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“ Regulation of the balance is dynamic and is one function of the endocrine and neuroendocrine system.
Metabolic processes affect ALL cells of the body and whole-body metabolic regulation involves
numerous endocrine structures, the liver, muscle and fat cells.”
1. LIVER - largest gland about 2.5 of TBW; located in the RUQ ; lies under the R lung and above the
stomach and intestines. Liver flow represents about 20% of CO (1L/min)
a. Hepatic artery –supplies the liver about 1/3 of its blood, carries O2 blood
b. Portal vein – supplies the liver about 2/3 of its blood; carries deO2 blood; formed by the
junction of superior and inferior mesenteric veins and splenic veins which receive blood from
pancreas, spleen, stomach, intestines, and gallbladder; carries nutrients, metabolites and
toxins from digestive organs to liver for processing, detoxification or assimilation
c. BP in the liver is low hence and increase in CVP causes liver engorgement
c. Thyroid Gland - Located in the neck, just below the cricoid , H-shaped
1. Triidothyronine (T3) – rapid effect on target tissue, 3 days for peak effect
2. Thyroxine (T4) – requires 11 days for peak effect
a. Requires Iodine for synthesis of thyroid hormones
b. Release is dependent on TSH via negative feedback
FUNCTIONS:
a. Increases metabolism
b. Promotes growth
c. Balance between CHON anabolism and catabolism
d. Assists in acclimitization to cold env’ts by the increasing metabolic rate (heat
pdxn is a by product of metabolism)
e. Increases DNA translation and transcription
d. Pancreas
1. Insulin – Beta Cells
a. Enhance glucose transport into the cell. (adipose tissue formation)
b. Enhances amino acid transport into the cell
c. Works with growth hormone to promote cell hypertrophy and hyperplasia
2. Glucagon – alpha cells
a. Elevates plasma glucose when blood glucose levels drop below 90 mg/dl
3. Somatostatin –delta cells
a. Delay nutrient absorption at the GI tract
b. Regulates release of insulin and glucose
e. Adrenal Glands - Paired endocrine organs situated at the superior poles of the kidney
1. Cortex
a. Aldosterone – primary mineralocorticoid secreted by the adrenal cortex,
degraded in the liver and excreted by the as glucosonide or SO4, conserves
Na and excretes K
b. Cortisol – primary glucocorticoid, stress hormone
Facilitates gluconeogenesis – increases plasma glucose
Stimulates appetite – which leads to central deposition of fat
2. Medulla – postganglionic sympathetic nerve secreting catecolamines
a. Epinephrine – 80% of secretion, strong beta adrenergic effects, potent
stimulator of HR, contractility, increases met. Rate by 100%
b. Norepinephrine
f. Gonads – Males- androgens primarily testosterone (promotes CHON synthesis and musculoskeletal
growth), have a potent anabolic action; Females- estrogen estradiol, puberty related increase in
musculoskeletal growth
I. NURSING ASSESSMENT
a. History Taking
i. Biographic and Demographic Data
Determine AGE, GENDER, ETHNIC BACKGROUND, GEOGRAPHICAL LOCATION
As person ages, fewer hormones and metabolic secretions may be produced and their
effect on target organs may diminish.
ii. Chief Complaint – take note of the onset, duration, intensity, characteristic manifestations and
alterations in growth patterns esp. changes in weight, height or hand, foot, or head size.
1. Integumentary manifestations
a. Non – inflammatory blisters on the dorsum of the hand - common among patients w/
Hepa C virus
b. Jaundice – viral hepatitis, cirrhosis, obstructive or cholestatic liver
c. Unexplained punctured holes – route for entry of hepa virus
d. Spider Angiomas – liver cirrhosis
e. Dilated abdominal veins (caput medusa) – liver cirrhosis
f. Skin lesions that do not heal – pancreatic dysfunction, DM
g. Changes in pigmentation – hyperpigmentation in addison’s dse, hypopigmentation such
as vitiligo (patches) and albinism (general hypopigmentation)
h. Hard, non pitting edema – hypothyroidism (myxedema)
i. Changes in appearance of hands, head, feet and face – acromegaly produces
enlargement of head, hands and feet, coarsening of facial features; cushing’s syndrome
moonlike face, thin extremities and truncal obesity
j. Growth – stunted growth (dwarfism); excessive (gigantism), inappropriate (acromegaly)
k. Hair distribution, amount and texture – hirsutism (excessive hair may indicate ovarian or
adrenocortical d/o; loss of pubic and ancillary hair (pituitary problem); dry brittle hair
(hypothyroidism); soft silky (hyperthyroidism)
l. Diaphoresis – hyperthyroidism and pheochromocytoma
2. Cardiovascular manifestations
a. Epistaxis - problem w/ liver decreases ability to produce clotting factors
b. Hemorrhoids – indicative of hepatic disorder in which fluid overload results from the
liver’s improper functioning and metabolism of hormones and ADH
c. Changes in V/S – elevated in hyperthyroidism and pheochromocytoma
d. Hypertension – portal HPN in liver dse.
e. Elevated HR, flushing - elevated in hyperthyroidism and pheochromocytoma
f. Kussmaul’s Respiration - DKA
g. Tolerance to heat/ cold – heat intolerance in hyperthyroidism; cold intolerance in
hypothyroidism
3. Neurologic Manifestations
a. Weakness –late manifestation of DM, liver and pancreatic dses.
b. Depression – pancreatic cancer or endocrine disorder (decrease cortisol-decrease
endorphins)
c. Changes in mental status or mood – diabetic neuropathy, hepatic encephalopathy
d. Emotional lability - diabetic neuropathy, hepatic encephalopathy
e. Pain – radiating to the back pancreatic, gallbladder or biliary tract d/o
f. Tremors – hyperthyroidism – increased calcitonin decreases serum calcium
g. Muscle weakness- DM due to muscle wasting; hypothyroidism decreased calcitonin
increases serum calcium
h. Loss of sensation – DM neuropathy
4. Ophthalmic Manifestations
a. Exophthalmos - hyperthyroidism
b. Diminished/ blurring of vision - DM retinopathy or pituitary tumor
5. GIT
a. Glossitis – enlarged red tongue in severe DM and acromegaly
b. Changes in weight – decreased in hypothyroidism and increased in hypothyroidism
c. Anorexia – liver d/o
d. Polydipsia - DM
e. Nausea and Vomiting – pancreatitis and hepatobiliary obstruction
f. RUQ Pain – gallbladder and liver dse.
g. Fatty food intolerance – hepatobiliary dse and pancreatitis
h. Belching (excessive eructation or aerophagia) – gall bladder dse and pancreatitis
because of fat malabsorption and reflux of bile and acid
i. Heartburn – gall bladder dse and pancreatitis because of fat malabsorption and reflux of
bile and acid
j. Changes in bowel habits – diarrhea in hyperthyroidism, constipation in hypothyroidism
k. Constipation/ diarrhea
l. Changes in stool appearance – acholic stool in hepatobiliary obstruction, steatorrhea in
pancreatitis
6. GUT
a. Tea – colored urine - hepatobiliary obstruction
b. Frequent urination - DM
c. Menstrual cycle irregularities – endocrine d/o
d. Calcium stones – hypothyroidism or hyperparathyroidism
v. Psychosocial History
Stress and patient’s coping mechanisms – stress can increase the severity of DM
Work environment – job related stressors, exposure to hepatotoxic chemicals such as lead,
anesthethic agents such as nitrous oxides
Physical activity – balance in activity and rest promotes utilization of glucose in DM
Sleep and rest patterns
Nutrition
• Food preferences – Laennec’s cirrhosis in alcoholism
• Eating patterns
• Meal preparation – Hepa A
Travel in areas where hepa/pancreatitis is endemic
Eating raw or steamed selfish (oysters, clams, scallops) from polluted H2O
Swimming or bathing in polluted water
Any known contact w/ hepa infected host
b. Physical Assessment
i. General Appearance and Nutritional Status
Level of consciousness – client’s mood, affect, orientation, alertness, verbal and nonverbal
memory, speech patterns
Appearance
Obtain the weight
iii. Integument
Hair texture and distribution
Skin color
Palpate skin for texture, moisture
iv. Head
Symmetry of facial features
v. Eyes
Position, symmetry, shape, eyelid lag
Visual acuity and Extraocular movements
NOSE – assess mucosa for swelling and color; listen for noisy breathing
MOUTH – note size and shape of the jaw. Inspect the color of the oral mucosa and the condition of
client’s teeth. Note malocclusion. Observe tongue size, activity and fasciculations
vi. Neck
Inspect for symmetry, alignment, bulging over the thyroid gland
Palpate thyroid gland in two ways
• Anterior
o Stand in front of the client.
o To palpate the thyroid gland’s right lobe, flex the client’s head toward the right to
relax the neck muscles on that side.
o Use the fingers of your right hand to displace the trachea slightly to the client’s
right.
o Ask the client to swallow while you palpate the right lobe of the thyroid with the
fingers of examiner’s left hand.
o Repeat with the left lobe.
o *** the nurse can also palpate for enlargement by palpating deep on each side of
the sternocleidomastoid muscles.
• Posterior approach
o Stand behind the client.
o Ask the client to lower the chin to relax the neck muscles.
o Tilt the head slightly to the right to examine the right lobe of the thyroid.
o Use the fingers of your left hand to displace the trachea and the slightly to the
right. This moves the thyroid laterally.
o Palpate between the trachea and the sternocleidomastoid for the right lobe with
the fingers of the right hand.
o Ask the client to swallow while you palpate; doing so will cause the gland to rise
in the neck.
o Repeat for the left lobe by reversing hand placement and positioning the client
toward the left.
vii. Abdomen
Inspection
Observe for distention with tight and shiny skin.
Take note of distended veins
Obtain abdominal girth if ascites is present. Measure weight.
Auscultation
Hum
Friction rub
Systolic bruit
Percussion
Size
• Right Midclavicular line
• Begin at 3rd ICS
• Percuss downwards until the sound changes from resonant to dull.
• Mark.
• Inferiorly, percuss from the typanic area and progress upward until the sound changes
to dull.
• Mark
• LIVER SPAN:
• 6 – 12 cm.
• Midsternal Line
• Percuss upward from above the umbilicus from tympany to DULL.
• Mark.
• Superiorly, percuss down the sternum until the percussion note changes.
• Mark.
• Liver span: 4 – 8 cm.
Liver span may increase more than 12 cm, more than slightly tender, rigid
• Liver Descent
• Mark the distance of liver descent by:
• Ask your patient to inhale deeply and hold it.
• Percuss the lower border of the liver from right midclavicular line.
• Mark and measure.
• Normal: 2 – 3 cm descent
Palpation
Assess muscle guarding and tenderness
RUQ/ Epigastric Pain
WOF Rebound Tenderness
LIVER
• Left hand of the examiner under the right posterior thorax (11th and 12th ribs).
• Push thorax upwards.
• Right hand over the previously marked level of liver descent.
• Examiner’s fingers are pushed up as the client takes a deep breath using the
abdominal muscles.
• Feel for the firm, sharp, smooth and regular border of the
SPLEEN – located by percussion of LMAL bet 6th to 10th ribs; Normal: 2 ½ to 3 inches
• Do not palpate if enlarged (ruptured spleen)
• If no enlargement, ask client to turn into the right side allowing gravity to bring the
spleen forward and down, closer to the abdominal wall.
• Normal spleen is not palpable
• Enlargement in portal HPN
c. Diagnostic Tests
i. Tests for Endocrine Pancreas Function
1. Fasting Blood Glucose (FBS)
• Patient to be on NPO for 8 hours
2. Glycosylated Hemoglobin (HBA1C) – glucose normally attaches itself to the hgb molecules
once attached, it cannot dissociate; stated in percentage and is useful in evaluating long
term glycemic control
• Average blood glucose measured over the previous 3 months
• Normal 6-7%
3. Oral Glucose Tolerance Test (OGTT) – unnecessary if FBS > 140 mg/dl; bedrest, infection,
trauma, medications and stress can alter result
• Diet of at least 150 g of CHO/ day for 3 days
• Blood sample withdrawn for FBS
• Client drinks 75 g of glucose in water
• Blood samples are obtained in between regular intervals (at 1 and 2 hours)
• Client cannot consume any food or fluid other than water between glucose load
ingestion and the end of the test
5. Adrenal Tendon Reflexes - Achilles Tendon Reflex test measures the amplitude and duration
of the ankle jerk and special instrument, which is used to tap the strong tendon at the back
of the heel. Hyperactive in hyperthyroidism.
PROCEDURE:
1. Obtain a written signed consent
2. Check Lab records to see if the client has a normal or adequate clotting factors
3. Prepare skin and administer preprocedural meds
4. Instruct client to be on NPO status and to empty bladder and bowel before the procedure
5. Instruct client to expect difficult breathing when air is placed in the abdominal activity,
Instruct client to hold on breath to protect major organs during needle insertion
POSTPROCEDURE:
1. Bed rest for 24 hours if ever the biopsy is done, If not, client can resume normal activity after recovery
from effects of the medication
COMMON COMPLICATIONS: Pneumothorax, subcutaneous emphysema, air embolism, bile
peritonitis, shoulder or abdominal pain
B. PORTAL PRESSURE MEASUREMENT – N: 5-10mmHg
a. Diagnose portal hypertension
b. Indicate severity of portal hypertension
c. Guide decisions about appropriate intervention
A. URINE UROBILINOGEN (0.3 – 3.5 mg/dl in random test; 0.05 – 2.5 in 24 hour test); test done after 2
hours or 24 hour afternoon collection placed in brown refrigerated bottle w/ NaHCO3 preservative
o Bilirubin is transformed in to urobilinogen by the action of bacteria in the bowel
o Increased in erythrocyte hemolysis and certain drug liver and toxic hepatitis
o Decreased billary obstruction or liver damage
B. FECAL UROBILINOGEN- -75- 275 EU/100 g,
o Results from the breakdown of direct bilirubin to fecal urobilinogen by the action of
bacteria in the bowel.
o Increased in erythrocyte hemolysis
o Decreased in billary obstruction
C. ALPHA PHETO PROTEIN- < 40 mg/ml or < 40 mg/dl, Used as tumor marker to identify cancers such
as hepatomas. No fasting required ; 7-10 ml of blood is sent to the lab
D. IMMUNOGLOBULIN (electrophoresis)
o Used to assist in diagnosis and monitoring of therapeutic response in many disease status
such as liver disorders.
o 1 gG- 565- 1765 mg/dl- increased in chronic liver disease
o 1 gA- 85-385 mg/dl- increased in chronic liver disease
o 1 gM-55-375 mg/dl- increased in chronic liver dysfunction, hepatitis, billary cirrhosis
o No fasting is required, venous blood is taken 7-10 ml is sent to the lab
o Note drugs that can increase Ig (INH, Phenytoin, Contraceptives, steroids, tetanus toxoid,
ATS)
Imaging Studies
1. ABDOMINAL ULTRASOUND- visualizes abdominal organs. A transducer is passed over the organ
Reminders:
1. Client may or may not fast
2. Assure that procedures is relatively painless and safe, and may take 20 minutes only
3. COMPUTED TOMOGRAPHY- identifies and evaluates liver, billary tract, gallbladder and pancreatic
disorders. Useful in distinguishing cysts or tumors and differentiating obstructive from non-obstructive
jaundice.
PREPROCEDURE:
a. NPO 4 hours before tests; except water
b. Contrast dye is used. Note for allergy to iodine
4. ANGIOGRAPHY- Allows visualization of the hepatic, billary, and pancreatic arterial vessels after
administration of contrast medium. Injection of contrast medium through femoral artery than a
catheter is placed in the cliac/mesenteric artery afterwards series of x-ray will be done
4. Client needs sedation or anesthesia with midazolam or diazepam to help allay client’s fears
and make him comfortable during the procedure.
5. Place in a supine or left latest position with the right arm elevated
6. Instruct client to exhale during the insertion of the needle and to hold his breath on
expiration for 5-10 seconds to avoid puncture of the diaphragm
POSTPROCEDURE:
1. Monitor V/S q 15 minutes for 2 hours, every 30 minutes q 2 hours q 1 hour for 4 hours
2. Assess Tachycardia, Hypotension
3. Check puncture sites and observe crepitus, hematoma formation
4. Observe pain in the RUQ of abdomen caused by subcapsular accumulation of bid or bile or
at the rt. Shoulder as a result of bid on the undersurface of the diaphragm.
5. Beginning after 2 hours posttest, elevate head at 30 degrees. After 2 hours, 45 degrees
6. Maintain bed rest for 24 hours
7. Lying on the rt side for the 1st 1-2 hours decreases the risj of hemorrhage and bile leakage
8. Vit. K if prescribed
9. Observe for dyspnea
6. CT PICTOGRAM- provide accurate picture of the liver when a small tumors are suspected. Helpful to
surgeon contemplating live resection, NPO for 2-4 hours before the test. Contrast dye is injected through a
catheter positioned I the splenic artery using CT Scan.
7. GALLIUM SCAN- low level of gallium uptake esp. in the liver and spleen. Used when WBC tend to
aggregate; gallium has high affinity to infectious cells, inflammation and tumor cells
Hepatic System
IV. Risk Factors in the development of metabolic d/o
• Diet/ hygiene (poor)
• Hepatitis
Hep A – infected H2O, milk, raw food, shellfish from contaminated H2O
- crowding/ poor sanitation
Hep B – health workers in contact with blood or carriers multiple blood transfusion/ analysis
- homosexual (men), morticians
- Tatorin; IV drug user, saliva and serum of carriers
Hep C – parenterally by blood
Hep D- blood contact (blood products)
- IV drug user/ people with hemophilia
Hep E- travel to counters with incidence of Hep E consuming food and H 2O contaminated with
virus
Cirrhosis- alcohol ingestion especially in the absence of proper nutrition use