Nursing II
Kathleen C. Ashton
The Client With Alterations in
Integrative And Regulatory Patterns
The Liver
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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:
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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
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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
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Types:
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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
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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
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Liver Function Studies:
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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
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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
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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:
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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
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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
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Ascites - assessed by:
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percussion for fluid wave
bulging flanks when lying supine
Management:
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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
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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
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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”
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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
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Obstruction may produce jaundice in some
people.
Nausea and vomiting common
Dark urine, clay colored stools
Diagnosis:
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Ultrasound to detect obstruction or stones
ERCP: endoscopic retrograde cholangiopancreatography - provides direct visualization with
removal of stone if low enough
Management
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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
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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
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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
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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)
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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)
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Usually occurs after age 40, associated with
obesity
Frequently discovered when complications
develop: vision problems, leg pain, impotence
Prone to vascular complications
Diagnosis:
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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
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Diet:
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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
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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
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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 preprandial glucose level near normal
Teaching:
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technique for administration
aspiration not necessary and no need to rotate sites
with Humelin
complications
Insulin, cont’d
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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
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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
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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
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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
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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
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New drugs coming out almost daily
For Type 2:
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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
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Pituitary: “Master Gland”
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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
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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
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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
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Usually 4, may be 6 or 8. Lie behind thyroid.
Produce parathormone, maintain calcium level,
help excrete phosphorus
Hyperparathyroidism:
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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
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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
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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
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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
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Produce same effects as Cushing’s Syndrome
Uses:
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Higher doses result in more effects & more
danger:
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adrenal insufficiency (eg, Addison’s)
anti-inflammatory
anti-allergy
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!