Nclex 9 Part 8 PDF

632 UNIT IX Endocrine Problems of the Adult Client TABLE 48.1 Medications for Type  Diabetes Class and Specific Agents Actions Major Adverse Effects Adult—Endocrine...

632 UNIT IX Endocrine Problems of the Adult Client TABLE 48.1 Medications for Type  Diabetes Class and Specific Agents Actions Major Adverse Effects Adult—Endocrine Oral Medications Biguanides Metformin Decreases glucose production by the liver; increases tissue Gastrointestinal (GI) symptoms: decreased response to insulin appetite, nausea, diarrhea Second-Generation Sulfonylureas Glimepiride Promote insulin secretion by the pancreas; may also in- Hypoglycemia Glipizide crease tissue response to insulin Weight gain Glyburidea Meglitinides (Glinides) Nateglinide Promote insulin secretion by the pancreas Hypoglycemia Repaglinide Weight gain Thiazolidinediones (Glitazones) Pioglitazone Decrease insulin resistance, thereby increasing glucose up- Hypoglycemia, but only in the presence of Rosiglitazone take by muscle and adipose tissue and decreasing glucose excessive insulin production by the liver Heart failure Bladder cancer Fractures Ovulation and thus possible unintended pregnancy α-Glucosidase Inhibitors Acarbose Delay carbohydrate digestion and absorption, thereby de- GI symptoms: atulence, cramps, abdominal Miglitol creasing the postprandial rise in blood glucose distention, borborygmus DPP-4 Inhibitors (Gliptins) Alogliptin Enhance the activity of incretins (by inhibiting their break- Pancreatitis Linagliptin down by DPP-4), thereby stimulating a decrease in blood Hypersensitivity reactions Saxagliptin glucose levels, increasing insulin release, reducing glucagon Sitagliptin release, and decreasing hepatic glucose production Sodium-Glucose Cotransporter 2 (SGLT-2) Inhibitors Canagliozin Increase glucose excretion via the urine by inhibiting SGLT-2 Genital mycotic infections Dapagliozin in the kidney tubules, decreasing glucose levels and induc- Orthostatic hypotension Empagliozin ing weight loss via caloric loss through the urine Ertugliozin (a combination with metformin is available) Dopamine Agonist Bromocriptine Activates dopamine receptors in the central nervous system; Orthostatic hypotension how it improves glycemic control is unknown Exacerbation of psychosis Noninsulin Injectable Medications Glucagon-like Peptide- Agonists Incretin Mimetics Dulaglutide Lower blood glucose by slowing gastric emptying, stimulat- Hypoglycemia Exenatide ing glucose-dependent insulin release, suppressing post- GI symptoms: nausea, vomiting, diarrhea Exenatide extended-release prandial glucagon release, and reducing appetite Pancreatitis Semaglutide Renal insuciency Thyroid C cell tumor (semaglutide) Amylin Mimetics Pramlintide Delays gastric emptying and suppresses glucagon secretion, Hypoglycemia decreasing the postprandial rise in glucose Nausea Injection-site reactions aCommonly known as glibenclamide outside the United States. Adapted from Burchum, J., & Rosenthal, L. (2019). Lehne’s pharmacology for nursing care. (10th ed.). St. Louis: Elsevier. p. 693. Metformin needs to be withheld temporarily before i. Instruct the client about how to take each spe- and for 48 hours after having any radiological study that cic medication, such as with the rst bite of involves the administration of intravenous contrast dye the meal for meglitinides and α-glucosidase because of the risk of contrast-induced nephropathy and inhibitors. lactic acidosis. The PHCP needs to be consulted for spe- j. Advise the client to wear a MedicAlert bracelet. cic prescriptions.  CHAPTER 48 Endocrine Medications 633 b. Insulin injected into the abdomen may absorb CLINICAL JUDGMENT: more evenly and rapidly than at other sites. c. Systematic rotation within one anatomical GENERATE SOLUTIONS Adult—Endocrine area is recommended to prevent lipodystro- The nurse is reviewing the medical record of a hospitalized phy and to promote more even absorption; client scheduled later that day for a computerized tomogra- clients should be instructed not to use the phy (CT) scan with an intravenous contrast dye. On review same site more than once in a 2- to 3-week of the record the nurse notes that the client has diabetes period. mellitus and is taking metformin. The nurse prepares to take d. Injections should be 1 to 1.5 inches (2.5 to the following actions: 3.8 cm) apart within the anatomical area. Contact the radiology department to inform them that the e. Heat, massage, and exercise of the injected client is taking metformin and for rescheduling the scan. area can increase absorption rates and may Check with the primary health care provider about the result in hypoglycemia. time for withholding the metformin after the scan is com- f. Injection into scar tissue may delay absorp- pleted. tion of insulin. Encourage uid intake after the scan is completed. 6. Administering insulin (also see Chapter 47) Check the serum creatinine level before resuming the metformin. Insulin glargine cannot be mixed with any other types of insulin. C. Insulin a. To prevent dosage errors, be certain that there 1. Insulin acts primarily in the liver, muscle, and is a match between the insulin concentration adipose tissue by attaching to receptors on cel- noted on the vial and the calibration of units lular membranes and facilitating the passage of on the insulin syringe; the usual concentra- glucose, potassium, and magnesium. tion of insulin is U-100 (100 units/mL). 2. Insulin is prescribed for clients with type 1 dia- b. The Humulin R brand of regular insulin is betes mellitus and for clients with type 2 diabe- the only insulin that is formulated in a U-500 tes mellitus whose blood glucose levels are not strength. U-500 strength insulin is reserved adequately controlled with oral antidiabetic for clients with severe insulin resistance who agents. require large doses of insulin. A special sy- 3. The onset, peak, and duration of action depend ringe calibrated for use with U-500 insulin is on the insulin type (Tables 48.2 and 48.3). required. 4. Storing of insulin (Box 48.9) c. Prelled syringes (pens) are commonly used; 5. Insulin injection sites a new needle needs to be attached before a. The main areas for injections are the abdo- each injection. men, arms (posterior surface), thighs (ante- d. Most insulin syringes have a 27- to 29-gauge rior surface), and hips (Fig. 48.1). needle that is about 0.5-inch long (1.3 cm). TABLE 48.2 Types of Insulin: Time Course of Activity After Subcutaneous Injection Time Course Generic Name Onset (min) Peak (hr) Duration (hr) Short Duration: Rapid Onset Insulin lispro 15-30 0.5-2.5 3-6 Insulin aspart 10-20 1-3 3-5 Insulin glulisine 10-15 1-1.5 3-5 Short Duration: Slower Onset Regular insulin 30-60 1-5 6-10 Intermediate Duration NPH insulin 60-120 6-14 16-24 Long Duration Insulin glargine 70 None 18-24 Insulin detemir 60-120 12-24 Varies Insulin degludec 60-120 None >40 Hours Adapted from Burchum, J., & Rosenthal, L. (2019). Lehne’s pharmacology for nursing care. (10th ed.). St. Louis: Elsevier. p. 684.  634 UNIT IX Endocrine Problems of the Adult Client TABLE 48.3 Premixed Insulin Combinationsa Time Course Adult—Endocrine Description Onset (min) Peak (hr) Duration (hr) 70% NPH insulin/30% regular insulin (Humulin) 30-60 1.5-16 10-16 70% NPH insulin/30% regular insulin (Novolin) 30-60 2-12 10-16 50% NPH insulin/50% regular insulin 30-60 2-12 10-16 70% insulin aspart protamine/30% insulin aspart 10-20 1-4 15-18 75% insulin lispro protamine/25% insulin lispro 15-30 1-6.5 10-16 50% insulin lispro protamine/50% insulin lispro 15-30 0.8-4.8 10-16 aUse only after the dosages and ratios of the components have been established as correct for the client. Adapted from Burchum, J., & Rosenthal, L. (2019). Lehne’s pharmacology for nursing care. (10th ed.). St. Louis: Elsevier. p. 688. BOX 48.9 Storing Insulin Avoid exposing insulin to extremes in temperature. Insulin should not be frozen or kept in direct sunlight or in a hot car. Before injection, insulin should be at room temperature. If a vial of insulin will be used up in 1 month, it may be kept at room temperature; otherwise, the vial should be refrigerated. e. NPH insulin is an insulin suspension; the ap- pearance is cloudy. All other insulin types are Front Back solutions; the appearance of all other insulin products is clear. FIG. 48.1 Common insulin injection sites. f. Before use, NPH insulins must be rotated, or rolled, between the palms to ensure that the insulin suspension is mixed well; otherwise, Some rapid- and short-acting insulins can be an inaccurate dose will be drawn; vigorously administered intravenously. shaking the bottle will cause bubbles to form. It is not necessary to rotate or roll clear insu- D. Glucagon-like peptide (GLP-1) receptor agonists lins before using. 1. Noninsulin injectable agents that are analogs of g. Inject air into the insulin bottle (a vacuum human GLP-1 and cause the same effects as the makes it difcult to draw up the insulin). GLP-1 incretin hormone in the body, which are h. When mixing insulins, draw up the shortest- to stimulate the glucose level–dependent release acting insulin rst. of insulin, to suppress the postprandial release i. Short-duration (i.e., regular, lispro, aspart, of glucagon, to slow gastric emptying, and to and glulisine) insulin may be mixed with suppress appetite NPH. 2. Used for clients with type 2 diabetes mellitus j. Administer a mixed dose of insulin within 5 (not recommended for clients with type 1 dia- to 15 minutes of preparation; after this time, betes, nor should clients be taken off insulin and the short-acting insulin binds with the NPH given a GLP-1 receptor agonist) insulin and its action is reduced. 3. GLP-1 receptor agonists restore the rst-phase k. Aspiration after insertion of the needle gener- insulin response (rst 10 minutes after food in- ally is not recommended with self-injection gestion), lower the production of glucagon after of insulin. meals, slow gastric emptying (which limits the l. Administer insulin at a 45- to 90-degree an- rise in blood glucose level after a meal), reduce gle in clients with normal subcutaneous mass fasting and postprandial blood glucose levels, and at a 45- to 60-degree angle in thin per- and reduce caloric intake, resulting in weight loss. sons or those with a decreased amount of 4. Packaged in premeasured doses (pens) that re- subcutaneous mass. quire refrigeration (cannot be frozen)  CHAPTER 48 Endocrine Medications 635 5. Administered as a subcutaneous injection in 3. Injects air into NPH insulin vial rst the thigh, abdomen, or upper arm; usually pre- 4. Injects an amount of air equal to the desired dose scribed twice daily or once weekly, depending on of insulin into each vial Adult—Endocrine the medication 6. Because delayed gastric emptying slows the ab- 2. The home care nurse visits a client recently diag- sorption of other medications, other prescribed nosed with diabetes mellitus who is taking Humu- oral medications should be given an hour before lin NPH insulin daily. The client asks the nurse how injection of these medications. to store the unopened vials of insulin. The nurse E. Amylin mimetic: pramlintide would tell the client to take which action? 1. Synthetic form of amylin, a naturally occurring 1. Freeze the insulin. hormone secreted by the pancreas 2. Refrigerate the insulin. 2. Used for clients with types 1 and 2 diabetes mel- 3. Store the insulin in a dark, dry place. litus who use insulin; administered subcutane- 4. Keep the insulin at room temperature. ously before meals to lower blood glucose level after meals, leading to less uctuation during the 3. Glimepiride is prescribed for a client with diabetes day and better long-term glucose control mellitus. The nurse instructs the client that which 3. Associated with an increased risk of insulin- food items are most acceptable to consume while induced severe hypoglycemia, particularly in cli- taking this medication? Select all that apply. ents with type 1 diabetes mellitus 1. Alcohol 4. GI effects, including nausea, can occur. 2. Red meats 5. Unopened vials are refrigerated; opened vials 3. Whole-grain cereals can be refrigerated or kept at room temperature 4. Low-calorie desserts for up to 28 days. 5. Carbonated beverages 6. Reduces postprandial hyperglycemia by delaying gastric emptying and suppressing postprandial 4. The nurse is providing discharge teaching for a cli- glucagon release ent newly diagnosed with type 2 diabetes mellitus 7. Because pramlintide delays gastric emptying, who has been prescribed metformin. Which client other prescribed oral medications should be giv- statement indicates the need for further teaching? en 1 hour before or 2 hours after an injection of 1. “It is okay if I skip meals once in a while.” pramlintide. 2. “I need to let my doctor know if I get unusually F. Glucagon tired.” 1. Hormone secreted by the alpha cells of the islets 3. “I need to constantly watch for signs of low blood of Langerhans in the pancreas sugar.” 2. Increases blood glucose level by stimulating gly- 4. “I will be sure to not drink alcohol excessively cogenolysis in the liver and also can be adminis- while on this medication.” tered for a beta blocker overdose. 3. Can be administered subcutaneously, intramus- 5. The primary health care provider (PHCP) prescribes cularly, or intravenously semaglutide for a client with type 1 diabetes melli- 4. Used to treat insulin-induced hypoglycemia tus who takes insulin. The nurse would plan to take when the client is semiconscious or unconscious which most appropriate intervention? and is unable to ingest liquids 1. Withhold the medication and call the PHCP, 5. The blood glucose level begins to increase with- questioning the prescription for the client. in 5 to 20 minutes after administration. 2. Teach the client about the signs and symptoms of 6. Instruct the family in the procedure for adminis- hypoglycemia and hyperglycemia. tration. 3. Monitor the client for gastrointestinal side effects 7. See Chapter 47 for additional information regard- after administering the medication. ing insulin and interventions for hypoglycemia. 4. Withdraw the insulin from the prelled pen into an insulin syringe to prepare for administration. 6. A client with diabetes mellitus is taking Humulin PRACTICE QUESTIONS NPH insulin and regular insulin every morning. The 1. The nurse is teaching a client with diabetes mellitus nurse would provide which instructions to the cli- how to mix regular insulin and NPH insulin in the ent? Select all that apply. same syringe. Which action, if performed by the cli- 1. Hypoglycemia may be experienced before din- ent, indicates the need for further teaching? nertime. 1. Withdraws the NPH insulin rst 2. The insulin dose needs to be decreased 2. Withdraws the regular insulin rst if illness occurs.  636 UNIT IX Endocrine Problems of the Adult Client 3. The insulin should be administered at room 10. The nurse is monitoring a client receiving levothy- temperature. roxine sodium for hypothyroidism. Which ndings 4. The insulin vial needs to be shaken vig- indicate the presence of a side effect associated with Adult—Endocrine orously to break up the precipitates. this medication? Select all that apply. 5. The NPH insulin would be drawn into 1. Insomnia the syringe rst, then the regular insulin. 2. Weight loss 3. Bradycardia 7. The home health care nurse is visiting a client who 4. Constipation was recently diagnosed with type 2 diabetes mel- 5. Mild heat intolerance litus. The client is prescribed repaglinide and met- formin. The nurse would provide which instruc- 11. The nurse provides instructions to a client who is tions to the client? Select all that apply. taking levothyroxine. The nurse would tell the client 1. Diarrhea may occur secondary to the metform- to take the medication in which way? in. 1. With food 2. The repaglinide is not taken if a meal is 2. At lunchtime skipped. 3. On an empty stomach 3. The repaglinide is taken 30 minutes be- 4. At bedtime with a snack fore eating. 4. A simple sugar food item is carried and 12. The nurse would tell the client who is taking levo- used to treat mild hypoglycemia episodes. thyroxine to notify the primary health care provider 5. Muscle pain is an expected effect of met- (PHCP) if which problem occurs? formin and may be treated with acetami- 1. Fatigue nophen. 2. Tremors 6. Metformin increases hepatic glucose 3. Cold intolerance production to prevent hypoglycemia associ- 4. Excessively dry skin ated with repaglinide. 13. The nurse is providing instructions to the client 8. The nurse is teaching the client about prescribed newly diagnosed with diabetes mellitus who has prednisone. Which statement, if made by the client, been prescribed pramlintide. Which instruction indicates that further teaching is necessary? would the nurse include in the discharge teaching? 1. “I can take aspirin or my antihistamine if I need 1. “Inject the pramlintide at the same time you take it.” your other medications.” 2. “I need to take the medication every day at the 2. “Take your prescribed pills 1 hour before or 2 same time.” hours after the injection.” 3. “I need to avoid coffee, tea, cola, and chocolate 3. “Be sure to take the pramlintide with food so that in my diet.” you don’t upset your stomach.” 4. “If I gain 5 pounds or more a week, I will call my 4. “Make sure you take your pramlintide immedi- doctor.” ately after you eat so that you don’t experience a low blood sugar.” 9. A client with hyperthyroidism has been given methimazole. Which nursing considerations are 14. The nurse teaches the client who is newly diagnosed associated with this medication? Select all that with diabetes insipidus about the prescribed intra- apply. nasal desmopressin. Which statements by the client 1. Administer methimazole with food. indicate understanding? Select all that apply. 2. Place the client on a low-calorie, low-protein 1. “This medication will turn my urine orange.” diet. 2. “I need to decrease my oral uids when 3. Assess the client for unexplained bruising I start this medication.” or bleeding. 3. “The amount of urine I make should in- 4. Instruct the client to report side and ad- crease if this medicine is working.” verse effects such as sore throat, fever, or head- 4. “I need to follow a low-fat diet to avoid aches. pancreatitis when taking this medicine.” 5. Use special radioactive precautions when 5. “I need to report headache and drowsi- handling the client’s urine for the rst 24 hours ness to my doctor since these symptoms could following initial administration. be related to my desmopressin.”  CHAPTER 48 Endocrine Medications 637 15. A daily dose of prednisone is prescribed for a client. 4. “I need to take this medication rst thing The nurse provides instructions to the client regard- in the morning on an empty stomach.” ing administration of the medication and would in- 5. “I can pick a time to take this medica- Adult—Endocrine struct the client that which time is best to take this tion that best ts my lifestyle as long as I take medication? it at the same time each day.” 1. At noon 2. At bedtime 17. A client with diabetes mellitus visits a health care 3. Early morning clinic. The client’s diabetes mellitus previously had 4. Any time, at the same time, each day been well controlled with glyburide daily, but re- cently the fasting blood glucose level has been 180 16. The client with hyperparathyroidism is taking alen- to 200 mg/dL (10 to 11.1 mmol/L). Which medi- dronate. Which statements by the client indicate un- cation, if added to the client’s regimen, may have derstanding of the proper way to take this medica- contributed to the hyperglycemia? tion? Select all that apply. 1. Atenolol 1. “I need to take this medication with food.” 2. Prednisone 2. “I need to take this medication at bed- 3. Phenelzine time.” 4. Allopurinol 3. “I need to sit up for at least 30 minutes after taking this medication.” ANSWERS flushing, palpitations, and nausea. Alcohol can also potenti- ate the hypoglycemic effects of the medication. Clients need 1. Answer: 1 to be instructed to avoid alcohol consumption while taking Rationale: When preparing a mixture of short-acting insu- this medication. Low-calorie desserts should also be avoided. lin, such as regular insulin, with another insulin preparation, Even though the calorie content may be low, carbohydrate the short-acting insulin is drawn into the syringe first. This content is most likely high and can affect the blood glucose. sequence will avoid contaminating the vial of short-acting The items in options 2, 3, and 5 are acceptable to consume. insulin with insulin of another type. Options 2, 3, and 4 iden- Test-Taking Strategy: Note the strategic word, most. tify correct actions for preparing NPH and short-acting insulin. Remembering that alcohol can affect the action of many Test-Taking Strategy: Note the strategic words, need for fur- medications will assist in eliminating option 1. Next, recalling ther teaching. These words indicate a negative event query that carbohydrates need to be controlled in a diabetic diet will and ask you to select an option that is an incorrect action. assist in eliminating option 4. Remember RN—draw up the Regular (short-acting) insulin References: Burchum, J., & Rosenthal, L. (2019). Lehne’s phar- before the NPH insulin. macology for nursing care. (10th ed.). St. Louis: Elsevier. pp. Reference: Lilley, L., Rainforth Collins, S., & Snyder, J. (2020). 693, 695; Kizior, R., & Hodgson, B. (2021). Saunders nursing Pharmacology and the nursing process. (9th ed.). St. Louis: drug handbook 2021. St. Louis: Elsevier. p. 557. Elsevier. p. 507. 4. Answer: 3 2. Answer: 2 Rationale: Metformin is classified as a biguanide and is the Rationale: Insulin in unopened vials needs to be stored under most commonly used medication for type 2 diabetes melli- refrigeration until needed. Vials are not to be frozen. When tus initially. It is also often used as a preventive medication stored unopened under refrigeration, insulin can be used up to for those at high risk for developing diabetes mellitus. When the expiration date on the vial. Options 1, 3, and 4 are incorrect. used alone, metformin lowers the blood glucose after meal Test-Taking Strategy: Note the subject, how to store intake, as well as fasting blood glucose levels. Metformin does unopened vials of insulin. Options 3 and 4 are comparable not stimulate insulin release and therefore poses little risk or alike regarding where to store the insulin and would be for hypoglycemia. For this reason, metformin is well suited eliminated. Remembering that insulin is not to be frozen will for clients who skip meals. Unusual somnolence as well as assist in eliminating option 1. hyperventilation, myalgia, and malaise are early signs of lac- Reference: Lilley, L., Rainforth Collins, S., & Snyder, J. (2020). tic acidosis, a toxic effect associated with metformin. If any Pharmacology and the nursing process. (9th ed.). St. Louis: of these signs or symptoms occur, the client needs to inform Elsevier. p. 507. the primary health care provider immediately. While it is best to avoid consumption of alcohol, it is not always realistic or 3. Answer: 2, 3, 5 feasible for clients to quit drinking altogether; for this reason, Rationale: When alcohol is combined with glimepiride, a clients need to be informed that excessive alcohol intake can disulfiram-like reaction may occur. This syndrome includes cause an adverse reaction with metformin.  638 UNIT IX Endocrine Problems of the Adult Client Test-Taking Strategy: Note the strategic words, need for fur- Reference: Kizior, R., & Hodgson, B. (2021). Saunders nursing ther teaching. These words indicate a negative event query and drug handbook 2021. St. Louis: Elsevier. p. 618. Adult—Endocrine the need to select the incorrect client statement as the answer. Recalling the adverse effects and drug interactions associated 7. Answer: 1, 2, 3, 4 with this medication will assist you in eliminating options 2 Rationale: Repaglinide, a rapid-acting oral hypoglycemic and 4. Next, recalling the mechanism of action of this medi- agent that stimulates pancreatic insulin secretion, is to be taken cation will help you determine that this medication is suited before meals (approximately 30 minutes before meals) and for clients who skip meals, thereby leading you to the correct would be withheld if the client does not eat. Hypoglycemia option. is a side effect of repaglinide, and the client needs to be pre- Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., pared by carrying a simple sugar at all times. Metformin is an Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: oral hypoglycemic given in combination with repaglinide and Assessment and management of clinical problems. (11th ed.). St. works by decreasing hepatic glucose production. A common Louis: Elsevier. pp. 1118, 1120. side effect of metformin is diarrhea. Muscle pain may occur as an adverse effect from metformin, but it might signify a more 5. Answer: 1 serious condition that warrants primary health care provider Rationale: Semaglutide is a glucagon-like peptide-1 agonist notification, not the use of acetaminophen. used for type 2 diabetes mellitus only. It is not recommended Test-Taking Strategy: Focus on the subject, oral medications for clients with type 1 diabetes. Hence the nurse would with- to treat diabetes mellitus. Thinking about the pathophysiol- hold the medication and question the PHCP regarding this ogy of diabetes mellitus and recalling the actions and effects prescription. Although options 2 and 3 are correct statements of these medications are needed to answer correctly. about the medication, in this situation the medication would Reference: Burchum, J., & Rosenthal, L. (2019). Lehne’s phar- not be administered. The medication is packaged in prefilled macology for nursing care. (10th ed.). St. Louis: Elsevier. pp. pens ready for injection without the need for drawing it up 696, 708. into another syringe. Test-Taking Strategy: Note the strategic words, most appropri- 8. Answer: 1 ate. Focus on the name of the medication, recalling that it is Rationale: Aspirin and other over-the-counter medications used for the treatment of type 2 diabetes mellitus. Eliminate would not be taken unless the client consults with the PHCP. option 4 because the medication is packaged in prefilled pens The client needs to take the medication at the same time ready for injection. From the remaining options, focus on the every day and would be instructed not to stop the medica- data in the question. Although options 2 and 3 are appropri- tion. A slight weight gain as a result of an improved appetite is ate when administering this medication, this client would not expected; however, after the dosage is stabilized, a weight gain receive this medication. of 5 pounds (2.25 kg) or more weekly needs to be reported References: Burchum, J., & Rosenthal, L. (2019). Lehne’s phar- to the PHCP. Caffeine-containing foods and fluids need to be macology for nursing care. (10th ed). St. Louis: Elsevier. p. 693; avoided because they may contribute to steroid-ulcer develop- Ignatavicius, D., Workman, M., Rebar, C., & Heimgartner, N. ment. (2021). Medical-surgical nursing: Concepts for interprofessional Test-Taking Strategy: Note the strategic words, further teach- collaborative care. (10th ed.). St. Louis: Elsevier. pp. 1275-1276. ing is necessary. These words indicate a negative event query and ask you to select an option that is an incorrect statement. 6. Answer: 1, 3 Remember that a client taking prednisone would not take Rationale: Humulin NPH is an intermediate-acting insulin. other medications, especially over-the-counter medications, The onset of action is 60 to 120 minutes, it peaks in 6 to 14 without first consulting with the PHCP. hours, and its duration of action is 16 to 24 hours. Regular References: Burchum, J., & Rosenthal, L. (2019). Lehne’s phar- insulin is a short-acting insulin. Depending on the type, the macology for nursing care. (10th ed.). St. Louis: Elsevier. pp. onset of action is 30 to 60 minutes, it peaks in 1 to 5 hours, 879-880; Skidmore-Roth, L. (2021). 2021 Mosby’s nursing drug and its duration is 6 to 10 hours. Hypoglycemic reactions most reference. (34th ed.). St. Louis: Elsevier. p. 1034. likely occur during peak time. Insulin should be at room tem- perature when administered. Clients may need their insulin 9. Answer: 1, 3, 4 dosages increased during times of illness. Insulin vials would Rationale: Common side effects of methimazole include never be shaken vigorously. Regular insulin is always drawn nausea, vomiting, and diarrhea. To address these side effects, up before NPH. this medication needs to be taken with food. Because of the Test-Taking Strategy: Focus on the subject, client instructions increase in metabolism that occurs in hyperthyroidism, the regarding insulin. Eliminate option 4 because of the word vig- client needs to consume a high-calorie diet. Antithyroid medi- orously. Use knowledge regarding the characteristics of insu- cations can cause agranulocytosis with leukopenia and throm- lin; procedures for administration; and the onset, peak, and bocytopenia. Sore throat, fever, headache, or bleeding may duration of action for insulin and insulin administration to indicate agranulocytosis, and the primary health care provider select from the remaining options. Remember that NPH insu- needs to be notified immediately. Methimazole is not radio- lin peaks in 6 to 14 hours and that regular insulin peaks in 1 active and would not be stopped abruptly, due to the risk of to 5 hours. thyroid storm.  CHAPTER 48 Endocrine Medications 639 Test-Taking Strategy: Focus on the subject, nursing consid- or 2 hours after an injection of pramlintide; therefore, instruct- erations for administering methimazole. Focus on the client’s ing clients to take their pills 1 hour before or 2 hours after Adult—Endocrine diagnosis. Think about the pathophysiology associated with the injection is correct. Pramlintide would not be taken at the the diagnosis and the medication and the actions and effects same time as other medications. Pramlintide is given immedi- of antithyroid medications to assist in answering correctly. ately before the meal in order to control postprandial rise in Reference: Skidmore-Roth, L. (2021). 2021 Mosby’s nursing blood glucose, not necessarily to prevent stomach upset. It is drug reference. (34th ed.). St. Louis: Elsevier. pp. 821-822. incorrect to instruct the client to take the medication after eat- ing, as it will not achieve its full therapeutic effect. 10. Answer: 1, 2, 5 Test-Taking Strategy: Focus on the subject, client instructions Rationale: Insomnia, weight loss, and mild heat intolerance regarding pramlintide as it pertains to administration. Use are side effects of levothyroxine sodium. Bradycardia and con- knowledge regarding the action of the medication and treat- stipation are not side effects associated with this medication, ment measures for diabetes mellitus to answer the question. and rather are associated with hypothyroidism, which is the Remember that this medication is used in conjunction with disorder that this medication is prescribed to treat. insulin to prevent postprandial rise in blood glucose and that Test-Taking Strategy: Focus on the subject, side effects of hypoglycemia is a potential adverse effect. Also remember that levothyroxine. Thinking about the pathophysiology of hypo- this medication causes delayed gastric emptying and should thyroidism and the action of the medication will assist you in not be taken with other medications. determining that insomnia, weight loss, and mild heat intol- Reference: Burchum, J., & Rosenthal, L. (2019). Lehne’s phar- erance are side effects of thyroid hormones. macology for nursing care. (10th ed.). St. Louis: Elsevier. pp. 702- Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., 703. Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: Assessment and management of clinical problems. (11th ed.). St. 14. Answer: 2, 5 Louis: Elsevier. p. 1157. Rationale: In diabetes insipidus, there is a deficiency in antidiuretic hormone (ADH), resulting in large urinary losses. 11. Answer: 3 Desmopressin is an antidiuretic hormone that enhances reab- Rationale: Oral doses of levothyroxine need to be taken on sorption of water in the kidney. Clients with diabetes insipi- an empty stomach to enhance absorption. Dosing would be dus drink high volumes of fluid (polydipsia) as a compen- done in the morning before breakfast. satory mechanism to counteract urinary losses and maintain Test-Taking Strategy: Note that options 1, 2, and 4 are com- fluid balance. Once desmopressin is started, oral fluids need parable or alike in that these options address administering to be decreased to prevent water intoxication. Therefore, cli- the medication with food. ents with diabetes insipidus need to decrease their oral fluid Reference: Kizior, R., & Hodgson, B. (2022). Saunders nursing intake when they start desmopressin. Headache and drowsi- drug handbook 2022. St. Louis: Elsevier. pp. 698-699. ness are signs of water intoxication in the client taking des- mopressin and need to be reported to the primary health 12. Answer: 2 care provider. Desmopressin does not turn urine orange. The Rationale: Excessive doses of levothyroxine can produce signs amount of urine would decrease, not increase, when desmo- and symptoms of hyperthyroidism. These include tachycardia, pressin is started. Desmopressin does not cause pancreatitis. chest pain, tremors, nervousness, insomnia, hyperthermia, Test-Taking Strategy: Focus on the subject, understanding extreme heat intolerance, and sweating. The client would be of desmopressin. Recall that in diabetes insipidus there is a instructed to notify the PHCP if these occur. Options 1, 3, and deficiency of ADH and that desmopressin is an antidiuretic 4 are signs of hypothyroidism. hormone. Recalling the pathophysiology of this disorder will Test-Taking Strategy: Focus on the subject, the need to notify assist you in answering correctly. the PHCP. Recall the symptoms associated with hypothyroid- Reference: Skidmore-Roth, L. (2021). 2021 Mosby’s nursing ism, the purpose of administering levothyroxine, and the drug reference. (34th ed.). St. Louis: Elsevier. pp. 373-375. effects of the medication. Options 1, 3, and 4 are symptoms related to hypothyroidism. 15. Answer: 3 Reference: Lewis, S., Harding, M., Kwong, J., Roberts, D., Rationale: Corticosteroids (glucocorticoids) need to be Hagler, D., & Reinisch, C. (2020). Medical-surgical nursing: administered before 9 a.m. Administration at this time helps Assessment and management of clinical problems. (11th ed.). St. minimize adrenal insufficiency and mimics the burst of gluco- Louis: Elsevier. p. 1157. corticoids released naturally by the adrenal glands each morn- ing. Options 1, 2, and 4 are incorrect. 13. Answer: 2 Test-Taking Strategy: Note the strategic word, best. Note the Rationale: Pramlintide is used for clients with types 1 and 2 suffix -sone and recall that medication names that end with diabetes mellitus who use insulin. It is administered subcuta- these letters are corticosteroids. Remember that a daily dose neously before meals to lower blood glucose level after meals, of a corticosteroid needs to be administered in the morning. leading to less fluctuation during the day and better long-term Reference: Lilley, L., Rainforth Collins, S., & Snyder, J. (2020). glucose control. Because pramlintide delays gastric emptying, Pharmacology and the nursing process. (9th ed.). St. Louis: any prescribed oral medications would be taken 1 hour before Elsevier. p. 520.  640 UNIT IX Endocrine Problems of the Adult Client 16. Answer: 3, 4 17. Answer: 2 Rationale: Alendronate is a bisphosphonate used in hyper- Rationale: Prednisone may decrease the effect of oral hypo- Adult—Endocrine parathyroidism to inhibit bone loss and normalize serum glycemics, insulin, diuretics, and potassium supplements. calcium levels. Esophagitis is an adverse effect of primary con- Option 1, a beta blocker, and option 3, a monoamine oxi- cern in clients taking alendronate. For this reason the client is dase inhibitor, have their own intrinsic hypoglycemic activity. instructed to take alendronate first thing in the morning with Option 4 decreases urinary excretion of sulfonylurea agents, a full glass of water on an empty stomach, not to eat or drink causing increased levels of the oral agents, which can lead to anything else for at least 30 minutes after taking the medica- hypoglycemia. tion, and to remain sitting upright for at least 30 minutes after Test-Taking Strategy: Focus on the subject, an increase in the taking it. blood glucose level. Recalling that prednisone is a corticoste- Test-Taking Strategy: Focus on the subject, the correct roid and that corticosteroids decrease the effects of hypoglyce- method to take alendronate. Recall that the primary concern mics will direct you to the correct option. with alendronate is esophagitis. Eliminate options 1 and 2, Reference: Lilley, L., Rainforth Collins, S., & Snyder, J. (2020). since taking with food and taking at bedtime will each place Pharmacology and the nursing process. (9th ed.). St. Louis: the client at increased risk of reflux. Eliminate option 5 Elsevier. pp. 517, 521. because alendronate needs to be taken first thing in the morn- ing on an empty stomach. Reference: Burchum, J., & Rosenthal, L. (2019). Lehne’s phar- macology for nursing care. (10th ed). St. Louis: Elsevier. pp. 910- 912. Level of Cognitive Ability: Evaluating Level of Cognitive Ability: Analyzing Client Needs: Physiological Integrity Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Integrated Process: Teaching and Learning Clinical Judgment/Cognitive Skill: Evaluate Outcomes Clinical Judgment/Cognitive Skill: Take Action Content Area: Pharmacology: Endocrine Medications: Insulin Content Area: Pharmacology: Endocrine Medications: Oral Health Problem: Adult Health: Endocrine: Diabetes Mellitus Hypoglycemic Priority Concepts: Patient Education; Glucose Regulation Health Problem: Adult Health: Endocrine: Diabetes Mellitus Priority Concepts: Patient Education; Glucose Regulation Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Level of Cognitive Ability: Evaluating Integrated Process: Teaching and Learning Client Needs: Physiological Integrity Clinical Judgment/Cognitive Skill: Take Action Integrated Process: Teaching and Learning Content Area: Pharmacology: Endocrine Medications: Insulin Clinical Judgment/Cognitive Skill: Evaluate Outcomes Health Problem: Adult Health: Endocrine: Diabetes Mellitus Content Area: Pharmacology: Endocrine Medications: Priority Concepts: Patient Education; Safety Corticosteroids Health Problem: N/A Priority Concepts: Patient Education; Safety Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Level of Cognitive Ability: Analyzing Clinical Judgment/Cognitive Skill: Generate Solutions Client Needs: Physiological Integrity Content Area: Pharmacology: Endocrine Medications: Oral Integrated Process: Nursing Process—Planning Hypoglycemic Clinical Judgment/Cognitive Skill: Generate Solutions Health Problem: Adult Health: Endocrine: Diabetes Mellitus Content Area: Pharmacology: Endocrine Medications: Priority Concepts: Patient Education; Glucose Regulation Antithyroid Medications Health Problem: Adult Health: Endocrine: Thyroid Disorders Priority Concepts: Clinical Judgment; Safety Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Level of Cognitive Ability: Applying Clinical Judgment/Cognitive Skill: Evaluate Outcomes Client Needs: Physiological Integrity Content Area: Pharmacology: Endocrine Medications: Oral Integrated Process: Nursing Process—Assessment Hypoglycemic Clinical Judgment/Cognitive Skill: Recognize Cues Health Problem: Adult Health: Endocrine: Diabetes Mellitus Content Area: Pharmacology: Endocrine Medications: Priority Concepts: Patient Education; Glucose Regulation Thyroid Hormones Health Problem: Adult Health: Endocrine: Thyroid Disorders Priority Concepts: Clinical Judgment; Thermoregulation Level of Cognitive Ability: Analyzing Client Needs: Safe and Effective Care Environment Integrated Process: Nursing Process—Planning Level of Cognitive Ability: Applying Clinical Judgment/Cognitive Skill: Generate Solutions Client Needs: Physiological Integrity Content Area: Pharmacology: Endocrine Medications: Oral Integrated Process: Teaching and Learning Hypoglycemic Clinical Judgment/Cognitive Skill: Take Action Health Problem: Adult Health: Endocrine: Diabetes Mellitus Content Area: Pharmacology: Endocrine Medications: Priority Concepts: Clinical Judgment; Glucose Regulation Thyroid Hormones Health Problem: Adult Health: Endocrine: Thyroid Disorders Priority Concepts: Patient Education; Thermoregulation Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Level of Cognitive Ability: Applying Clinical Judgment/Cognitive Skill: Take Action Client Needs: Physiological Integrity Content Area: Pharmacology: Endocrine Medications: Insulin Integrated Process: Teaching and Learning Health Problem: Adult Health: Endocrine: Diabetes Mellitus Clinical Judgment/Cognitive Skill: Take Action Priority Concepts: Patient Education; Glucose Regulation Content Area: Pharmacology: Endocrine Medications: Thyroid Hormones Health Problem: Adult Health: Endocrine: Thyroid Disorders Priority Concepts: Patient Education; Safety .e  Level of Cognitive Ability: Applying Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Integrated Process: Nursing Process—Evaluation Clinical Judgment/Cognitive Skill: Generate Solutions Clinical Judgment/Cognitive Skill: Evaluate Outcomes Content Area: Pharmacology: Endocrine Medications: Oral Content Area: Pharmacology: Endocrine Medications: Hypoglycemics Bisphosphonates and Calcium Regulators Health Problem: Adult Health: Endocrine: Diabetes Mellitus Health Problem: Adult Health: Endocrine: Parathyroid Priority Concepts: Patient Education; Safety Disorders Priority Concepts: Patient Education; Safety Level of Cognitive Ability: Evaluating Client Needs: Physiological Integrity Level of Cognitive Ability: Analyzing Integrated Process: Teaching and Learning Client Needs: Physiological Integrity Clinical Judgment/Cognitive Skill: Evaluate Outcomes Integrated Process: Nursing Process—Analysis Content Area: Pharmacology: Endocrine Medications: Clinical Judgment/Cognitive Skill: Analyze Cues Antidiuretics Content Area: Pharmacology: Endocrine Medications: Health Problem: Adult Health: Endocrine: Pituitary Disorders Corticosteroids Priority Concepts: Patient Education; Fluids and Electrolytes Health Problem: Adult Health: Endocrine: Diabetes Mellitus Priority Concepts: Clinical Judgment; Glucose Regulation Level of Cognitive Ability: Applying Client Needs: Physiological Integrity Integrated Process: Teaching and Learning Clinical Judgment/Cognitive Skill: Take Action Content Area: Pharmacology: Endocrine Medications: Corticosteroids Health Problem: N/A Priority Concepts: Patient Education; Hormonal Regulation .e  Adult—Gastrointestinal UNIT X Gastrointestinal Problems of the Adult Client Maintaining standard precautions and other precau- Pyramid to Success tions as appropriate Obtaining referrals for home care and community ser- Pyramid Points focus on diagnostic tests and nursing care vices related to gastrointestinal problems, gastric or intestinal Preventing disease transmission tubes, gastric surgery, cirrhosis, hepatitis, pancreatitis, Prioritizing hypotheses based on client needs and colostomy care. Preprocedure and postprocedure care of the client undergoing a gastrointestinal diagnos- Health Promotion and Maintenance tic test is a focus. Remember that an informed consent Generating solutions for effective colostomy or ileos- is required for any invasive procedure. Important points tomy care include diet restrictions and safety implications before Performing physical assessment techniques of the gas- and after the diagnostic test. Pyramid Points also include trointestinal system instructions to the client and family regarding the pre- Preventing disease related to the gastrointestinal system vention of gastrointestinal problems and the complica- Providing health screening and health promotion pro- tions associated with the problem. Client and family grams related to gastrointestinal problems teaching about diet and nutrition specic to the prob- Recognizing cues that indicate a gastrointestinal prob- lem, tube and wound care, preventing the transmission lem of infection such as with hepatitis, and care of a colos- Teaching on prescribed dietary and other treatment tomy or ileostomy is addressed. Psychological impact in measures clients with a gastrointestinal problem is noted, with a Teaching on preventing the transmission of disease specic focus on the client with a diversion, such as an ileostomy or colostomy; the social isolation issues that Psychosocial Integrity can occur; and effective coping strategies. Assessing coping mechanisms Considering end-of-life and grief and loss issues Identifying available support systems Client Needs: Learning Outcomes Monitoring for concerns related to body image changes Safe and Effective Care Environment Physiological Integrity Consulting with the interprofessional team regarding Administering medications as prescribed specic to the the client’s care and nutritional status gastrointestinal problem Ensuring that condentiality issues related to the gastro- Analyzing cues related to infectious diseases of the gas- intestinal problem are maintained trointestinal tract Ensuring that informed consent for treatments and sur- Assisting with personal hygiene gical procedures has been obtained Evaluating outcomes for treatment effectiveness Handling infectious drainage and secretions safely Monitoring elimination patterns 1  642 UNIT X Gastrointestinal Problems of the Adult Client Monitoring for complications related to tests, proce- Providing adequate nutrition and oral hydration dures, and surgical interventions Providing care for gastrointestinal tubes Adult—Gastrointestinal Monitoring for uid and electrolyte imbalances Providing nonpharmacological and pharmacological Monitoring laboratory values related to gastrointestinal comfort measures problems Providing preprocedure and postprocedure care for Monitoring parenterally administered uids, including diagnostic tests related to the gastrointestinal system total parenteral nutrition (TPN) Taking action in emergency situations  CHAPTER 49 Adult—Gastrointestinal Gastrointestinal Problems Contributor: Jessica Grimm, DNP, APRN, ACNP-BC, CNE PRIORITY CONCEPTS Elimination; Nutrition I. Anatomy and Physiology 7. Intrinsic factor comes from parietal cells and is A. Functions of the gastrointestinal (GI) system necessary for the absorption of vitamin B12 1. Process food substances 8. Gastrin controls gastric acidity. 2. Absorb the products of digestion into the blood E. Small intestine 3. Excrete unabsorbed materials 1. The duodenum is the rst 8 to 10 inches (20 to 4. Provide an environment for microorganisms to 25 cm) and is attached to the distal end of the synthesize nutrients, such as vitamin K pylorus; it contains the openings of the bile and 5. For risk factors associated with the GI problems, pancreatic ducts. see Box 49.1 2. The jejunum is about 8 feet (2.5 meters) long. B. Mouth 3. The ileum is about 12 feet (3.7 meters) long. 1. Contains the lips, cheeks, palate, tongue, teeth, 4. The small intestine terminates in the cecum. salivary glands, muscles, and maxillary bones F. Pancreatic intestinal juice enzymes 2. Saliva contains the enzyme amylase (ptyalin), 1. Amylase digests starch to maltose. which aids in digestion. 2. Maltase reduces maltose to monosaccharide glu- C. Esophagus cose. 1. Collapsible muscular tube about 7 to 10 inches 3. Lactase splits lactose into galactose and glucose. (18 to 25 cm) long 4. Sucrase reduces sucrose to fructose and glucose. 2. Carries food from the pharynx to the stomach 5. Nucleases split nucleic acids to nucleotides. D. Stomach 6. Enterokinase activates trypsinogen to trypsin. 1. Contains the cardia, fundus, body, and pylorus G. Large intestine 2. Mucous glands are located in the mucosa and 1. About 5 feet (1.5 meters) long prevent autodigestion by providing an alkaline 2. Absorbs water and eliminates wastes protective covering. 3. Intestinal bacteria play a vital role in the synthe- 3. The lower esophageal (cardiac) sphincter pre- sis of some B vitamins and vitamin K. vents reux of gastric contents into the esopha- 4. Colon: Includes the ascending, transverse, de- gus. scending, and sigmoid colons and rectum 4. The pyloric sphincter regulates the rate of stom- 5. The ileocecal valve prevents contents of the large ach emptying into the small intestine. intestine from entering the ileum. 5. Hydrochloric acid kills microorganisms, breaks 6. The internal and external anal sphincters control food into small particles, and provides a chemi- the anal canal. cal environment that facilitates gastric enzyme 7. The anal canal is the last 1 to 1.5 inches (3 to 4 activation. cm) of the large intestine. 6. Pepsin is the chief coenzyme of gastric juice, H. Peritoneum: Lines the abdominal cavity and forms which converts proteins into proteoses and pep- the mesentery that supports the intestines and blood tones. supply   644 UNIT X Gastrointestinal Problems of the Adult Client BOX 49.1 Risk Factors Associated with the BOX 49.2 Common Gastrointestinal System Adult—Gastrointestinal Gastrointestinal System Diagnostic Studiesa Allergic reactions to food or medications Abdominal ultrasound Cardiac, respiratory, and endocrine disorders that may Capsule endoscopy lead to slowed gastrointestinal (GI) movement or consti- Computerized tomography (CT) scan pation Endoscopic retrograde cholangiopancreatography (ERCP) Chronic alcohol use Endoscopic ultrasound Chronic high stress levels Fiberoptic colonoscopy Chronic laxative use Gastric analysis Chronic use of aspirin or nonsteroidal antiinammatory Gastrointestinal motility studies drugs (NSAIDs) Hydrogen and urea breath test Diabetes mellitus, which may predispose to oral candidal Laparoscopy: Liver and pancreas laboratory studies infections or other GI disorders Liver biopsy Family history of GI disorders (colorectal cancer, inam- Magnetic resonance cholangiopancreatography (MRCP) matory bowel disease) Magnetic resonance imaging Long-term GI conditions, such as ulcerative colitis, that Paracentesis may predispose to colorectal cancer Stool specimens Neurological disorders that can impair movement, par- Sigmoidoscopy ticularly with chewing and swallowing Upper gastrointestinal endoscopy or esophagogastroduo- Previous abdominal surgery or trauma, which may lead to denoscopy adhesions Upper gastrointestinal tract study (barium swallow) Tobacco use Videouoroscopic swallowing study a Informed consent is obtained for a diagnostic study that is invasive. References: Ignatavicius, Workman, Rebar, Heimgartner (2021), p.1071; Lewis etal. (2020), p. 843-844. I. Liver 1. The largest gland in the body, weighing 3 to 4 pounds (1.4 to 1.8 kg) 2. Contains Kupffer cells, which remove bacteria in 4. The presence of fatty materials in the duodenum the portal venous blood stimulates the liberation of cholecystokinin, 3. Removes excess glucose and amino acids from which causes contraction of the gallbladder and the portal blood relaxation of the sphincter of Oddi. 4. Synthesizes glucose, amino acids, and fats K. Pancreas 5. Aids in the digestion of fats, carbohydrates, and 1. Exocrine gland proteins a. Secretes sodium bicarbonate to neutralize the 6. Stores and lters blood (200 to 400 mL of blood acidity of the stomach contents that enter the stored) duodenum 7. Stores vitamins A, D, and B and iron b. Pancreatic juices contain enzymes for digest- 8. The liver secretes bile to emulsify fats (500 to ing carbohydrates, fats, and proteins. 1000 mL of bile/day). 2. Endocrine gland 9. Hepatic ducts a. Secretes glucagon to raise blood glucose lev- a. Deliver bile to the gallbladder via the cystic els and secretes somatostatin to exert a hypo- duct and to the duodenum via the common glycemic effect bile duct b. The islets of Langerhans secrete insulin. b. The common bile duct opens into the duode- c. Insulin is secreted into the bloodstream and num, with the pancreatic duct at the ampulla is important for carbohydrate metabolism. of Vater. c. The sphincter prevents the reux of intestinal II. Diagnostic Procedures (Box .) contents into the common bile duct and pan- A. Upper GI tract study (barium swallow) creatic duct. 1. Description: Examination of the upper GI tract J. Gallbladder under uoroscopy after the client drinks barium 1. Stores and concentrates bile and contracts to sulfate force bile into the duodenum during the diges- 2. Preprocedure: Withhold foods and uids for 4 to tion of fats 8 hours prior to the test. 2. The cystic duct joins the hepatic duct to form the 3. Postprocedure common bile duct. a. A laxative may be prescribed. 3. The sphincter of Oddi is located at the entrance b. Instruct the client to increase oral uid intake to the duodenum. to help pass the barium.  CHAPTER 49 Gastrointestinal Problems 645 c. Monitor stools for the passage of barium 2. Preprocedure (stools will appear gray or chalky white for a. Fasting for at least 8 to 12 hours is required Adult—Gastrointestinal 24 to 72 hours postprocedure) because bari- before the test. um can cause a bowel obstruction. b. Use of tobacco and chewing gum is avoided B. Capsule endoscopy for 24 hours before the test. 1. Description: A procedure that uses a small wire- c. Medications that stimulate gastric secretions less camera shaped like a medication capsule that are withheld for 24 to 48 hours. the client swallows; the test will detect bleeding d. Informed consent needs to be obtained. or changes in the lining of the small intestine. 3. Postprocedure 2. The camera travels through the entire digestive a. Client may resume normal activities. tract and sends multiple pictures to a small box b. Refrigerate gastric samples if not tested with- that the client wears like a belt; the small box in 4 hours. saves the pictures, which are then transferred to D. Upper GI endoscopy a computer for viewing once the test is complete. 1. Description 3. The client visits the gastroenterologist’s ofce in a. Also known as esophagogastroduodenoscopy the morning and swallows the capsule, and the b. Following sedation, an endoscope is passed recording belt is applied by the ofce staff. Then down the esophagus to view the gastric wall, the client returns at the end of the day so that sphincters, and duodenum; tissue specimens pictures can be transferred to the computer. can be obtained. 4. Preprocedure: 2. Preprocedure a. A bowel preparation will be prescribed. a. Informed consent needs to be obtained. b. Informed consent needs to be obtained. b. The client must be NPO for 6 to 8 hours be- c. The client will need to maintain a clear liq- fore the test. uid diet on the evening before the exam; ad- c. Clients are usually advised to avoid antico- ditionally, NPO (nothing by mouth) status agulants and nonsteroidal antiinammatory is maintained for the rst 2 hours of testing drugs for several days before the test unless (time for NPO status is prescribed by the gas- otherwise indicated by their primary health troenterologist). care provider. d. Clients may need to reduce insulin amounts d. A local anesthetic (spray or gargle) is admin- during the NPO period according to the gas- istered along with medication that provides troenterologist’s recommendations. moderate sedation just before the scope is in- 5. Postprocedure: serted. a. Observe vital signs. e. Medication may be administered to reduce b. Inform the client that the sedation may cause secretions, and medication may be adminis- amnesia for a few hours. tered to relax smooth muscle. C. Gastric analysis f. The client is positioned on the left side to 1. Description facilitate saliva drainage and to provide easy a. Gastric analysis can be used to assess clients access of the endoscope. with recurrent ulcers after surgical vagotomy. g. Airway patency is monitored during the test, b. Gastric analysis requires the passage of a and pulse oximetry is used to monitor oxy- nasogastric (NG) tube into the stomach to gen saturation; emergency equipment should aspirate gastric contents for the analysis of be readily available. acidity (pH), appearance, and volume; the 3. Postprocedure entire gastric contents are aspirated, and then a. Monitor vital signs. specimens are collected every 15 minutes for b. Client must be NPO until the gag reex re- 1 hour. Gastric analysis tests gastric output in turns (1 to 2 hours). NPO status may be basal and stimulated states. maintained longer if the client required in- c. Medication, such as histamine or pentagas- tervention during the procedure or if ongoing trin, may be administered subcutaneously bleeding is unresolved. to stimulate gastric secretions; some medica- c. Monitor for signs of perforation (pain, bleed- tions may produce a ushed feeling. ing, unusual difculty in swallowing, elevat- d. Esophageal reux of gastric acid may be di- ed temperature). agnosed by ambulatory pH monitoring; a d. Maintain bed rest and keep side rails raised (per probe is placed just above the lower esopha- agency policy) for the sedated client until alert. geal sphincter and connected to an external e. Lozenges, saline gargles, or oral analgesics recording device. It provides a computer can relieve a minor sore throat (but are not analysis and graphic display of results. given to the client until the gag reex returns).  646 UNIT X Gastrointestinal Problems of the Adult Client E. Fiberoptic colonoscopy BOX 49.3 Signs of Bowel Perforation and 1. Description Adult—Gastrointestinal Peritonitis a. Colonoscopy is a beroptic endoscopy study in which the lining of the large intestine is Guarding of the abdomen visually examined; biopsies and polypecto- Abdominal distention mies can be performed. Nausea and vomiting b. Cardiac and respiratory function is moni- Diminished bowel sounds tored continuously during the test. Inability to pass atus c. Colonoscopy is performed with the client Rebound tenderness or “Blumberg’s sign” Increased temperature lying on the left side with the knees drawn Pallor up to the chest; position may be changed Progressive abdominal distention and abdominal pain during the test to facilitate passing of the Restlessness or altered mental status scope. Tachycardia and tachypnea 2. Preprocedure Dizziness and light-headedness a. Adequate cleansing of the colon is necessary, Decreased blood pressure and tachycardia as prescribed by the PHCP. b. A clear liquid diet is started on the day before the test. Red, orange, and purple (grape) liq- uids are to be avoided. c. Consult with the gastroenterologist regarding G. Endoscopic retrograde cholangiopancreatography medications that must be withheld before (ERCP) the test. 1. Description d. Client is NPO for 4 to 6 hours prior to the a. ERCP is often used when an intervention will test. probably be required. If an intervention is e. Informed consent needs to be obtained. unlikely, a noninvasive diagnostic test is pre- f. Moderate sedation is administered intrave- ferred. nously. b. Examination of the hepatobiliary system is g. Medication may be administered to relax performed via a exible endoscope inserted smooth muscle. into the esophagus to the descending duo- 3. Postprocedure denum; multiple positions are required a. Monitor vital signs. during the procedure to pass the endo- b. Provide bed rest and keep side rails up (per scope. agency policy) until alert. c. If medication is administered before the pro- c. Do not allow anything by mouth until the cedure, the client is monitored closely for client is alert. signs of respiratory and central nervous sys- d. Maintain left lateral position to promote tem depression, hypotension, oversedation, passing of atus. and vomiting. e. Monitor for signs of bowel perforation and 2. Preprocedure peritonitis (Box 49.3). a. Client is NPO for 6 to 8 hours. f. Remind the client that passing atus, abdom- b. Informed consent needs to be obtained. inal fullness, and mild cramping are expected c. Inquire about previous exposure to contrast for several hours. media and any sensitivities or allergies. g. Instruct the client to report any bleeding to d. Avoid anticoagulants and nonsteroidal the PHCP. antiinflammatory drugs unless otherwise h. Teach the client to avoid activities requiring indicated by the primary health care pro- concentration and decision-making. vider. e. Clients are asked about implantable medical The client receiving oral liquid bowel cleansing devices and are asked to have them deactivat- preparations or enemas is at risk for uid and electrolyte ed if present. imbalances. f. Moderate sedation is administered. 3. Postprocedure F. Laparoscopy is performed with a beroptic laparo- a. Monitor vital signs. scope that allows direct visualization of organs and b. Monitor for the return of the gag reex, and structures within the abdomen; biopsies may be ob- wait to provide food and uids until gag re- tained. ex has returned.  CHAPTER 49 Gastrointestinal Problems 647 c. Monitor for signs of perforation or peritonitis (see Box 49.3). CLINICAL JUDGMENT: TAKE Adult—Gastrointestinal d. If the intervention was completed, monitor lab values postprocedure, including liver en- ACTION BOX zymes and pancreatic enzymes. A 59-year-old client with ascites is scheduled to have a H. Magnetic resonance cholangiopancreatography paracentesis. The nurse would take the following actions to (MRCP) prepare the client for the procedure: 1. Description: Uses magnetic resonance to visual- Ensure that the client understands the procedure and that ize the biliary and pancreatic ducts in a noninva- informed consent has been obtained. sive way. This test is often used as a noninvasive Obtain vital signs. alternative to ERCP. Obtain weight. 2. Preprocedure and postprocedure: See Chapter 59 Assist the client to void and empty the bladder. discussing MRI. Measure abdominal girth. I. Endoscopic ultrasonography Position the client upright. 1. Description: Provides images of the GI wall and digestive organs 3. Postprocedure 2. Preprocedure and postprocedure: Care is similar a. Assist the primary health care provider to that implemented for endoscopy. (PHCP) in providing comfort and support during the procedure. Following endoscopic procedures, monitor for the b. Apply a dressing to the site of puncture; mon- return of the gag reex before giving the client any oral itor the site for bleeding. substance. If the gag reex has not returned, the client c. Monitor for hematuria caused by bladder could aspirate. trauma. d. Monitor vital signs, especially blood pressure J. Computed tomography (CT) scan and pulse, and monitor for mental status 1. Description changes because these parameters provide a. Noninvasive cross-sectional view that can de- information postparacentesis on rapid vaso- tect tissue densities in the abdomen, includ- dilation; maintain the client on bed rest. ing in the liver, spleen, pancreas, and biliary e. Measure abdominal girth and weight (the cli- tree. ent should experience a weight loss). b. Can be performed with or without contrast f. Monitor for hypovolemia and electrolyte medium. loss. 2. Preprocedure g. Measure the amount of uid removed, and a. Client is NPO for at least 4 hours. document the amount and a description of b. If contrast medium will be used, assess for the uid. previous sensitivities and allergies. h. Label and send the uid for laboratory analy- c. Encourage the client to verbalize concerns sis; testing should be performed immediately because some clients have claustrophobia. to avoid false results because of chemical or 3. Postprocedure cellular deterioration. a. Encourage client to drink uids