N107
Nursing Care of Clients with Alterations in Nutrition and Metabolism
LAN Cajucom
Liver, pancreas, gallbladder
Diabetes and thyroid problems, pituitary disorders
Application of the Nursing Process to the Clients with Nutritional and Metabolic Alterations
Focused Assessment of Patient with Hypertension and Nephropathy secondary to Diabetes
-Gordon’s patterns indicate specific areas which makes person at risk
-Chief complaint (Is this a sign of metabolic or nutritional alteration or is it already a complication?)
-History of present illness (Events leading to chief complaint)
-Past medical history (Examine conditions that may have contributed to current problem i.e. liver disease – did client have abdominal pain or jaundice?)
-Family history (Non-communicable/Genetic diseases; TB is included because it has high communicability)
-Health maintenance and management
Lifestyle (risk factor assessment)
Does not eat on time (peptic ulcer disease, GERD)
Picky on foods eaten
Takes supplements which may have contraindications to the medications the patient is taking i.e. TB meds with herbal meds
Patients who smoke have a high probability of developing cancer i.e. lungs and GIT
Assessment
Health History
- Dietary pattern; changes in appetite(other than the 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)
- Indigestion, heartburn/regurgitation: pattern, frequency – drugs used, effectiveness (fat malabsorption occurs with bile problem; cholelithiasis is an emergency because it is 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 overproduction of acid and will therefore not be relieved by antacids and eating, antacids are only given to adequately control the pain)
- Difficulty in swallowing (dysphagia): onset (i.e. GERD; may be neurologic problem)
- Difficulty tolerating certain foods: allergies, malabsorption syndromes(note lactose intolerance so that care and advice given will be appropriate)
- Vomiting or Nausea: character of vomiting; amount, characteristics, pattern of nausea, relationship to intake or other events (liver, endocrine diseases manifest with vomiting and nausea; projectile vomiting is manifestation of neuro problem; other event: smelled something foul or rode a vehicle)
- Abdominal distention, flatus, belching, fullness(manifests even with liver disease)
- History of abdominal surgery or trauma (Past medical history: do you have any operations? Where? Any medical surgery predisposes the patient to adhesions, especially if abdominal; abdominal pain with constipation may be related to a possible adhesion; surgery is assessment cue for adhesion)
- Bleeding: onset, duration and extent (liver disease predisposes patient to bleeding tendency)
- Alcohol intake
- Family history (cancer in the GIT, peptic ulcer, Hirschsprung’s disease), lifestyle pattern (preferred food, frequency of food intake, etc.)
Physical Examination
Inspection:
-Skin: color (jaundice), bruises, hemaotmas (absorption 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 foul-smelling 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 to obstruction has bowel sound while distal to it has absent bowel sound; prior to obstruction may be hyperperistaltic, distal not)
-Sites to auscultate for bruits (if pulsation is noted in other areas other than those mentioned, there may be masses pushing on the vessels)
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)
Palpation
-Note areas of pain, tenderness; organ size and position (If 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))
-Moderate Palpation
-Deep Palpation
-Description of masses
If you identify a mass, first distinguish it from a normally palpable structure or enlarged organ. Then note its:
- Location
- Size
- Shape
- Consistency (soft, firm, hard)
- Surface (smooth, nodular)
- Mobility (movement with respirations)
- Pulsatility (vessel is involved – has mass or compressed by mass)
- Tenderness
*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
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))
-General Nursing Interventions for patients undergoing diagnostic tests:
- Provide general information about the test and the activities involved
- Instructions about pre and post procedure care including activity restrictions (KUB ultrasound – drink 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
-Hepatobiliary Function Test: Total bilirubin, Direct and indirect bilirubin, Cholesterol, Triglyceride, Prothrombin time
-GI function: Gastrin
-Pancreatic function: Serum glucose, Lipase, Amylase
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)
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, administerVit 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 lung)
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)
-Risk for Infection
-Deficient Knowledge
Catch early on so that complications may not arise i.e. gas exchange problem, decreased CO
General Nursing Planning, Implementation and Evaluation
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.)
-Implementation:
- Increase or decrease dietary intake of specific food as ordered(intake depends on restriction i.e. low salt for 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
- 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:
- Administer pain medication as ordered
- Teach client non-pharmacologic methods for pain management such as massage, imagery, distraction techniques, and other relaxation techniques
- Position client to the position of comfort and provide a restfulenvironment
- Teach client what foods, activity to avoid to prevent triggering the pain experience
-Evaluation: Client’s pain rating is reduced/lowered or non-existent; 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:
- Institute replacement therapy or restrictions as ordered
- Instruct patienton importance of increasing or decreasing fluid intake in relation to illness
- Monitor I&O accurately
- Monitor daily weight
-Evaluation: Clients fluid and electrolyte levels are within normal limits
Goal 4:Client will be knowledgeableabout disease process, treatment regimen, and prevention of complications
-Implications
- Explain disease process including possible complications
- Discuss rationale for ordered treatment regimen
- Provide information regarding the administration and side effects of all medications
- 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
NOTE: Goal addresses the nursing diagnosis.Objectives address the etiology (related to).Nursing interventions encompasses both the goal and objectives.
Problems in the Accessory Organs
Cholecystitis with Cholelithiasis
-Occurs when something irritates the gallbladder and triggersan 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 obstructthe hepatic duct and intrahepatic duct (faster jaundice if intrahepatic. Gallbladder may burst due to obstruction.
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
-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
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 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 seafoodminus 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 IVtherapy
-Provide adequate information and support
-Provide peri-op care
Acute Pancreatitis
Assessment
-Risk Factors: gallbladder disease (40%), alcohol abuse (40%), abdominal trauma, infection (specially viral)(targets glands), idiopathic(sudden changes in diet) (15%)
Clinical Manifestations:
-Extremeabdominal pain usually epigastric or left upper quadrant
-Vomiting, abdominaldistentionand 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 black area due to hemorrhage)
-Gray turner’s sign – flankhemorrhages
-Colon cut off (No blood supply to colon due to bleeding)
Diagnostics:
-Serum amylase(most accurate) and lipase, urinary amylase (elevated)