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Nursing IIKathleen C. Ashton
The Client With Alterations in Integrative And Regulatory Patterns
The Liver Largest organ of the body (with exception of
skin) Divided into 4 lobes: right and left caudate and
right and left quadrate Two blood supply sources:
portal vein from gi tract brings nutrients, and toxins for processing
hepatic artery is source of oxygen Drained by hepatic vein Responsible for regulation of glucose and protein
metabolism, bile production, and circulatory blood reserve
Assessment
Inspection: look for jaundice Ascites vs. anasarca Palpation: liver edge may be palpable in
right upper quadrant on inspiration. Tenderness indicates enlargement
Percussion: dullness delineates borders
Jaundice - indicates high billirubin
Types: Hepatocellular: caused by liver’s inability to
remove billirubin from the blood. Liver damage may be result of infection (hepatitis A, B, or C) or drug or chemical toxicity. May be result of cirrhosis.
Obstructive: bile duct is plugged by tumor, gallstone, or inflammation.
Effects of Jaundice Excess bile in blood carried throughout
body. Stains skin, mucous membranes and sclera.
Urine turns deep orange and foamy. No bile in gi tract, so stools become clay
colored or light brown. Pruritis: may be relieved by oil baths Fatty food intolerance may accompany
jaundice
Diagnostic Tests Liver Function Studies:
Billirubin: measures liver’s ability to conjugate and excrete billirubin. Levels increase with impaired excretion. Measured in blood and urine.
Prothrombin time: Pro time or PT will be prolonged in liver disease (>15 seconds). Vitamin K will not return it to normal if severe liver damage
Serum enzymes
AST - aspartate aminotranferase ALT - alanine aminotransferase LDH - lactic dehydrogenase These enzymes are released into the blood stream
with parenchymal damage. May also indicate other organ damage.
Ammonia increases with liver disease Cholesterol increases with biliary obstruction,
decreases with parenchymal disease
Other tests Liver scan: to detect tumors, show size and shape
of liver. May use Technetium Barium swallow (upper gi) shows esophageal
varices which indicate increased portal pressure Angiography looks at vessels Liver biopsy: invasively samples tissue for
histologic study. Nursing implications: Check pro time first to ascertain bleeding
abnormalities Needle is inserted as patient holds breath after
expiration to bring liver against chest wall Afterwards, position on right side to prevent bleeding Bedrest for 1-2 hours
Results of Liver Dysfunction Portal hypertension: elevated blood pressure
reflected throughout the portal venous system. Results in:
Esophageal, gastric, & hemorrhoidal varices from high BP in all veins that drain into the portal system.
Likely to rupture and bleed. Worsened by blood clotting abnormalities
Surgical interventions: portacaval shunt - directs some blood into vena cava, bypasses liver. Various types.
Other Complications Ascites - assessed by:
percussion for fluid wave bulging flanks when lying supine Management:
record abdominal girth daily weight low salt intake diuretics salt-poor albumin helps increase serum osmotic pressure and
draw fluid back into the bloodstream for excretion by the kidneys
paracentesis may be used to remove up to 2-3 liters of fluid from the abdomen
More complications
Nutritional deficiencies: more pronounced when alcohol is involved. Need ample quantities of vitamins A, B complex, C, K, and folic acid
Bleeding abnormalities: bruising, nosebleeds, gi bleeds
Altered glucose metabolism Increased sensitivity to drugs - reduced dosages
required
Biliary conditions Cholecystitis: inflammation or infection of the
gall bladder Cholelithiasis: gallstones composed of either
cholesterol or pigment 95% of people with cholecystitis have gall stones Assessment: “Fair, fat, female and forty”
may have symptoms related to diseased gall bladder or symptoms related to blocked bile ducts
fried or fatty food ingestion typically causes bloating, fullness, pain. May have fever if gall bladder infected.
Pain: severe, colicky, & may radiate to shoulders or back.
Signs and Symptoms
Obstruction may produce jaundice in some people.
Nausea and vomiting common Dark urine, clay colored stools Diagnosis:
Ultrasound to detect obstruction or stones ERCP: endoscopic retrograde cholangio-
pancreatography - provides direct visualization with removal of stone if low enough
Management
Diet: low fat, fluids Actigall: dissolves cholesterol stones, takes
months up to 5 years Lithotripsy shatters stones via shock waves Surgery: cholecystectomy: removal of gall
bladder. Laproscopic if first attack. Faster recovery, can be up in 4 hours. Traditional surgery requires incision, T-tube which drains bile until swelling subsides (up to 500 ml. in first 24 hours) and Jackson-Pratt drain. T-tube clamped for 2 hours before meals to add bile. Unclamp if emesis.
Discharge Planning Tubes removed in 1-2 weeks post op Morphine used with caution – can cause spasms
of sphincter of Oddi Diet: Low fat, high protein and high carbohydrate Fat restriction lifted 4-6 weeks post op when
biliary ducts able to accommodate the bile previously stored by gall bladder.
Care of skin, incision, and drainage tubes - bile is corrosive to skin.
Diabetes A chronic disease involving the inability to
synthesize insulin Prevalence felt to be related to longevity,
obesity and increased standard of living Etiology is unclear Involves genetics, auto-immune response,
virus, obesity, infection Affects over 18 million Americans with 1.3
new cases/year – an epidemic
Types Type 1 - Insulin-dependent, pancreas does not
produce sufficient insulin. Requires injections. Type 2 - Non-insulin dependent, insufficient insulin
used or cells are not sensitive to insulin. Increase among adolescents.
Gestational - diabetes developed during pregnancy Individuals may move from one category to
another. Metabolic Syndrome – predictive – FBS 110mg or
>, waist >35in, triglyceride >150mg, HDL < 50mg, BP >130/85mmHg.
Type 1 (formerly IDDM) Usually begins in childhood, may occur in adults Weight loss, polydipsia, polyuria, polyphagia,
weakness Ketosis leads to ketoacidosis (DKA), from
protein breakdown Kussmaul respirations - fast and deep Insulin needed for life Maintenance of glucose levels below 150 may
forestall retinopathy, neuropathy, nephropathy, sexual concerns and cardiovascular effects
Type 2 (Formerly NIDDM) Usually occurs after age 40, associated with
obesity Frequently discovered when complications
develop: vision problems, leg pain, impotence Prone to vascular complications Diagnosis:
glucose tolerance test (GTT) >140, tests for high glucose levels after ingestion of high carbohydrates. Necessary for accurate diagnosis. FBS may be normal. May only have elevated GTT and signs and symptoms.
Blood samples more reliable than urine samples
Management - Diet and Exercise Diet:
meet nutritional and energy needs maintain ideal weight reduce blood lipid levels maintain normal blood glucose levels High protein, high fiber to assist in glucose
absorption 55-60% protein, 30% or less fat, 12-15%
carbohydrate Patient teaching aimed at variety and
acceptability Complex carbohydrates gaining approval over
simple carbohydrates
Exercise
May call for readjustment of dose Exercise reduces blood glucose, may
reduce need for insulin Oral anti-diabetic agents used when diet
alone isn’t enough; these directly stimulate pancreas to secrete insulin
Used with diet to achieve lower glucose When oral agents no longer work, may
need insulin injections
Insulin An interdependent function - nurse and physician
work together to determine proper dosage Regular insulin given with intermediate and
increased until urine free of glucose and the pre-prandial glucose level near normal
Teaching: technique for administration aspiration not necessary and no need to rotate sites
with Humelin complications
Insulin, cont’d Glucose monitoring mostly a client function
using a variety of devices Teach: importance, accuracy, and recording Blood monitoring more accurate than urine which
depends on kidney function Insulin delivery pumps deliver dosage over a 24
hour period. Size of a beeper. Cost: $1500 to $3000. Must be used with a monitoring system. May alter body image and be a reminder of diabetes.
Types of insulin: Regular, long-acting, 70/30
Complications Insulin reaction - hypoglycemia - usually before
meals but can be at any time. Glucose below 50 or 60 mg. From increased exercise, increased insulin, or lack of food. May be from NPH or lente insulin peaking.
S&S: weakness, headache, sweating, tremor, palpitations, mental changes. Will lead to coma.
Give juice with sugar Memory aid: Symptom Implication Cold and clammy… give hard candy Hot and dry... glucose is high
Complications, cont’d Ketoacidosis (DKA) - lack of insulin from
abnormal metabolism of protein, fat & carbohydrates
Three main clinical features: dehydration, electrolyte loss & acidosis
May be triggered by an infection S&S: polyuria, polyphagia, polydipsia,
dehydration followed by oliguria, malaise, visual changes, aches, ketone (sweet) breath, & Kussmaul respirations.
Give low dose insulin, IV’s of NSS and correct electrolyte imbalances.
Other complications Vascular complications: blood vessels lose
elasticity legs and peripheral circulation affected most kidney failure common with Type I - may be
from diabetes or from insulin administration Eye disorders: vessels become fragile hemorrhaging in fundus Neuropathy: widespread throughout body Results in sexual dysfunction, impotence Research on women lacking
Complications con’t Foot and leg problems: teach about care Trim toenails slightly rounded Well-fitting shoes, clean socks, avoid cold Infections: can be fatal. Adjust insulin
doses Encourage vaccines for prevention Prevent injury Good teaching Involve the family
Newer Developments New drugs coming out almost daily For Type 2:
Glucotrol: stimulates release of insulin from pancreas Glucophage: reduces hepatic production of glucose Avandia: reduces or ends dependence on insulin
injections. Resensitizes the body to insulin, makes better use of insulin.
HbA1C determines average blood glucose over previous 3 months (life of Hgb=120 days) A1C should be <6.5% for glycemic control
Neuroendocrine Regulation Pituitary: “Master Gland”
Diabetes Insipidus - disorder of water metabolism due to lack of vasopressin (ADH). From trauma, tumors
S&S: increased thirst, increased output of dilute, water-like urine (10-20 liters/day). ADH given for life.
Giantism - from excessive growth hormone in child before closure of epiphyses. May grow to 8 or 9 feet. Results in HBP, cardiomegaly, osteoporosis, and muscle weakness
Acromegaly - Tumor which secretes growth hormone. Occurs after puberty. Hands, feet, and jaw enlarge. Abe Lincoln.
Neuroendocrine Regulation Thyroid: straddles larynx. Good assessment Diet: 1 mg iodine/week. Needed for hormone
formation Hypofunction: BMR decreased to about 40% of
normal: child:cretinism, adult: Hashimoto’s disease S&S: tired, menstrual disturbances, dry skin, brittle
nails, hair loss, loss of libido, numbness Severe - Myxedema - weight gain, subnormal
temperature, apathetic, slow speech, pale, menstrual disturbances
Occurs 5x more often in women, usually between age 30 & 60. Synthroid given as replacement
Thyroid, con’t Hyper - Graves’ Disease – most common type Affects women 8x more than men. S&S: rapid pulse, weight loss, weakness, HBP,
palpitations, diaphoresis, amenorrhea, thyroid enlargement, exophthalmos
If untreated, results in death from tachycardia Treatment: radiation, surgery, drugs to block
hormones. Tapazole commonly used. Goiter: a tumor that is large enough to produce
swelling. From lack of iodine or excess lithium Thyroid Storm: crisis. Fever, tachycardia, coma.
Parathyroid Glands Usually 4, may be 6 or 8. Lie behind thyroid. Produce parathormone, maintain calcium level,
help excrete phosphorus Hyperparathyroidism:
1o - increased growth of glands leads to bony calcifications and renal stones
2o - from renal problems - phosphorus elevates, so parathyroids overwork.
S&S: apathy, fatigue, demineralization, pathological fractures, constipation, N&V, psychosis, cardiac disturbances.
Treatment: surgery
Parathyroids, con’t
Hypoparathyroidism: from atrophy or too aggressive removal in surgery
S&S: hyperphosphotemia, hypocalcemia, tetany (stiffness, numbness, tremor), convulsions
Treatment: Give calcium gluconate in emergency, OsCal or Tums (calcium carbonate) orally
Adrenal conditions Addison’s Disease: decreased cortical
activity from atrophy, TB, or virus (histoplasmosis)
S&S: weakness, fatigue, emaciation, dark pigmentation, low BP, low glucose and sodium, reduced BMR, high potassium, dehydration
Treatment: correct electrolyte imbalance, give cortisol for life. May be exacerbated by stress
Cushing’s Syndrome From excessive ACTH or cortisone, hyperplasia of
cortex or pituitary tumor S&S: high sodium & glucose, low K, increased
cortisol, increased bone age, stunted growth, hirsuitism, amenorrhea, breast atrophy, “buffalo hump”, masculinization, thin ecchymotic skin, round face with increased oil and hair, decreased libido, osteoporosis, HBP, “moon face”.
Treatment: Diet: High protein and potassium, low carbohydrate and sodium. Surgery for pituitary tumor.
Considerations with corticosteriods Produce same effects as Cushing’s Syndrome Uses:
adrenal insufficiency (eg, Addison’s) anti-inflammatory anti-allergy
Higher doses result in more effects & more danger: moon face, buffalo hump, abnormal distribution of
body fat, peptic ulcer, osteoporosis, infections from lack of defenses
CNS effects: euphoria, gregariousness, mood swings, depression. May stunt growth in children.
Give early morning and withdraw gradually!