0133427269 Module12 Metabolism LectureOutline

Module 12 Metabolism The Concept of Metabolism After nutrients are ingested, digested, absorbed, and transported across cell membranes ( must be metabolized into individual chemicals that can be used by cells to maintain life Metabolismprocesses of biochemical reactions occurring in the bodys cells that are necessary to produce energy, repair cells, maintain life Hormoneschemical messengers secreted by various glands that exert controlling effects on cells of body Normal metabolism Major endocrine organs are Pituitary gland Thyroid gland Parathyroid glands Adrenal glands Pancreas Gonads See Table 12-1 ORGANS, HORMONES, FUNCTIONS, AND FEEDBACK MECHANISMS OF THE ENDOCRINE SYSTEM, P. 726 See Figure 12-1 LOCATION OF THE MAJOR ENDOCRINE GLANDS, P. 727 Genetic and lifespan considerations Endocrine system responsible for sexual differentiation during fetal development and for stimulating growth and development during childhood and adolescence See Table 122 AGE-RELATED ENDOCRINE CHANGES, p.727 Alterations to metabolism Disorders of structure and function of endocrine glands alter normal hormone levels, way body tissues use hormones Alterations and manifestations Diabetes ( disorder of metabolism related to the bodys use production and use of insulin Type 1 absolute deficiency of insulin Type 2 relative deficiency of insulin Obesity ( state in which excess calories are stored as fat Graves disease ( autoimmune disorder that results in hyperthyroidism Hypothyroidism ( underactive thyroid gland Osteoporosis ( metabolic bone disorder in which the rate of bone resorption increases and the rate of bone formation decreases Cirrhosis ( widespread destruction of the liver See ALTERATIONS AND THERAPIES Endocrine and Metabolic Disorders, p. 6 Other metabolic alterations not included as part of this concept Leukodystrophies Menkes disease Niemann-Pick disease Phenylketonuria Porphyria Tay-Sachs disease Zellweger syndrome Maple syrup urine disease Prevalence Diabetes ( In 2011, 25.8 million in U.S. diagnosed estimated 7 million not yet diagnosed Obesity ( 33 of adults 17 of youth Thyroid disorders ( Thyrotoxicosis 2 of women, 0.2 of men Hypothyroidism 7.5 of women, 2.8 of men Osteoporosis ( 12 million in U.S. Cirrhosis ( Major cause of death in U.S. Genetic considerations and nonmodifiable risk factors Diabetes ( Type 1 must inherit risk factor from both parents Type 2 runs in families Obesity ( genetics play a role Osteoporosis ( a predisposition is inherited Cirrhosis ( not usually inherited, but some diseases that result in cirrhosis are genetic in origin Case Study Part 1 ( Mary Bell is a 65-year-old Caucasian female who comes to the clinic with back and hip pain Prevention The most prevalent metabolic disorders have modifiable risk factors Diabetes ( encourage healthy lifestyle, screenings Liver disease ( avoid alcohol Assess using CAGE questionnaire Obesity ( encourage less food intake, increased activity, screenings Osteoporosis ( encourage balanced nutrition, activity Assessment Endocrine gland functions assessed using findings from diagnostic tests, health assessment interview, physical assessment Nursing assessment Health assessment interview Consider genetic influences on health of adult Assess for manifestations of genetic disorder Endocrine system may be focus of assessment or part of screening Clients medical history Family history Social and personal history Changes in normal growth, development, height, weight Injuries See ASSESSMENT INTERVIEW Endocrine System, p. 733 Physical assessment Part of total health assessment or focused assessment Thyroid gland ( only one palpable See ENDOCRINE ASSESSMENTS, pp. 734-737 Diagnostic tests Serum blood sugar A1c T3, T4, TSH Individual hormone levels Serum electrolytes Liver enzymes Bilirubin serum albumin Serum calcium Case Study Part 2 ( Ms. Bells T score is found to be -3.2 in the spine and -3 in the hip Interventions and therapies Multidisciplinary care for multiple problems Holistic approach essential component of nursing care Independent therapies Educate client regarding diagnostic testing, disease state, therapies Help develop a lifestyle that will limit complications For diabetes ( educate, coach, advocate to help clients attain optimum health For osteoporosis ( help client and family ensure safe environment Collaborative therapies May work with exercise physiologists and dietitians Behavioral therapy Pharmacologic therapy Replacement therapy See MEDICATIONS Metabolic and Endocrine Disorders, p. 738 Review The Concept of Metabolism Relate Link the Concepts Ready Go to Companion Skills Manual Refer Go to Student Nursing Resources Reflect Case Study Part 3 ( Ms. Bell falls while out grocery shopping and is brought to the emergency room with a fracture of the L3 and L4 Exemplar 12.1 Diabetes Overview Diabetes mellitus ( disorder of hyperglycemia resulting from defects in insulin secretion, insulin action, or both ( leading to abnormalities in carbohydrate, protein, and fat metabolism 4 major types Type 1 diabetes mellitus (type 1 DM) Type 2 diabetes mellitus (type 2 DM) Gestational diabetes Other specific types Role of hormones Endocrine pancreas produces hormones necessary for metabolism and cellular utilization of carbohydrates, proteins, fats Cells that produce hormones ( islet cells Alpha cells ( glucagon ( stimulates breakdown of glycogen in liver, formation of carbohydrates in liver breakdown of lipids in both liver and adipose tissue Glucagon ( glycogenolysis and gluconeogenesis ( prevents blood glucose from decreasing below a certain level Beta cells ( insulin ( facilitates movement of glucose across cell membranes into cells, decreasing blood glucose levels Prevents excessive breakdown of glycogen in liver Facilitates formation of lipid while inhibiting breakdown of stored fat Helps move amino acids into cells for protein synthesis Delta cells ( somatostatin ( neurotransmitter that inhibits production of both glucagon and insulin Blood glucose homeostasis All body tissues, organs require constant supply of glucose ( not all tissues require insulin from glucose uptake Normal blood glucose maintained in healthy people primarily through actions of insulin and glucagon See Figure 123 REGULATION (HOMEOSTASIS) OF BLOOD GLUCOSE, p. 741 Type 1 diabetes mellitus Type 1 DM juvenile-onset diabetes IDDM ( result of pancreatic islet cell destruction and total deficit of circulating insulin Pathophysiology and etiology Results from destruction of beta cells of islets of Langerhans in the pancreas ( insulin no longer produced Autoimmune or idiopathic ( insulinitis ( chronic inflammatory response that occurs in response to autoimmune destruction of islet cells Etiology Most often occurs in childhood, adolescence ( can occur at any age Genetic predisposition plays role in development of type 1 DM ( environmental factors trigger development of disorder Risk factors 1 in 400 to 1 in 1000 in general population Child of person with diabetes ( 1 in 20 to 1 in 50 Clinical manifestations Hyperglycemia Breakdown of body fats and proteins Development of ketosis Clinical manifestations result from lack of insulin to transport glucose across cell membrane into cells Hyperglycemia causes serum hyperosmolality ( draws water from intracellular spaces into general circulation ( increased blood volume increases renal blood flow ( hyperglycemia acts as osmotic diuretic Polyuria Glucosuria Polydipsia Glucose cannot enter cell without insulin ( energy production decreases ( stimulates hunger Polyphagia Loses weight with loss of water, breakdown of proteins and fate People with type 1 DM require exogenous insulin See CLINICAL MANIFESTATIONS AND THERAPIES Type 1 Diabetes Mellitus, p. 742 Type 2 diabetes mellitus adult onset NIDDM ( results from insulin resistance with a defect in compensatory insulin secretion Pathophysiology and etiology Condition of fasting hyperglycemia that occurs despite availability of endogenous insulin Function of insulin impaired by insulin resistance Etiology Can occur at any age, usually middle age and older Major factor is cellular resistance Increased by obesity, inactivity, illness medications, increasing age Risk factors History of diabetes in parents or siblings Obesity Physical inactivity Race/ethnicity History of gestational diabetes, polycystic ovary syndrome Hypertension Metabolic syndrome Clinical manifestations Slow onset of manifestations ( hyperglycemia increases gradually and may exist for a long time before diagnosis ( may already have complications Symptoms similar to type 1 ( not as severe Treatment usually begins with prescriptions for weight loss and increased activity See CLINICAL MANIFESTATIONS AND THERAPIES Type 2 Diabetes Mellitus, p. 743 See MULTISYSTEM EFFECTS OF DIABETES, p. 744 Complications of diabetes Complications involve many body systems Acute complications Hyperglycemia Complications from hyperglycemia ( diabetic ketoacidosis and hyperosmolar hyperglycemic state See Table 123 COMPARISON OF DKA, HHS, AND HYPOGLYCEMIA, p. 745 Dawn phenomenon ( rise in blood glucose between 4 a.m. and 8 a.m. not in response to hypoglycemia Somogyi phenomenon ( a combination of hypoglycemia during night with rebound morning rise in blood glucose to hyperglycemic levels Diabetic ketoacidosis (develops when there is an absolute deficiency of insulin and increase in insulin counterregulatory hormones Glucose production by liver increases ( peripheral glucose use decreases ( fat mobilization increases ( ketogenesis is stimulated Increased glucagon levels ( activate gluconeogenic and ketogenic pathways to liver ( hepatic overproduction of beta-hydroxybutyrate and acetoacetic acids ( increased ketone concentrations and increased release of free fatty acids ( increased ketone causes loss of bicarbonate ( bicarbonate buffering does not occur ( diabetic metabolic acidosis (DKA) See Figure 124 IN TYPE 1 DIABETES MELLITUS, p. 747 DKA ( may also occur when energy requirements increase during physical or emotional stress DKA involves 4 metabolic problems Hyperosmolarity from hyperglycemia and dehydration Metabolic acidosis from an accumulation of ketoacids Extracellular volume depletion from osmotic diuresis Electrolyte imbalances from osmotic diuresis Manifestations of DKA result from severe dehydration and acidosis ( require immediate medical attention 810 L fluid to replace losses IV fluids with 0.9 NS to 0.45 saline Regular insulin used Electrolyte imbalance requires monitoring ( potassium depletion with aggressive rehydration Hyperosmolar hyperglycemic state (HHS) ( occurs in people with type 2 DM ( plasma osmolarity of 340 mOsm/L or greater, greatly elevated blood glucose levels 600 mg/dL (often as high as 1,0002,000 mg/dL) and altered level of consciousness (LOC) Serious, life-threatening ( mortality high Precipitating factors ( infection, therapeutic agents, therapeutic procedures, acute illness, chronic illness Slow onset ( increased urine output ( plasma volume decreases, glomerular filtration rate drops ( glucose retained, water lost ( severe dehydration Dry skin and mucous membranes, extreme thirst, altered LOC Metabolic acidosis not part of this pathology Treatment directed toward correcting fluid and electrolyte imbalances, lowering blood glucose levels with insulin Admit to ICU ( blood glucose 700 mg/dL Establishing, maintaining adequate ventilation Correcting shock with adequate intravenous fluids If client is comatose ( nasogastric suction to prevent aspiration Maintaining fluid volume with IV isotonic or colloid solutions, administering potassium IV to replace losses Administering insulin to reduce blood glucose Hypoglycemia ( common in people with type 1 DM, occasionally with type 2 DM Insulin reaction ( mismatch between insulin intake, physical activity, carbohydrate availability Intake of alcohol, drugs can also cause hypoglycemia Manifestations ( result from compensatory autonomic nervous system response and from impaired cerebral function caused by decrease in glucose available for use by brain See Table 123, COMPARISON OF DKA, HHS, AND HYPOGLYCEMIA, p. 745 Hypoglycemic unawareness ( person does not experience symptoms when epinephrine counterregulatory response to hypoglycemia blunted Treatment for hypoglycemia 15 g of rapid-acting sugar ( 15 minutes, if still low ( 15 g more until blood glucose returns to normal Hospitalized if blood glucose 50 mg/dL coma, seizures, altered behavior hypoglycemia has been treated but no adult can be with client for next 12 hours episode cause by sulfonurea drug Administer 2550 glucose solution Glucagon subcutaneously, IM, or IV Chronic complications Alterations in the cardiovascular system Macrocirculation changes as result of atherosclerosis, abnormalities in platelets, RBCs, clotting factors, changes in arterial walls Microcirculation changes ( structural defects in basement membrane Coronary artery disease ( risk factor for development of MI Hypertension ( common complication of diabetes ( risk factor for CV disease, microvascular complications Stroke ( older adults with type 2 DM 26 times more likely to have a stroke Peripheral vascular disease ( both types of diabetes Diabetic retinopathy ( changes in retina ( has 3 stages Stage 1 nonproliferative retinopathy Stage II preproliferative retinopathy Stage III proliferative retinopathy Diabetic nephropathy ( disease of kidneys characterized by presence of albumin in urine, hypertension, edema, progressive renal insufficiency Thickening of basement membrane of glomeruli eventually impairs renal function First indication ( microalbuminuria Hypertension accelerated progress ( aggressive antihypertensive management Alterations in peripheral and autonomic nervous systems Diabetic neuropathies involve Thickening of walls of blood vessels that supply nerves, causing decrease in nutrients Demyelination of Schwann cells that surround and insulate nerves, slowing nerve conduction Formation and accumulation of sorbitol within Schwann cells, impairing nerve conduction Peripheral neuropathies ( polyneuropathies, mononeuropathies Polyneuropathy ( distal paresthesias, pain feelings of cold feet May have impaired sensation Mononeuropathy ( affect single nerve ( may include Palsy of third cranial nerve Radiculopathy Diabetic femoral neuropathy Entrapment or compression of medial nerve at wrist Visceral neuropathies ( may include Sweating dysfunction Abnormal papillary function Cardiovascular dysfunction Gastrointestinal dysfunction Genitourinary dysfunction Alterations in mood Chronic strains of living with complex self-care ( increased risk of depression Combination of antidepressant medications, psychotherapy Increased susceptibility to infection Vascular, neurologic impairments ( sensory impairments, diminished inflammatory response, slowed healing Nephrosclerosis, urinary retention ( predisposed to pyelonephritis, urinary tract infection (UTI) Periodontal disease Progresses more rapidly if diabetes poorly controlled Complications involving the feet Result of angiopathy, neuropathy, infection Vascular changes result in arteriosclerosis ( usually bilateral Diabetic neuropathy produces multiple problems Most common trauma ( cracks, fissures from dry skin, blisters, pressure, ingrown toenails Begin ( superficial skin ulcer ( extends deeper ( muscle, bone ( abscess, osteomyelitis ( gangrene can develop Collaboration Closely controlled blood glucose reduces risk of complications by 60 Diagnostic tests ( screening, ongoing management Diagnostic screening Symptoms of diabetes plus casual plasma glucose (PG) concentration 200 mg/dL Fasting plasma glucose (FPG) 126 mg/dL Two-hour PG 200 mg/dL ( oral glucose tolerance test (OGTT) Following levels used for FPG Normal FG 100 mg/dL Impaired FG 100 and 126 mg/dL Diagnosis of diabetes 126 mg/dL Following levels used for OGTT Normal glucose tolerance 2-hr PG 140 mg/dL Impaired GT (IGT) 2-hr PG ( 140 mg/dL and 200 mg/dL Diagnosis of diabetes 2-hr PG ( 200 mg/dL Prediabetes At increased risk of developing diabetes FPG between 100 and 126 mg/dL Diabetes management monitoring FPG ( 70110 mg/dL Glycosylated hemoglobin (c) (A1c) ( average blood glucose over 23 months ( 79 normal Urine glucose and ketone levels ( not as accurate as blood levels Urine test for protein Serum cholesterol and triglyceride levels Serum electrolytes Monitoring blood glucose Daily monitoring Urine testing ( inexpensive, noninvasive, painless ( not reliable Self-monitoring of blood glucose (SMBG) ( allows person with diabetes to monitor, achieve metabolic control, decrease danger of hypoglycemia 34 times a day for clients with type 1 DM American Diabetes Association (ADA) ( list of monitoring machines, strips with prices ( most medical insurance policies cover cost of machines Continuous glucose monitor (CGM) ( sensor under skin ( transmits data to insulin pump Equipment needed Lancet to perform finger stick Chemically impregnated test strips that change color when in contact with machine Blood glucose monitor Clients with higher hematocrit ( falsely low in blood glucose Medications may cause inaccurate results Be sure test strips compatible with glucose meter Pharmacologic therapy Insulin See CLIENT TEACHING TAKING INSULIN TO MANAGE DIABETES MELLITUS, p. 755 Type 1 DM ( requires lifelong exogenous source of insulin hormone Not cure ( means of controlling hyperglycemia People with diabetes ( unable to control glucose levels with oral antidiabetic drugs and/or diet People with diabetes experiencing physical stress or taking oral corticosteroids People with DKA or HHS People who are receiving high-calorie tube feedings or parenteral nutrition Insulin derived from animal or synthesized in lab ( biosynthetic human insulin Available in rapid-acting, short-acting, intermediate-acting, long-acting preparations See Table 124 INSULIN PREPARATIONS, p. 754 Insulin lispro (Humalog) ( rapid-acting, ultra-short-acting (15-minute onset) People with type 1 DM usually require concurrent use of longer-acting insulin product Less likely than regular insulin to cause tissue changes Regular insulin ( short-acting insulin, clear ONLY INSULIN THAT CAN BE GIVEN IV Used to treat DKA, initiate treatment for newly diagnosed type 1 DM NPH insulin ( buffers, protamin added ( prolong action ( intermediate- or long-acting insulins Preparations appear cloudy when properly mixed Insulin glargine ( 24-hour, long-acting rDNA human insulin analog, treat both type 1 and type 2 DM Constant effect ( no peak time Do not mix with other insulins Insulin dispensed as 100 unit/mL (U-100) and 500 unit/mL (U-500) U-100 standard concentration U-500 ( used in cases of insulin resistance Nursing implications ( see Box 121 MEDICATION ADMINISTRATION INSULIN, p. 754 All insulins given parenterally Subcutaneously Regular, rapid-acting insulins ( used in continuous insulin infusion (SCII) devices ( insulin pumps Type 2 diabetics cannot be managed with oral medication when hospitalized ICU patients ( less morbidity with intensive insulin therapy versus regular insulin therapy Decreases risk of postoperative infections, shortens hospital stays Intravenous insulin infusions ( maintain normal blood glucose with frequent monitoring, intensive nursing care Pumps allow more normal regulation of blood glucose, lifestyle flexibility Needle site must be kept clean, changed on regular basis Special injection products ( physical handicaps Vials at room temperature ( up to 4 weeks Regular insulin ( no mixing Other types ( gentle rolling between hands Injection sites recommended ( Figure 126 SITES OF INSULIN, p. 756 Do not massage site after injection ( pressure may be applied Box 122 TECHNIQUES TO MINIMIZE PAINFUL INJECTIONS, p. 756 Lipodystrophy or lipoatrophy ( same sites repeatedly, refrigerated insulin Hypoglycemic agents Used to treat type 2 DM Lower blood sugar by stimulating or increasing insulin secretion, preventing breakdown of glycogen to glucose by liver, increasing peripheral uptake of glucose Oral preparations Injectable ( exenatide (Byetta) Aspirin therapy Recommended once-daily dose of 81325 mg of enteric-coated aspirin Reduces atherosclerosis Nutrition Management ( balance of nutrients, expenditure of energy, dose and timing of medication ADA guidelines Maintain as near normal blood glucose levels as possible by balancing food intake with insulin and oral glucose Achieve optimal serum lipid levels Provide adequate calories to maintain or attain reasonable weights and to recover from catabolic illness Prevent and treat acute complications of insulin-treated DM, short-term illnesses, exercise-related problems, long-term complications of diabetes Improving overall health through optimal nutrition Carbohydrate intake individualized ( 4565 of daily diet Plant foods, milk, some dairy Sucrose substituted for other carbohydrates gram for gram Protein intake ( 1520 total daily kilocalorie intake Low in fat, cholesterol Lower than most people consume ( prevent, delay renal complications Dietary fat ( saturated fats 10 of total kcal/day, cholesterol 300 mg/day Saturated fat ( animal meats, cocoa butter, coconut oil, palm oil Polyunsaturated fat ( corn, safflower, sunflower, soybean, sesame seed, cottonseed oils Monounsaturated fat ( peanut, olive, canola oils Dietary fiber Helpful in treating or preventing constipation, GI disorders Ideal level of fiber ( recommended 2035 g/day Increase gradually Sodium 1,000 mg per 1,000 kcal, not to exceed 3,000 Diabetic diet plan Restricts refined sugars ( use noncaloric sweeteners Nutritive sweeteners Alcohol consumption ( may potentiate hypoglycemic effects of insulin, oral agents Signs of intoxication and hypoglycemia similar Two oral hypoglycemic agents may interact with alcohol (chlorpropamide, tolbutamide) Liqueurs, sweet wines, wine coolers, sweet mixes contain large amounts of carbohydrate Light beer is recommended alcoholic drink Alcohol should be consumed with meals and added to daily food intake Meal planning ( take into account individuals eating habits, diet history, food values, special needs Sick-day management Person with diabetes sick, or surgery ( glucose levels increase Guidelines Monitoring blood glucose at least 4 times a day throughout illness Testing urine for ketones if blood glucose is greater than 240 mg/dL Continuing to take the usual insulin dose or oral hypoglycemic agent Sipping 812 oz of fluid each hour Substituting easily digested liquids, soft foods if solid foods not tolerated Call healthcare provider if client unable to eat for more than 24 hours, vomiting and diarrhea last for more than 6 hours Exercise Regular exercise program ( improved physical fitness, improved emotional state, weight control, improved work capacity Consider usual exercise habits, living environment, community programs Proper footwear Avoid exercise in extremes of hot, cold Timing of exercise in relation to meals, injections General guidelines People who have frequent hyperglycemia, hypoglycemia should avoid prolonged exercise until glucose control improves Risk of exercise-induced hypoglycemia lowest before breakfast, when free-insulin levels tend to be lower than they are before meals later in the day or at bedtime Low-impact aerobic exercises are encouraged Exercise should be moderate and regular brief, intense exercise tends to cause mild hyperglycemia, prolonged exercise can lead to hypoglycemia Exercising at a peak insulin action time may lead to hypoglycemia Self-monitoring of blood glucose levels essential before and after exercise Food intake may need to be increased to compensate for the activity Fluid intake, especially water, is essential Training should begin slowly ( carbohydrate source after about 1 hour of exercise Exercise with type 2 DM important ( may decrease need for oral hypoglycemic Medical screening before beginning program Begin with mild exercises, gradually increase intensity and duration Self-monitor blood glucose before and after exercise Exercise at least 3 times a week or every other day, at least 2030 minutes Include muscle-strengthening, low-impact aerobic exercise in program Surgery Surgical management of diabetes involves replacing, transplanting pancreas, pancreatic cells, beta cells Investigative Surgery alters self-management Hyperglycemia, protein stored decreased High risk for postoperative infection, delayed wound healing, fluid and electrolyte imbalances, hypoglycemia, DKA Preoperative screening, glucose monitoring Insulin in pre-, intra-, postoperative periods individualized No intermediate- or long-acting insulin given day of surgery regular insulin given with IV glucose Half of usual intermediate- or long-acting insulin given before surgery, remaining half given in recovery room Total daily dose of insulin is divided into four equal doses of regular insulin ( one dose administered subcutaneously every 6 hours Clients with type 1 DM, or type 2 DM with preoperative blood glucose 200 mg/dL, receive IV glucose and insulin infusion Schedule procedure early as possible ( minimize fasting Postoperative ( regular glucose monitoring Nursing process Responses to diabetes complex, involve multiple body systems Client (and family) teaching is nursing responsibility ADA recommends three levels of teaching Survival skills ( basics Home management (self-reliance, independence in daily management of diabetes Improving lifestyle, educating clients ( individualize self- management of illness Health promotion focuses on preventing complications of diabetes Assessment Health history Hypertension Change in vision or speech Change in weight, appetite, infections, healing Frequent voiding Physical assessment Height/weight ratio Vital signs Sensory ability of extremities, peripheral pulses, skin mucous membranes Older adults ( be aware of normal aging changes Children Assess physiologic status Hydration Vital signs, LOC Assess family ( coping mechanisms, strengths, resources, ability to manage disease, educational needs Diagnosis Knowledge Deficit Risk for Impaired Skin Integrity Risk for Infection Risk for Injury Risk for Deficient Fluid Volume Sexual Dysfunction Ineffective Coping Planning Client describes how to administer medications, respond to side effects Client demonstrates meal planning compliant with the ADA Client demonstrates proper foot care and inspection Client demonstrates proper procedure for monitoring blood sugar levels Client describes strategies for reducing risk of infection Implementation Individualizedfocuses on teaching client, family about disease, management Information about normal metabolism, diabetes, how diabetes alters metabolism How diets help keep blood glucose in the normal range Exercise helps lower blood glucose Self-monitoring of blood glucose Medications ( insulin, oral agents Manifestations of acute complications of hypoglycemia, hyperglycemia Hygiene, including skin care, dental care, foot care What to do about food, fluids, medications when client is sick Helpful resources Adapt teaching to special needs, developmental level Older adult Changes in diet may be difficult to implement for many reasons Exercise of any type may not have been part of activities of daily living Diagnosis of chronic illness threatens a clients independence and self-worth Money to purchase medications, supplies often taken out of fixed income Visual deficits may make insulin administration difficult or impossible Maintain skin integrity Client at increased risk for altered skin integrity ( baseline, ongoing assessments Musculoskeletal assessment that includes foot and ankle joint range of motion (ROM), bone abnormalities, gait patterns, use of assistive devices for walking, abnormal wear patterns on shoes Neurologic assessment Vascular examination Assessment of hydration status Assessment for lesions Peripheral neuropathies and vascular disease may cause or contribute to many complications Teach foot hygiene Discuss importance of not smoking if client smokes Discuss importance of maintaining blood glucose levels Conduct foot care teaching sessions as often as necessary See CLIENT TEACHING Foot Care, p. 763 Promote healthy behaviors Use and teach meticulous hand washing Monitor for manifestations of infection Discuss importance of skin care Teach dental health measures Dental examination every 46 months Maintain careful oral hygiene Be aware of symptoms requiring dental health Monitor for need to make adjustments in insulin if dental surgery necessary Teach women with diabetes the symptoms and preventive measures for vaginitis caused by Candida albicans Maintain safety Assess for presence of contributing or causative factors that increase risk of injury Reduce environmental hazards in the healthcare facility, teach client about safety in the home Monitor for and teach client, family to recognize and seek care for manifestations of DKA in the client with type 1 DM HHS in client with type 2 DM Monitor for and teach client, family to recognize and treat manifestations of hypoglycemia Recommend wearing a medic alert bracelet or necklace Maintain sexual health Changes in sexual function, sexuality have been identified in both men and women with diabetes Include a sexual history as part of the initial ongoing assessment of the client with diabetes Provide information about the actual and potential physical effects of diabetes on sexual function Provide counseling, or make referrals as appropriate Promote eeffective coping Client with diabetes faced with lifelong changes Assess clients psychosocial resources Explore with client, family effects of diagnosis and treatment of diabetes on finances, occupation, energy levels, and relationships Teach constructive problem-solving techniques Provide information about support groups and resources Evaluation Client will demonstrate an age-appropriate understanding of self-management through medication, diet, exercise, blood glucose self-monitoring activities Skin integrity will remain intact Client will remain free of infection Client will remain free of injury Review Diabetes Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 12.2 Diabetes in Children Overview Classified as type 1, type 2, and other (MODY and NDM) See Box 12-2 MODY and NDM, p. 767 Type 1 diabetes mellitus in children Case Study Part 1 ( Lydia Moreland is a 6-year-olf female who was diagnosed with type 1 diabetes 3 months ago , p. 767 Risk factors genes, race, ethnicity, family history, congenital rubella Case Study Part 2 ( Three days later, Lydias DKA is resolved , p. 767 Clinical manifestations Increased thirst Hunger Urination Fatigue Blurred vision Weight loss Collaboration Rehabilitation Act of 1973 Individuals with Disabilities Education Act of 1990 and 2004 Increased Case Study Part 3 ( Lydia is discharged at the end of week 1 , p. 768 Diagnostic tests A1c level of 6.5 or higher BPG of 200 mg/dL or higher FPG of 126 g/dL or higher Glucose monitoring See Table 126 PLASMA BLOOD GLUCOSE AND HEMOGLOBIN, p. 770 Insulin See Table 127 RECOMMENDED INSULIN DOSES FOR CHILDREN, p. 771 Nutrition therapy Suitable for all children See Table 12-8 AGE-SPECIFIC NUTRITIONAL RECOMMENDATIONS, p. 771 Managing complications Celiac disease Thyroid disease Eating disorders Frequent and severe hypoglycemia Alcohol use (see Box 125 ALCOHOL AND HYPOGLYCEMIA, p. 772.) Increased Type 2 diabetes mellitus in children Risk factors gender (female), overweight, family history, ethnicity, insulin resistance, puberty Clinical manifestations Less acute than type 1 DM Related to hyperglycemia May include weight gain Skin changes Collaboration Overall goal is age-appropriate BMI If BMI greater than 85th percentile, counseling Diagnostic tests are same as screening tests Hypoglycemic agents Not first-line therapy Diet and exercise effective for control in less than 10 Metformin is adjunct to diet and exercise Insulin may precede metformin after stability in glycemic control Metformin takes 4 weeks to take effect Managing complications Adaptation of materials used for type 1 DM Nursing process Assessment Look at having skills for survival Recognize family stress and coping Continue with adequate follow-up Diagnosis Knowledge Deficit Ineffective Coping (family or individual, or both) Imbalanced Nutrition Chronic Pain Risk for Injury Risk for Infection Risk for Unstable Blood Glucose Planning Discharge planning begin at diagnosis Family involvement is crucial Implementation Educate client and family Assess for barriers to implementation Emphasize frequent glucose monitoring See CLIENT TEACHING Ten Tips for Better Glucose Control, p. 777 Ensure participation in recreational activities ( see COMMUNITY-BASED CARE CHILDREN WITH DIABETES, p. 778 Evaluation Realistic goals Free of infection and injury Adequate glucose controls Meet nutritional needs for growth and development Recognize early signs of lack of glucose control Prevent complications long-term Review Diabetes in Children Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Studies A and B Exemplar 12.3 Liver Disease Overview Liver is a complex organ with multiple metabolic and regulatory functions Essential functions of liver include metabolism of proteins, carbohydrates, fats Liver is vital to digestion and metabolism of nutrients, production of plasma proteins, metabolism and excretion of compounds as well as toxins Impaired function of liver cells Impaired protein metabolism with decreased production of albumin, clotting factors Disrupted glucose metabolism, storage resulting alterations in blood glucose levels Reduced bile production that impairs absorption of lipids, fat-soluble vitamins Impaired metabolism of steroid hormones Many disorders can disrupt liver function ( cirrhosis most common cause of liver disease in United States Cirrhosis ( end stage of chronic liver disease( progressive, irreversible disorder Alcoholic (Lannec) cirrhosis most common type of cirrhosis in North America Pathophysiology and etiology Functional liver tissue is gradually destroyed ( replaced by fibrous scar tissue Etiology Alcoholic cirrhosis ( end result of alcoholic liver disease ( directly related to alcohol consumption Alcohol causes metabolic changes in the liver ( triglyceride, fatty acid synthesis increases, formation and release of lipoproteins decrease ( fatty infiltration of hepatocytes Biliary cirrhosis Bile flow obstructed within the liver, or in biliary system ( retained bile damages and destroys liver cells Posthepatic cirrhosis Advanced progressive liver disease resulting from chronic hepatitis B or C, or from unknown cause Risk factors High-risk behaviors Excess alcohol use Injection drug use Clinical manifestations Early ( few manifestations Liver enlarged, may be tender Weight loss, weakness, anorexia As disease progresses ( manifestations related to liver cell failure, portal hypertension Treatment supportive ( directed at slowing progression to liver failure, reducing complications Portal hypertension Causes blood to be rerouted to adjoining, lower-pressure vessels Shunting to collateral vessels Splenomegaly Portal hypertension causes blood to be shunted to splenic vein ( increases rate at which RBCs, WBCs, and platelets removed from circulation and destroyed Ascites Accumulation of plasma-rich fluid in abdominal cavity Hypoalbuminemia ( decreases colloidal osmotic pressure of plasma Hyperaldosteronism ( sodium and water retention, contributing to ascites and generalized edema Esophageal varices Enlarged thin-walled veins that form in the submucosa of the esophagus Result from portal hypertension May rupture ( massive hemorrhage Portal systemic encephalopathy hepatic encephalopathy Results from accumulation of neurotoxins in the blood and cerebral edema Asterixis ( liver flapmuscle tremor that interferes with ability to maintain fixed position of the extremities causes involuntary jerking movements Changes in personality, mentation ( agitation, restlessness, impaired judgment, slurred speech are early manifestations Hepatorenal syndrome Renal failure with azotemia, sodium retention, oliguria, hypotension Appears to be result of imbalanced blood flow Spontaneous bacterial peritonitis In absence of known contamination ( inflammatory response to peritonitis worsens ascites See MULTISYSTEM EFFECTS OF CIRRHOSIS, p. 783 See CLINICAL MANIFESTATIONS LIVER DISEASE, p. 784 Collaboration Holistic ( address physiologic, psychosocial, spiritual needs Diagnostic tests Liver function studies CBC Coagulation studies Serum electrolytes Bilirubin Serum albumin Serum ammonia Abdominal ultrasound Esophagoscopy Liver biopsy Pharmacologic therapy Used to treat complications and effects ( do not reverse or slow process Diuretics reduce fluid retention and ascites Medications to reduce nitrogen load, lower serum ammonia levels Lactulose, neomycin Beta-blocker nadolol (Corgard) with isosorbide mononitrate (Ismo) to prevent rebleeding of esophageal varices Ferrous sulfate, folic acid ( treat anemia Packed RBCs with acute bleeding Antacids as prescribed Oxazepam (Serax) Nutritional therapy Sodium intake restricted to less than 2 g/day Fluid restrictions Serum ammonia levels high ( eliminate protein from diet High calories, moderate fat intake Vitamin and mineral supplements based on laboratory values Surgery Transplantation for some clients Nursing process Assessment Health history Current manifestations Pattern and extent of alcohol or injection drug use Physical assessment Diagnosis Excess Fluid Volume Risk for Acute Confusion Ineffective Protection Impaired Skin Integrity Imbalanced Nutrition Less Than Body Requirements Planning Client maintains proper hydration levels as indicated by urine specific gravity tests Client maintains appropriate diet Client reports regular bowel elimination pattern Client oriented to surroundings, person, place Client maintains vital signs within normal limits Client avoids alcohol Implementation Stress relationship between alcohol/drug abuse and liver disease Balance fluid volume Cirrhosis affects water and salt regulation Weigh daily Assess urine specific gravity Provide low-sodium diet, restrict fluids as ordered Maintain mental status Assess neurologic status, including LOC and mental status Avoid factors that may precipitate hepatic encephalopathy Plan for consistent nursing care assignments if possible Provide low-protein diet as prescribed teach family the importance of maintaining diet restrictions Administer medications or enemas as ordered to reduce nitrogenous products Orient client to surroundings, person, place Minimize bleeding Monitor vital signs, report tachycardia or hypotension Institute bleeding precautions Monitor coagulation studies and platelet count Carefully monitor client who has had bleeding esophageal varices for evidence of rebleeding hematemesis, hematochezia, tarry stools Maintain skin integrity Use warm water rather than hot water when bathing Use measures to prevent dry skin If indicated, apply mittens to hands to prevent scratching Institute measures to prevent skin and tissue breakdown Administer a prescribed antihistamine Promote bbalanced nutrition Weigh daily Provide small meals with between-meal snacks Unless protein is restricted because of impending hepatic encephalopathy, promote protein and nutrient intake Arrange consultation with dietitian for diet planning while hospitalized and at home Manage complications Paracentesis ( diagnostic or therapeutic Bleeding esophageal varices ( life-threatening, intensive care management Upper endoscopy to evaluate and treat Large nasogastric tube ( gastric lavage Varices may be banded, sclerosed Balloon tamponade if bleeding cannot be controlled Multilumen nasogastric tube inserted ( balloons inflated Tension applied to tube to further compress varices Risks ( aspiration, airway obstruction, tissue ischemia, necrosis Transjugular intrahepatic portosystemic shunt ( relieve portal hypertension and complications Short-term measure until a liver transplant can be performed Evaluation Monitor laboratory data Monitor biophysical data Review Liver Disease Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 12.4 Obesity Overview Obesity ( one of the most prevalent preventable health problems in the United States More than 30 of adult population is obese Pathophysiology and etiology Nutrients in food provide energy ( building blocks for growth and tissue repair Basal metabolic rate (BMR) ( amount of energy expended each day to maintain body function Energy stored primarily as adipose tissue Etiology Excess calories are stored as fat Appetite regulated by central nervous system, emotional factors Several hormones involved in regulating obesity ( thyroid hormone, insulin, lepton Risk factors Genetic, physiologic, psychologic, environmental, sociocultural factors Physical inactivity ( probably most important factor contributing to obesity Environmental factors ( food supply, fast-food restaurants, advertising, vending machines Psychologic factors ( self-esteem Clinical manifestations Defined by body mass index (BMI) ( indirect measure of amount of body fat BMI 2529.9 kg/m2 ( overweight BMI 30 kg/m2 ( classified as obese Upper body obesity (central obesity) ( identified by waist-to-hip ratio of greater than 1 in men or 0.8 in women More common in men Lower body obesity (peripheral obesity) ( identified by a waist-to-hip ratio of less than 0.8 More common in women Many contributing factors ( treatment is ongoing process requiring several strategies See Table 1213 CLASSIFICATION OF OVERWEIGHT AND OBESITY BY BMI, WAIST CIRCUMFERENCE, AND ASSOCIATED DISEASE RISKS, p. 793 See CLINICAL MANIFESTATIONS AND THERAPIES Obesity, p. 792 Complications of obesity Adverse consequences increase as obesity increases Morbid obesity ( 200 of ideal body weight ( risk of dying 12 times greater than that of people not obese Significant risk factor for cardiovascular disease 60 of obese individuals have metabolic syndrome Obesity increases risk of insulin resistance and type 2 DM Affects reproductive function in both men and women Increased weight ( increases risk for developing gallstones, several types of cancer, osteoarthritis See Table 1213 HEALTH-RELATED PROBLEMS ASSOCIATED WITH OBESITY, p. 793 Collaboration Treatment interdisciplinary ( focuses on reducing health risks by changing eating and exercise habits Diagnostic tests Body mass index ( divide weight (in kg) by height (in m2) Anthropometry Underwater weighing (hydrodensitometry) Bioelectrical impedance Waist circumference Other diagnostic tests Thyroid profile Serum glucose Serum cholesterol Lipid profile Electrocardiography Pharmacologic therapy Prescription and over-the-counter (OTC) drugs ( in combination with diet, exercise can help weight loss Amphetamines, nonamphetamine appetite suppressant Sibutramine (Meridia) ( CNS appetite suppressant Orlistat (Xenical) ( inhibits fat absorption from GI tract OTC Benzocaine, bulk-forming agents Exercise Critical element in weight loss and maintenance Client under care of physician for another condition ( consult treating physician Aerobic exercise program of 3040 minutes of exercise 5 or more days a week Nutrition Collaboration with nutritionist ( diet plan to create 5001,000-kcal deficit Low in kilocalories, fat, high in fiber Yo-yo dieting may lead to metabolic deficiencies ( makes subsequent weight loss efforts increasingly difficult Very-low-calorie diets ( reserved for clients who have BMI 30 Protein-sparing modified fast under close medical supervision May not be appropriate for use in people over age 50 Behavior modification Critical component of successful weight management ( food records, eliminating cues that precipitate eating Recording food intake, amount, location, situations that induce eating ( often help dieter to gain self-control Eating regulated by external cues for most overweight people Examine factors that affect eating behaviors Social support and group programs promote weight loss success through peer support Surgery Bariatric surgery ( morbidly obese clients( BMI 40 kg/m2 or 200 of ideal weight Thorough psychological evaluation done before surgery Restrictive/malabsorptive procedures Restrict stomach capacity ( bypass portion of small intestine to restrict absorption of calories and nutrients Roux-en-Y gastric bypass ( See Figure 129A TYPES OF SURGICAL, p.795 Have advantage of resulting in rapid weight loss Restrictive procedures Safer, generally less effective in long term Adjustable gastric banding ( see Figure 129B, p. 795 Vertical banded gastroplasty ( see Figure 129C, p. 795 Can be performed laparoscopically Complications of surgery Risk for postoperative complications high ( mortality rate low Anastomosis leak with peritonitis Abdominal wall hernia Gallstones Wound infections Deep vein thrombosis (DVT) Nutritional deficiencies GI symptoms Nursing process Maintaining healthy weight begins in childhood Adults commonly gain approximately 20 pounds between early and middle adulthood Assessment Health history Risk factors Recent weight gain/loss Perception of weight, health Diet/food intake Family history Physical examination Vital signs, height, weight Skinfold measurements Diagnosis Imbalanced Nutrition More Than Body Requirements Chronic Low Self-Esteem Noncompliance Activity Intolerance Planning Client makes sensible dietary choices in order to plan meals within the caloric limitations chosen by the collaborative team Client follows an exercise routine planned in collaboration with healthcare team Client relates strategies to deal with hunger and making unhealthy food choices Client will attend support group meetings to help him or her meet weight loss goals Client demonstrates appropriate weight loss, attending regular weigh-ins Implementation Caring interventions Encourage client to identify factors that contribute to excess food intake Establish realistic weight loss goals and exercise/activity objectives Assess the clients knowledge and discuss well-balanced diet plans Discuss behavior modification strategies, such as self-monitoring and environmental management Monitor weight loss, blood pressure, and laboratory data Encourage exercise Assess clients current activity level and tolerance of activity Upon medical clearance, plan program of regular, gradually increasing exercise Promote weight loss Discuss clients ability, willingness to incorporate changes into daily patterns Help client identify behavior modification strategies, support systems Have client establish strategies for dealing with stress eating or interruptions in the therapeutic regime Promote self-esteem Encourage client to verbalize experience of being overweight, validate clients experience Set small goals with client, and offer positive feedback and encouragement Refer client for counseling as appropriate Evaluation Identification and understanding of factors contributing to weight gain Understanding and application of behavioral modification techniques to lose weight Accomplishment of desired weight loss at a rate of 12 lb/week Incorporation of physical activity into routines Review Obesity Relate Link to Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 12.5 Osteoporosis Overview Osteoporosis ( metabolic bone disorder characterized by loss of bone mass, increased bone fragility, and increased risk of fractures Most often associated with aging as result of inadequate calcium intake Pathophysiology and etiology Exact pathophysiology unclear ( known to involve imbalance in activity of osteoblasts and osteoclasts Affects diaphysis and metaphysis ( diameter of bone increases, thinning outer supporting cortex Trabeculae lost from cancellous bone ( outer cortex thins to point that even minimal stress will fracture the bone Etiology 57 million people have osteoporosis or low bone mass 80 are women Risk factors Risk for developing osteoporosis depends on how much bone mass achieved between 25 and 35 ( and how much is lost Unmodifiable risk factors Thin, having small frame Family history Age and gender Both men and women are susceptible Osteoblasts and osteoclasts undergo alterations that diminish activity Women have significantly higher risk for manifestations and complication Ethnicity European Americans Asians Other chronic diseases Endocrine disorders Asthma and allergies Current low bone mass in children Conditions that interfere with ambulation, weight bearing Castings, bracing Modifiable risk factors Female athletes ( female athlete triad Disordered eating Low bone mass Amenorrhea Menopause Estrogen promotes activity of osteoblasts Calcium deficiency Acidosis High-protein diet Substance abuse Cigarettes Alcohol intake Sedentary lifestyle Weight-bearing exercises Medications Aluminum-containing antacids Anticonvulsants Glucocorticoid medication Clinical manifestations Most common Loss of height ( vertebral bodies collapse Progressive curvature of the spine ( dorsal kyphosis, cervical lordosis Low back pain ( fractures Fractures of forearm, spine, hip Pharmacotherapy used for prevention and treatment Collaboration Focus on stopping or slowing process, alleviating symptoms, preventing complications Diagnostic tests Dual-energy x-ray absorptiometry ( measures bone density Alkaline phosphatase Serum bone Gla protein Physical therapy Physical therapist ( appropriate exercises Comorbidities Dietary management Choose healthier menu items ( high in calcium and vitamin D Pharmacologic therapy Calcium gluconate, calcium supplementswith meals Bisphosphonatesinhibit bone resorption by suppressing osteoclast activity See Table 1214 SELECTED DRUGS FOR OSTEROPOROSIS, p. 802 Nursing process Preventable and treatable Assessment Health history ( age, risk factors Physical examination ( height, spinal curves Diagnosis Risk for Injury Imbalanced Nutrition Less Than Body Requirements Acute Pain Planning Client participates in weight-bearing exercise for 30 minutes/day at least 4 days/week Clients bone density evaluated at least every other year Client gets sufficient nutrition Client able to discuss risk factors for osteoporosis and how to prevent, minimize them Clients with a high risk for injury modify home and work environments Implementation Prevent injury Implement safety precautions for the client who is hospitalized, in a long-term care facility Avoid using restraints on hospitalized client or resident in long-term care facility Encourage older adults to use assistive devices to maintain independence in ADLs Teach older client about safety and fall precautions Promote balanc nutrition Teach adolescents, pregnant or lactating women, adults through age 35 to eat foods that high in calcium and maintain a daily calcium intake of 1,2001,500 mg Encourage postmenopausal women to maintain intake of 1,0001,500 mg daily through either diet or calcium supplement Teach clients taking calcium supplements the importance of taking the medication at the proper time and about side effects that may occur Inform clients that calcium absorption requires sufficient levels of vitamin D Relieve acute pain Suggest application of heat to relieve pain Suggest client take OTC anti-inflammatory pain medications for acute, chronic pain Encourage exercise Teach clients who are able to do weight-bearing exercises to perform them for a sustained period of 3040 minutes at least 3 times a week Prior to beginning teaching related to exercise, determine clients health problems, consult with primary provider to determine safety in beginning exercise regime Determine clients interests, plan exercise regimen in sync with clients preferences Promote healthy behaviors Not smoking Avoiding excessive alcohol intake Limiting caffeine intake Evaluation Client identifies and implements strategies to change or modify lifestyle factors such as smoking cessation, weight-bearing exercise, alcohol use Client achieves adequate calcium intake Client identifies and eliminate safety hazards Client experiences relief from acute pain Review Osteoporosis Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study Exemplar 12.6 Thyroid Disease Overview Thyroid gland ( small saddle-shaped gland that wraps around anterior portion of trachea Thyroid hormone (TH) affects all major organ systems Hyperthyroidism ( disorder caused by excessive delivery of TH to peripheral tissues Pathophysiology and etiology Effects of hyperthyroidism ( result of increased circulating levels of TH Increases metabolic rate, heightens sympathetic nervous systems physiologic response to stimulation Etiology Results from many factors Autoimmune stimulation Excess secretion of TSH Excessive intake of thyroid medications Risk factors Women at increased risk Genetic factors Increased iodine intake Age between 20 and 40 years Clinical manifestations Symptoms Increased appetite yet loses weight Hypermotile bowels, diarrhea Heat intolerance, insomnia Palpitations Increased sweating Hair may become fine, hair loss in scalp, eyebrow, axillary or pubic areas of the body See MULTISYSTEM EFFECTS OF HYPERTHYROIDISM, p. 807 Graves disease Autoimmune disorder sometimes associated with presence of other autoimmune disorders, such as myasthenia gravis, pernicious anemia Client with Graves disease ( enlarged thyroid gland (goiter), manifestations of hyperthyroidism Goiter ( can result from excess TSH stimulation Ophthalmopathy manifested as proptosis and visual dysfunction Proptosis ( exophthalmos ( results from accumulation of inflammation byproducts in the retro-orbital tissues See Figure 1211, EXOPHTHALMOS IN A CLIENT WITH GRAVES DISEASE, p. 806 Dermopathy of Graves disease ( pretibial myxedema Other manifestations ( fatigue, difficulty sleeping, hand tremors, changes in menstruation Toxic multinodular goiter Tumor characterized ( small, discrete, independently functioning nodules in thyroid gland tissue that secrete excessive amounts of TH Manifestations of hyperthyroidism develop slowly Excess TSH stimulation Overproduction of TSH by pituitary ( stimulates thyroid gland to produce excess TH Rare often results from pituitary adenoma Thyroiditis Most often result of viral infections Acute disorder that may be chronic ( resulting in a hypothyroid state as repeated infections destroy gland tissue Thyroid storm Extreme state of hyperthyroidism ( rare today Usually people with untreated hyperthyroidism, and people with hyperthyroidism who have experienced a stressor Life threatening Rapid increase in metabolic rated causes manifestation of thyroid storm Rapid treatment essential to preserve life Collaboration Preventing complications until TH levels brought into normal range Diagnostic tests Thyroid antibodies test (TA) TSH test T4 T3 T3 uptake test Radioactive iodine (RAI) uptake test Thyroid suppression test Pharmacologic therapy Treated by administering antithyroid medications that reduce TH production Therapeutic effects may not be seen for several weeks Radioactive iodine therapy Thyroid gland takes up iodine in any form ( RAI concentrates in thyroid gland ( damages, destroys thyroid cells Produce less TH Given orally Results typically take 68 weeks Surgery Thyroid gland so enlarged ( pressure on esophagus, trachea causes problems with breathing, swallowing Thyroidectomy Subtotal ( leaves enough gland in place to produce adequate amount of TH Before surgery ( client may be given antithyroid drugs to reduce hormone levels, iodine preparations to decrease vascularity and size of gland Nursing process Assessment Health history Other diseases, family history of thyroid disease, symptoms Physical assessment Muscle strength, tremors, vital signs, cardiovascular and peripheral vascular systems, integument, size of thyroid Diagnosis Decreased Cardiac Output Impaired Comfort, Impaired Health Maintenance, and Risk for Infection related to visual changes and vision loss Imbalanced Nutrition Less Than Body Requirements Disturbed Body Image Planning Client reports improvement related to manifestations Client describes situations requiring contact with the provider Client explains how to take prescribed medications Implementation Monitor cardiac output Monitor blood pressure, pulse rate, rhythm, respiratory rate, breath sounds Suggest keeping environment as cool and free of distractions as possible Encourage client to balance periods of activity with periods of rest Promote visual health Monitor visual acuity, photophobia, integrity of cornea, lid closure Teach measures for protecting eye from injury and maintaining visual acuity Tinted glasses or shields as protection Artificial tears to moisten eyes Cool, moist compresses to relieve irritation Cover or tape eyelids shut at night if they do not close Elevate the head of the bed 45( to promote periorbital fluid decrease Have client promptly report any pain or changes in vision Promote balanced nutrition Monitor nutritional status through results of laboratory tests Ask client to check his or her weight daily In collaboration with dietitian, teach client about need for diet high in carbohydrates and protein that includes between-meal snacks Improve body image Establish trusting relationship, encourage client to verbalize feelings about self and to ask questions about illness and treatment Evaluation Clients cardiac status will stabilize Client will regain or maintain visual acuity Client will take in appropriate amount of calories per day, no further weight loss Client will communicate feelings about changes in body image and will verbalize coping mechanisms Client will explain importance of daily medications and proper self-administration Hypothyroidism Disorder that results when thyroid gland produces insufficient amount of TH Pathophysiology and etiology TH production decreases ( thyroid gland enlarges in compensatory attempt to produce more hormone Older clients have decrease in T4 production Hypothyroid state in adults sometimes called ( myxedema Etiology May be primary or secondary Primary ( congenital defects in gland, loss of thyroid tissue, antithyroid medications, thyroiditis, endemic iodine deficiency Secondary ( pituitary TSH deficiency or peripheral resistance to TH Medications can cause Common in women age 3060 years Risk factors Women over age 50 years Close relative with autoimmune condition Thyroid surgery, radiation to neck Iodine deficiency Iodine necessary for synthesis, secretion of TH Goitrogenic drugs, foods Soil deficient in iodine Hashimoto thyroiditis Most common cause of goiter, primary hypothyroidism in adults, children Autoimmune disorder ( antibodies develop that destroy thyroid tissue Clinical manifestations Slow onset Goiter Fluid retention and edema Decreased appetite, weight gain Constipation Dry skin Dyspnea Pallor Hoarseness Muscle stiffness Decreased sense of taste and smell Menstrual disorders Anemias Cardiac enlargement Abnormalities in lipid metabolism Elevated serum cholesterol, triglyceride levels Myxedema coma Life-threatening complication of long-standing, untreated hypothyroidism Severe metabolic disorders Precipitated by trauma, infection, failure to take thyroid replacement medications, use of central nervous system depressants, exposure to cold temperatures See MULTISYSTEM EFFECTS OF HYPOTHYROIDISM, p. 814 Collaboration Collaboration with pharmacist Diagnostic tests Decrease in TH See Table 1216 LABORATORY FINDINGS IN HYPOTHYROIDISM, p. 813 Pharmacologic therapies Replace TH Levothyroxine Nursing process Assessment Health history Physical assessment Diagnosis Hypothyroidism affects all organ systems Cardiovascular function Elimination Skin integrity Planning Pulse and blood pressure remain within established limits Arrhythmias are not exhibited Skin remains warm and dry to touch Client remains free of edema Client will maintain visual acuity Activities resumed without heart rate exceeding, falling below established limits Elimination pattern returns to normal Skin remains intact Implementation Monitor cardiac output Monitor blood pressure, rate and rhythm of apical and peripheral pulses, respiratory rate and breath sounds Suggest client avoid chilling Explain need to alternate periods of activity with periods of rest Prevent constipation Encourage a fluid intake of up to 2,000 mL/day Discuss ways to maintain a high-fiber diet Encourage activity as tolerated Maintain skin integrity Monitor skin redness or lesions, especially if clients activity is greatly reduced Provide or teach the immobile client measures to promote optimal circulation Use turning schedule if client on bed rest, teach client to change position every 2 hours Limit time sitting in one position shift weight, lift body using arm rests every 2030 minutes Use pillows, pads, sheepskin or foam cushions for bed and/or chair Teach and implement schedule of ROM exercises Provide or teach client measures to maintain skin integrity Take baths only when necessary Use gentle motions when washing and drying skin Use alcohol-free skin oils and lotions Evaluation Determine whether client has met expected outcomes Review Thyroid Disease Relate Link the Concepts and Exemplars Ready Go to Companion Skills Manual Refer Go to Nursing Student Resources Reflect Case Study 2015 by Education, Inc. 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