq, Dous, Gwen, Talz University of the Philippines College of Nursing, Class 2010 N107 Nursing Care of Clients with Alterations in Nutrition and Metabolism LAN Cajucom Apply adequate pressure to insertion sites to minimize bleeding Provide skin care Change position q 2hrs Avoid using irritating soap and adhesive tapes Provide lotion to soothe skin Keep patient clean and dry especially over areas exposed to moisture Monitor for and manage complications Observe and monitor for s/sx of bleeding and shock Keep equipment to treat hemorrhage from esophageal varices ready: IVF, medications, Sengstaken Blakemore tube (prevent varices; balloon - - is in area that compresses varices; one port is for feeding while the other is for suctioning; balloon is deflated intermittently so that tissue will not necorse due to impaired blood flow in the vessels – pressure causes impaired blood flow; if ever 2 hrs deflation, make sure the tube is anchored) Assessment: Splayed teeth chewing difficulty: can patient eat adequately? Susceptibility to bronchitis: check history (respiratory problem) and physical examination (breath sounds; initially wheezing because bronchus is inflamed) for signs Kyphosis: is it causing an impairment in breathing due to altered structure of ribcage? Arthralgia: joint pain? Activity exercise? Atherosclerosis CVD and hypertension: history of elevate in BP, chest pain? Fat intake? Visual field defects: is activity altered? Nursing Diagnosis: Physical alterations lead to psychosocial problems: disturbed body image, social isolation Risk for Imbalanced Nutrition: Less than Body Requirements d/t decreased intake Risk for tissue perfusion problems due to hyperglycemia Ineffective tissue perfusion – CVD Sensory-Perceptual Alteration Activity Intolerance Pain Risk for Injury r/t presence of visual field defects secondary to compression of cranial nerves Impaired tissue perfusion d/t increased blood viscosity, increase in afterload (hyperglycemic, atherosclerosis, elevated BP) Nursing Care: a. Body image disturbance GOAL: Accept physical alterations without altering social functioning (no depression) Lessen main problem to psyche of patient b. Decrease effects of injury due to presence of visual field defects Do no aggravate to increase bulk of tissue in the brain/increased ICP The Endocrine System and Metabolism Hypothalamus (tertiary dysfunction) pituitary gland (secondary dysfunction) target organ (primary dysfunction) Hypopituitarism 1. 2. 3. 4. 5. Lack of GH: dwarfism Lack of LH: reproductive hormones are lost: menstrual irregularity and masculinity in female/femininity in male) Lack of FSH: decrease in egg/sperm count Lack of ACTH: adrenal deficiency Lack of TH: Hypothyroidism Acromegaly *Acromegaly (adult onset); Gigantism (pediatric onset; short life span due to hypermetabolism: 21 years) 6/27/2017 Dwarfism or Growth Hormone Deficiency 7 T&E by: Nel, Lea, Gela, Niq, Dous, Gwen, Talz University of the Philippines College of Nursing, Class 2010 N107 Nursing Care of Clients with Alterations in Nutrition and Metabolism LAN Cajucom - Replace sodium – increase dietary intake of sodium Dec fluid retention – given diuretics to urinate CNS dysfunction and supportive care Monitor Antiseizure Mannitol Prevent injury padded side rails, monitoring, seizure precautions Diabetes Insipidus Nursing Diagnosis: a. Body image disturbance b. Physiologic to be addressed: hypoglycemia – risk for injury d/t sudden loss of consciousness c. Endothelial dysfunction – problem in afterload perfusion problem CO problem if with cardiovascular problems d. Adiposity e. Risk for DM II – CO and tissue perfusion problems f. Decreased fat metabolism – imbalanced nutrition: more than body requirements d/t retention of fat; r/t decreased metabolism Clinical Manifestations: Polyuria, polydipsia Hypernatremia Hypertonic blood Nursing Diagnosis: Main problem: dehydration Fluid volume deficit Electrolyte imbalance risk for cardiac dysrhythmia; PC: cardiac dysrhythmia Nursing Care: Increase fluid intake/fluid replacement. Use distilled water so that osmolality will not increase Decrease sodium intake Eliminate foods that promote dieresis i.e. iced tea, coffee (water with coke is not contraindicated) Put something hypotonic to make blood isotonic SIADH Cushing’s Syndrome - Retention of water *Glucocorticoids and mineralocorticoid – retain sodium and water and releases K Clinical Manifestations: Oliguria Urine concentration (high specific gravity) Edema (water intoxication in brain decreased LOC) Hematocrit is decreased (hemodilution) and dec BUN Inc GFR inc sodium excretion hyponatremia Nursing Diagnosis: Fluid volume excess d/t excessive retention of water through ADH Activity intolerance d/t electrolyte imbalance and depressed neuromuscular activity Impaired mobility d/t flaccid paralysis Cerebral tissue perfusion d/t edema Nursing care: Inc ADH water retention Decreased fluid intake 6/27/2017 Causes: Usually drug-induced i.e. prednisone/steroidal drugs 8 T&E by: Nel, Lea, Gela, Niq, Dous, Gwen, Talz University of the Philippines College of Nursing, Class 2010 N107 Nursing Care of Clients with Alterations in Nutrition and Metabolism LAN Cajucom - Inc glucocorticoids and mineralocorticoids inc susceptibility to infection Labs: Eosinophil, Leukocyte count (drop) Neutrophils increase Physical Exam: Signs of infection History: Recurrent infections? Look whether existing or risk problem. Clinical Manifestations and Nursing Diagnosis: Alters fat, protein, glucose metabolism protein deficit, glucose excess, fat excess (anabolism) imbalanced nutrition, specify if excess or deficit; hyperglycemia alteration in tissue perfusion Signs of less: muscle wasting in extremities but fat trunk; weight does not drop or increase because there is portion that increases, portion that drops Electrolyte imbalance: Ca, Na, K (control both neuromuscular (Na, K) and cardiac muscle (Ca, K) activity) Inc Ca resorption elevated serum Ca renal calcium stones hypercalcemia; CP/PC: renal stone/urinary lithiasis/kidney problems; PC: cardiac dysrhytmias (tachyarrhythmias) Hypokalemia bradyarrhythmias, neuromuscular weakness constipation, dec physical mobility (patient can be paralyzed), activity intolerance severe respiratory muscle weakness impaired gas exchange respiratory arrest Ca vs K – depends on which occurs first Complications: CO problems (dec CO) r/t possible decompensatory mechanisms d/t increased workload, inc afterload and preload, dec contractility of the heart Nursing Care: High protein, low fat, low simple sugar diet to address imbalanced nutrition Cardiac problems: K-sparing diuretics, upright positioning (address increased preload), antihypertensives, rotating tourniquet, dec Na (address increased afterload), inotropic agents i.e. Dobutamine, Digoxin (increases contractility of heart), dec O2 consumption by rest and sleep, prevent stimulation of sympathetic NS, dec acitivty Medical Management: Taper down med if drug-induced. If not, patient may be operated on and given hormonal therapy/given antihormone Clinical Manifestations: If nangingitim, disease is primary. If not, higher disease (secondary or tertiary) Hypoglycemia no nutritional source for the brain Comatose Labs: Everything is elevated WBC count not good basis for presence of infection Nursing Diagnosis: Less than body requirements increased catecholamines increased metabolism Severly hypotensive; adrenal crisis Cardiovascular problems (dec CO) Decline in BP signs of cardiovascular collapse Dec cerebral tissue perfusion Tissue perfusion problems: cold, clammy, extremities Severe dehydration Hypernat; PC; dysrhythmias MEDICAL PAPER! KNOWLEDGE (PATHOPYSIOLOGY) MUST COINCIDE WITH NURSING CARE! Hypothyroidism (slow metabolism) Addison’s Disease 6/27/2017 9 T&E by: Nel, Lea, Gela, Niq, Dous, Gwen, Talz University of the Philippines College of Nursing, Class 2010 N107 Nursing Care of Clients with Alterations in Nutrition and Metabolism LAN Cajucom Myxedema coma: weakness, syncope, slow pulse rate, subnormal temperature, slow respirations, lethargy (no adequate thyroid hormone replacement) Teach the client to seek medical supervision on a regular basis and when any signs of illness develop Explain the importance of continued hormone replacement through life. Instruct client to: a. Report the occurrence of any side effects to the physician immediately b. Take medication as scheduled at the same time each day; do not stop abruptly c. Take radial pulse; notify physician if greater than 100 beats/minute d. Carry medical alert card e. Keep all scheduled appointments with physician; medical supervision is necessary f. Assess client for potentiation of anticoagulant effect - Assessment Subjective a. Dull mental processes b. Apathy c. Lethargy d. Intolerance to cold (does not produce heat d/t slow g. h. Assess client for signs of hyperthyroidism Evaluate client’s response to medication and understanding of teaching i. Explain that increased sensitivity to narcotic analgesics and tranquilizers necessitate dosage adjustment; OTC drugs should be avoided unless approved by physiancia j. Help the client and family recognize that client’s inability to adapt to cold temperature requires additional protection and modification of outdoor activity in cold weather k. Teach the client to avoid constipation by the use of adequate hydration and roughage in the diet l. Apply moisturizers to skin m. Teach the need to restrict calories, cholesterol and fat in the diet metabolism) e. Anorexia Objective a. Lack of facial expression (flat affect) b. Increase in weight c. Constipation d. Subnormal temperature and pulse e. Dry, brittle hair f. Pale, dry, coarse skin g. Enlarged tongue, drooling h. Decreased BMR i. Decreased thyroxine, t3, t4, t3ru j. Hoarseness of voice k. Thinning of lateral eyebrows l. Scalp, axilla and pubic hair loss m. Diminished hearing n. Decreased libido o. Periorbital edema Nursing Diagnosis Decreased CO r/t decreased myocardial activity Ineffective tissue perfusion Imbalanced nutrition: less than body requirements (do not - (do not take with aspirin) Hyperthyroidism eat; though no intake, weight still increases; body does not use food taken) Impaired thermoregulation/hypothermia High risk for impaired gas exchange High risk for injury CP: PC: Acute respiratory distress (hypoventilation – respiratory muscles do not functions adequately); cardiac arrest Nursing Interventions: Have patience Teach the client and family to be alert for signs of complications: Angina pectoris Cardiac failure 6/27/2017 Assessment Subjective a. Polyphagia b. Emotional lability and apprehension c. Heat intolerance Objective 10 T&E by: Nel, Lea, Gela, Niq, Dous, Gwen, Talz University of the Philippines College of Nursing, Class 2010 N107 Nursing Care of Clients with Alterations in Nutrition and Metabolism LAN Cajucom a. b. Weight loss Increased systolic blood pressure, temperature, pulse and respiration c. Tremors, hyperactive reflexes d. Diaphoresis e. Insomnia f. Exopthalmos, corneal ulceration g. Increased BMR h. Decreased TSH levels if thyroid disorder; increased TSH levels if secondary to pituitary disorder i. Inc t3, t4, protein-bound iodine (PBI), long acting thyroid stimulator (LATS), and radioactive iodine uptake j. Loose stools k. Thyrotoxic crisis (thyroid storm): a state of hypermetabolism that may lead to heart failure; usually precipitate by a period of severe physiologic or psychologic stress, thyroid surgery, or radioactive iodine therapy (carotid massagae, cardioversion) Nursing Diagnosis 1. Imbalanced nutrition: less than body requirements 2. Impaired thermoregulation: hyperthermia 3. High risk for decreased cardiac output 4. High risk for injury (myocardial tissue, cornea) (corneal Care for the client before a thyroidectomy: a. Administer prescribed antithyroid medications to achieve euthyroid state b. Teach DBE and use of hands to support neck Care for the client following a thyroidectomy: a. Observe for signs of respiratory distress and laryngeal stridor caused by tracheal edema (keep tracheostomy set available) b. Provide humidity with cold stem nebulizer to keep secretions moist when at home c. Keep bed in a semi-fowler’s position without pillows and teach client to support head (hyperextension of head/neck 5. CP: PC: Dysrhythmias; heart failure Therapeutics 1. Antithyroid medications such as propylthiouracil (PTU) and methimazole (tapazole) to block the synthesis of thyroid hormone (with straw because can stain teeth; can be g. d. e. f. aberration – eye cannot close and eye dries up) 2. 3. 4. h. taken with juice or water; WOF agranulocytosis in PTU and prone to infection) Antithyroid medications such as iodine (Lugol’s solution or SSKI) to reduce the vascularity of the thyroid gland Radioactive iodine to destroy thyroid gland cells, thereby decreasing the production of thyroid hormone (atomic cocktail) (isolated due to radiation; double flushing and separate things; no visitors while infused; distance, time, shuleding – BRAD? therapy) Medications to relieve the symptoms r/t the increased metabolic rate (e.g. digitalis, propanolol [Inderal], Phenobarbital) 5. Well-balanced, high-calorie diet with vitamin and mineral supplements 6. Surgical intervention: subtotal or total thyroidectomy Interventions Environmental modification – restful, quiet Reduce stress Provide diet high in calories, proteins, and carbohydrates with supplemental feedings between meals and at bedtime; vitamin and mineral supplements should be given as prescribed Understand that the client is upset by lability of mood and exaggerated response to environmental stimuli; take time to explain disease processes involved Provide eye care; eye drops and eye patches may be needed (waear dark-colored glasses when going out) Teach the importance of taking antithyroid medications regularly and to observe for adverse effects (euthyroid is not allowed to avoid strain on suture line) Use a soft cervical collar if ordered to prevent unnecessary neck movement Observe dressings at the operative site and back of the neck and shoulders for signs of hemorrhage Observe for signs of thyroid storm; may result from manipulation of the gland during surgery, which releases thyroid hormone into bloodstream 1. High fever 2. Tachycardia 3. Irritability, delirium 4. Comatose Notify the physician immediately for signs of thyroid storm; administer propanolol Observe for signs of tetany (parathryroid gland), which can occur after accidental trauma or removal of the parathyroid glands 1. Numbness or twitching of extremities 2. Spasms of the glottis 3. If tetany occurs, give calcium gloconate or calcium chloride (IV) as prescribed 4. Assess for hoarseness 5. Teach client signs and symptoms of: a. Hypothyroidism and b. Hyperthyroidism Diabetes Mellitus state given prior to operation to prevent arrest) 6/27/2017 11 T&E by: Nel, Lea, Gela, Niq, Dous, Gwen, Talz University of the Philippines College of Nursing, Class 2010 N107 Nursing Care of Clients with Alterations in Nutrition and Metabolism LAN Cajucom Nursing Interventions 1. Attempt to manage with lifestyle changes 2. Weight control: if overweight or obese, client should lose excess body fat, which alters glucose metabolism (obesity leads to insulin resistance); this can be reversed by weight loss) 3. Exercise: increases insulin sensitivity but must be regular; vigorous but not jarring exercise, such as brisk walking, swimming, and bicycling is recommended 4. Diet: current recommendations include: a. Calories controlled to maintain ideal body weight b. 50% to 60% of caloric intake should be from carbohydrates (low glycemic index – slow metabolism; no fruits); emphasis should be on complex carbohydrates, high-fiber foods rich in watersoluble fiber (oat bran, peas, all forms of beans, pectin-rich fruits and vegetables); particular attention should be paid to the glycemic effect of foods, those with a high glycemic index should be avoided; glycemic index refers to the effect of particular foods on blood glucose (e.g. waterinsoluble fiber has little effect on blood glucose) c. Protein: intake should be consistent with Diabetic Dietary Guidelines, usually between 60 and 85 g depending on calorie intake; should be 12% to 20% of daily intake d. Moderate fat intake: should not exceed 30% of daily calories (70 to 90 g/day); keep saturated fat intake low; emphasize monounsaturated and polyunsaturated fats e. Dietary ratio: carbohydrate to protein to fat usually about 5:1:2 f. Distribute food fairly evenly throughout the day in 3 or 4 meals with snacks added between Insulin administration a. Adjusted after considering the client’s physical and emotional stresses, selecting a specific type of insulin, depending on the condition and needs of the patient Assessment Subjective a. Polydipsia b. Polyphagia c. Fatigue d. Blurred vision from retinopathy e. Peripheral neuropathy Objective a. Polyuria b. Weight loss c. Hyperglycemia: detected by fasting blood sugar, glucose tolerance test, 2-hour postprandial glucose and glycosylated hemoglobin (provides measure…) d. Glycosuria e. Peripheral vasuckla changes and gangrene Nursing Diagnosis Ineffective tissue perfusion Imbalanced nutrition: more/less than body requirements - (onset more but becomes less because of sever hypoglycemia) High risk for injury High risk for Fluid volume excess High risk for Infection PC: DKA; HHNK; hypoglycemia (can lead to neuroglycopenia); CVD b. (mother cannot take OHA or oral) Somogyi effect: insulin-induced hypoglycemia that rebounds to hyperglycemia (produced glucose but then there is low metabolic rate after insulin administration) 1. 2. 6/27/2017 12 Epinephrine is released and the blood glucose level is low Glucagon is released by alpha cells of the pancreas T&E by: Nel, Lea, Gela, Niq, Dous, Gwen, Talz University of the Philippines College of Nursing, Class 2010 N107 Nursing Care of Clients with Alterations in Nutrition and Metabolism LAN Cajucom 3. - - These reactions cause mobilization of the liver’s stored glucose and iatrogenically induce hyperglycemia 4. Somgyi phenomenon is treated by gradually lowering insulin dosage while monitoring blood glucose, particularly during the night (when hypoglycemia is most likely to occur) Oral hypoglycemic for certain clients; however these patients should WOF a. Skin rash b. Jaundice c. Pruritus d. Allergic reactions Monitoring glucose control (intermediate acting insulin (8- Avoid tight shoes and smoking, which will constrict circulation Continuous medical supervision and follow up care, including visits to eye care Teach the client and the family the signs of impending hypoglycemia Teach the client and family signs of impending diabetic coma Teach the client and family about somgyi effect and the associated s/sx 12 hrs) – give then feed immediately after and warn patient that client has to eat 8 hrs after insulin injection; if short acting (15-30 mins peak) do not give if patient has not eaten; long-acting insulin (18-22 hrs) patient must eat at midnight if given in the morning or else patient will have serum hypoglycemia) a. - Self-monitoring of blood glucose; may be done before meals and at hour of sleep b. Glycosylated hemoglobin; reflects long-term serum glucose control and is done at routine medical evaluations c. Encourage the client to express feeling about illness and the necessary changes in lifestyle and self-image d. Assist the client and family in understanding the disease process e. Help the client with the administration of medication until self administration f. Assist the client to recognize the need for continuous health supervision g. Encourage follow-up nutritional counseling Teach client to : Avoid infection Care for the legs, feet and toenails properly: inspect, bathe, dry and lubricate except between toes; avoid exposure of feet to heat sources (wear socks; cut toenails straight) Administer insulin by using sterile technique; rotating injection sites; measuring dosage; noting types, strengths of insulin, and peak action periods; need to carry carbohydrate source (ask where patient was last injected for rotation; give hard candy/juice) - Use Self-monitoring of blood glucose proper medication administration procedure Comply with dietary program including snacks Avoid alcohol, especially when taking chlorpropamide Use proper procedure for urine and/or bloodtesting Teach to administer SQ Draw regular insulin into the syringe first when mixing insulin if premixed insulin (70-30) is not available (oral) (clear the cloudy) Slight dosage adjustment may be necessary when switching from one form of insulin to another because of differing pharmacokinetics Comply to treatment and that medication is lifelong 6/27/2017 13 T&E by: Nel, Lea, Gela, Niq, Dous, Gwen, Talz