Download N107 Nursing Care of Clients with Alterations in Nutrition and

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)
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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)
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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)
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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.)
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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
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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
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percussed)
Fetus (dull when percussed)
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 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
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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
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than 7 cm indicates splenomegaly)
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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
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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
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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.)
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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
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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)
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Implementation:
1. Increase or decrease dietary intake of specific food as
ordered (intake depends on restriction i.e. low salt for
2.
3.
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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
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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
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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
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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
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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
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Gray turner’s sign – flank hemorrhages
Colon cut off (No blood supply to colon due to bleeding)
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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)
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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
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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)
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draw blood because all will be elevated; insulin only med
that can be put in TPN)
Liver Cirrhosis
amylase levels have normalized)
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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
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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)
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6/27/2017
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 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
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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
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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.
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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
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T&E by: Nel, Lea, Gela, Niq, Dous, Gwen, Talz