ABDULLAH, ASNIAH H.

EVEL 4 ASSIGNMENT

A. PEPTIC ULCER DISEASE

SITUATION: A 39-year old man visits his health provider with complaints of
burning, epigastric pain occurring about two hours after he eats. He consistently
feels bloated and obtains little or no relief from over-the-counter (OTC) antacids.
His past medical history reveals cigarette smoking, stressful jobs, and chronic use of
NSAIDs for low back pain.

1. What further information related to risk factors and manifestations does the nurse
need to collect from the client about his chief complaint?
 The nurse asks the patient to describe the pain, its pattern and whether or
not it occurs predictably and strategies how to relieve it.
 The nurse also asks the patient to list his usual food intake for 72 hour period
.
 Ask for any familial tendency
 How often he uses NSAIDs and smoked?

(Hinkle, Cheever, 2014) p. 1268

2. What is the client’s most serious risk factor for peptic ulcer disease?
 Chronic use of NSAIDs

(Hinkle, Cheever, 2014) p. 1266

3. Why is smoking contraindicated for clients with peptic ulcer disease?

 Smoking can decreased the secretion of bicarbonate from pancreas into the
duodenum, resulting increased acidity of duodenum which may inhibits
peptic ulcer repair.
(Hinkle, Cheever, 2014) p. 1268
4. The client’s practitioner prescribes an H2 receptor antagonist, an antibiotic, and a *-
ytoprotective agent. What is the rationale for administering these drugs to clients with
peptic ulcer disease?
 Antibiotic – It exerts bacteriostatic effects to eradicate H.Pylori bacteria in
the gastric mucosa.
 H2 Receptor Antagonists - Decreased amount of HCL produced by the
stomach by blocking action of histamine on histamine receptors of parietal
cells in the stomach
 Cytoprotective agent – Protects the gastric mucosa from agents that causes
ulcers. Increased mucosal production and bicarbonate levels
(Hinkle, Cheever, 2014) p. 1264
5. List 3 priority nursing diagnoses for a client with peptic ulcer disease.
 Acute pain related to the effect of the gastric acid and secretion of the
damaged tissue
  Anxiety related to the acute illness
 Imbalanced nutrition: less than body requirements related to change in diet

(Hinkle, Cheever, 2014) p. 1268

B. GASTRECTOMY

SITUATION: A 44-year-old woman on first day postoperative subtotal gastrectomy

for stomach cancer. Her vital signs are stable and she has been up to the side of the
bed one time. She has a nasogastric tube in place, which is connected to low
intermittent suction.

1. What assessments will the nurse need to make when evaluating the client’s nasogastric
suction?
 Assess bowel sounds
 Monitor closely to ensure proper functioningof NGT to prevent strain on
anastomosis site
 The nurse assessed the fluid and electrolytes
 Monitor vital signs
 Place in Fowler’s position for comfort and to promote drainage

(Hinkle, Cheever, 2014) p. 1271

2. What potential problem the client is at risk for when she begins to consume food and
fluids and what can be done to prevent it?
 Dumping syndrome
 Diarrhea and vomiting
 Hypoglycemia
 Vitamin B12 deficiency
 Hemmorhage
Maam B PPT. (Gastrointestinal system, slide 222)

 Inject B12 required for life.

 Monitor IV therapy, nutritional status, intake and output,weighs daily
 Antiemetic meds

(Hinkle, Cheever, 2014) p. 1280

3. The client is ready to be discharged to home. What problems or symptoms will the
nurse teach the client to report if they occur?
 Bleeding
 Obstruction
 Perforation

(Hinkle, Cheever, 2014) p. 1280

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C. DUM*-I*-G*-SYNDROME
SITUA*-ION: A 45-year-old client with peptic ulcer disease who has undergone a
Billroth II surgical procedure has been discharged home and has developed
dumping syndrome. During her first postoperative visit to the clinic, the client tells
the nurse practitioner that she experiences weakness, diaphoresis, tachycardia,
faintness, and abdominal distention 15-30 minutes after every meal. The client also
mentions that two or three hours after eating she experiences the symptoms of a
hypoglycemic reaction: sweating, mental confusion, anxiety, weakness, and
tachycardia. The nurse practitioner provides the client with a Teaching Guide,
which lists dietary regulations and restrictions for people with dumping syndrome.
She also advises the client to lie down following meals.
1. What causes the early manifestations of dumping syndrome?
 Hypertonic gastric food boluses that quickly transit into the intestines drew
extracellular fluid from the circulatory blood volume into the small into the
small intestines , causes a rapid exuberant release of metabolic peptides that
are responsible for the symptoms.

2. How does it benefit the client to eat a high-fat, high protein, low carbohydrate diet?
 High fat, high protein, low carbs diet may not be induced vomiting or painful
esophageal distention and prevent occurring of the condition

(Hinkle, Cheever, 2014) p. 1276-1277

3. Why is it important for clients with dumping syndrome to lie down after a meal?
 This delays stomach emptying and decreased likelihood of dumping
syndrome

(Hinkle, Cheever, 2014) p. 1276

4. Why does postprandial hypoglycemia occur two to three hours after eating in clients
with dumping syndrome?
 There is rapid elevation of blood glucose, followed increased insulin secretion

(Hinkle, Cheever, 2014) p. 1277

D. ULERATIVE COLITIS

SITUATION: A 35-year-old woman is hospitalized for an exacerbation of ulcerative

colitis following a stressful holiday season spent with relatives. The client is
experiencing abdominal cramping, distention, and diarrhea, and she has signs of
dehydration. The client tells the admitting nurse that she has been eating a lot of
high-fat holiday foods, which she ordinarily avoids: rich gravies, turkey dressing
made with sausage, and creamy pies. In addition, she has been drinking bourbon
and several glasses of wine during dinner. The client explains that she had become
very upset when she allowed her mother, who was visiting, to bring up a lot of
painful issues from the past, which they normally never discuss unless they are
drinking.

1. How has the client’s behavior over the holiday triggered exacerbations of ulcerative
colitis?
 It affects the superficial mucosa of the colon and which are characterized by
multiple lacerations, diffuse inflammation and desquamation or shedding the
caloric epithelium.
(Hinkle, Cheever, 2014) p. 1277
2. What role do diet, alcohol, and stress play in producing symptoms of ulcerative colitis?
 Eventually the bowel narrows, shortens and thickens because of hypertrophy
and fat deposits, stress and alcohol may induced increased intestinal motility
and exacerbate inflammation of linings.
(Hinkle, Cheever, 2014) p. 1303
3. What information can the nurse give this client that will help her prevent future attacks
of ulcerative colitis?
 The nurse provides the management about the nutritional status : a bland
low residue diet, high protein, highcaloric, high vitamin relieve symptoms
and decreased diarrhea
(Hinkle, Cheever, 2014) p. 1307

E. CROHN’S DISEASE

SITUATION: A 25-year-old woman with an exacerbation of Crohn’s disease is

admitted to the emergency department with complaints of diarrhea, intermittent
abdominal pain, flatulence, abdominal distention, and severe fatigue. The client’s
temperature is 38° C. The client states that she has felt under stress because she
recently lost her job, and has not yet secured new employment. As a result, she is very
anxious about her finances.

1. The client’s diarrhea and fever can create nutritional and hydration problems. What
should the nurse assess for and what nursing actions should be taken?
 Temperature, weight, intake and output, assess for pallor and bowel sounds
 IV fluid access and nutritional diet( low fiber, high protein)

(Hinkle, Cheever, 2014) p. 1303-1304

2. The client’s Crohn’s disease was apparently aggravated by recent stressful events. How
can the nurse help the client cope better with stress?
 Stress reduction measures that may used may include relaxation technique,
visualization, breathing exercises and biofeedback
 Professional counselling may be needed to help the patient and family issues
illness and disability

(Hinkle, Cheever, 2014) p. 1307

3. What instruction can the nurse give this client that will help to prevent another
exacerbation of this disease?
 The nurse initiates measures decrease diarrhea (e.g dietary restrictions, stress
reduction and dietary: low residue, highhh protein, high caloric intake,)
 Family support is vital, individual and family counselling

(Hinkle, Cheever, 2014) p. 1308

E. CONSTIPATION

SITUATION: a 75-year-old man with congestive heart failure is being admitted to a

long-term care facility. The client develops fatigue and dyspnea upon exertion, and
consequently tends to severely limit his activities. The client experienced chronic
constipation when at home that, at one point resulted in an impaction that had to be
manually removed by a home health nurse. During admission, the client’s daughter
told the nurse that her father had not had a bowel movement in several days, and
had been straining at stools without results.

1. Given the daughter’s description of the client’s bowel history, what possible
complications should be of concern to the nurse?
 Hypertension
 Fecal impaction
 Hemorrhoids
 Megacolon

(Hinkle, Cheever, 2014) p. 1287

2. How should the nurse assess the client for fecal impaction?
 Fecal impaction occurs when an accumulated mass of dry feces cannot be
expelled. The mass may be palpable on digital examination, may produce
pressure on colonic mucosa that results in ulcer formation, and frequently
cause seepage of liquid tools.
(Hinkle, Cheever, 2014) p. 1287
3. What nursing activities will help to correct the client’s constipation following
admission?
 Patient can be educated to sit on the toilet with legs supported and to utilize
the gastrocolic reflex by attempting to defecate following a med and warm
drink
 Biofeedback is the technique that can be used to help the patient learn to
relax the sphincter mechanism to expel the stool
(Hinkle, Cheever, 2014) p. 1288

F. HYPOTHYROIDISM

SITUATION: A 46-year-old client visits the outpatient clinic for symptoms of

fatigue, cold intolerance, dry scaly skin, hoarseness, weight gain, and fluid retention.
Based on her symptoms, the nurse practitioner obtained thyroid studies, which
revealed an elevated TSH (thyroid stimulating hormone) and decreased T3 and T4
levels. The client was placed on Synthroid 0.1 mg PO daily and instructed to return
to the clinic in one month.

1. What is the significance of the client’s laboratory findings?

 Increased TSH, low leves of thyroid hormone (T3 and T4) slows the basal
metabolic rate (BMR) : The low BMR affects the lipid metabolism. Increased
cholesterol and triglycerides levels affects the RBC production, leading to
anemia and folate deficiency

Ma’am B PPT ( Gastrointestinal, slide 622)

2. What does the client need to be taught about her condition and prescribed medication
 Medications are administered with extreme precations because of the
potential for altered metabolism and exretion, as well as metabolic rate , and
resp. Status .
 Take the meds in the morning with full glass of water
 Importance of nutrition and diet to promote weight loss and normal bowel
patterns

(Hinkle, Cheever, 2014) p. 1475-1478

3. How will the nurse know if the client is responding effectively to the prescribed drug
therapy?
 If replacement therapy is adequate the symptoms of myxedema disappears
and normal ativity is resumed

G. THYROIDECTOMY

SITUATION: A 25-year-old female client is being admitted to the postanesthesia

care unit (PACU) following a thyroidectomy for hyperthyroidism. The client had
undergone three months of preoperative treatment with antithyroid medications
and iodine preparations to establish a euthyroid status prior to surgery. At the
client’s bedside the nurse has set up a tracheostomy set, endotracheal tube
laryngoscope, and suction equipment. There are ampules of calcium gluconate on
hand. The nurse places the client in a semi-Fowler’s position, and is supporting her
head and neck with pillows and sandbags. The nurse frequently checks the client’s
vital signs, and assesses her suture line for strain and bleeding. Once the immediate
postoperative period has passed, the client will be transferred to the surgical floor
where she will recuperate and learn about lifelong thyroid replacement therapy.

1. Why is it so important for the client to be euthyroid prior to thyroidectomy?

 To avoid potential complications , thyrotoxicosis( fever, tachycardia,
irriatability, delirium and coma)

Ma’am B PPT. ( Gastrointestinal, slide 616)

2. Why is it mandatory to have an emergency equipment and ampules of clacium
gluconate on hand following thyroidectomy?

 Hypocalcemia can occur after accidental trauma or removal of parathyroid

glands
 If tetany occurs, you can give it

Ma’am B PPT. (Gastrointestional, slide 617)

3. Why is it important to support the client’s head and neck with sandbags and pillows?
 To reduce edema

Ma’am B PPT( Gastrointestinal, slide 616)

H. CUSHING’S SYNDROME
SITUATION: A 62-year-old woman has been taking 10 mg prednisone PO for over
two years to control pulmonary inflammation from COPD. When assessing the
client, the nurse notes she has a round appearing puffy face, a large abdomen, and
thin arms and legs. There are multiple bruises on the woman’s arms and legs.

1. What is the relationship between the woman’s chronic use of the steroid drug
prednisone and her physical appearance?
 Use of corticosteroid may affects over production of cortisosteroid : arms of
growth, obesity and muscular changes and glucose

(Hinkle, Cheever, 2014) p. 1496

2. Why should the nurse caution the client not to stop taking her oral steroid drug without
consulting health practitioner first?
 An attempt is made to reduce or taper the medications to minimum dosage
needed to treat the underlying process
 Alternative day therapy decreases the symptoms and allows recovery of
adrenal gland responsive

(Hinkle, Cheever, 2014) p. 1498

3. The nurse observes the nursing diagnosis “risk for injury: fractures” on the client’s
nursing care plan. Why is the client at risk for fractures?
 The patient is very weak, the skin is very fragile, thin and easily traumatized:
ecchymoses and striage develop.

(Hinkle, Cheever, 2014) p. 1496

I. DIABETES MELLITUS
SITUATION: A 43-year-old female client has a 24-year history of Type 1 DM. She
lives with her husband and two teen-aged daughters. The client has been able to
adequately manage her DM, care for her family and work full-time as a cook at the
local elementary school cafeteria, where she enjoys cooking and interacting with the
children. The client’s past medical history includes common childhood illnesses,
tonsillectomy at age 6, and vaginal hysterectomy at age 39 for dysfunctional uterine
bleeding secondary to fibroid tumor growth. She is 5’ 4” tall and weighs 138 pounds.

1. What are the similarities and differences between Type 1 and Type 2 DM.

SIMILARITIES DIFFERENCES

Type 1 o Familial tendency o Usually <30

o Stress o Sudden
o Lack of exercise o Thin or normal
o S/S; Polyuria, o Insulin-dependent diabetes
polydipsia, mellitus
polyphagia o Often have islet antibodies
o Little or no endogenous
insulin
o Need exogenous insulin to
preserve life
o Ketosis prone when insulin is
absent
o DKA
 Type 2 o Usually >30
o Gradual
o Obese
o Non- insulin- dependent
diabetes mellitus
o No islet cell antibodies
o Decrease in endogenous
insulin , or increased with
insulin resistance
o Most pts. Can control bld.
Glucose thru weight loss if
obese
o Oral antidiabetic agents may
improve blood glucose levels
if diatary modification and
exercise are unsuccessful
o May need insulin on short or
long-term basis to prevent
hyperglycemia
o Ketosis uncommon, except in
stress and infection
o Acute complication
hyperglycaemic
hyperosmolar syndrome
(Hinkle, Cheever, 2014) p. 1418

2. List the common clinical manifestations that occur from DM, noting those that occur
early in the disease process, those that occur late in the disease process.

A. Early clinical manifestations

o Polyuria
o Polydipsia
o Polyphagia
B. Late clinical manifestations
o Vision changes, tingling and numbness in hands or feet, dry skin, skin lesions
or wounds that slow to heal and recurrent infections, ulcers and gangrene
(Hinkle, Cheever, 2014) p. 1420

3. What are the major consequences of insulin deficiency to each of the following
organs/tissues, and what is the overall result of such consequences?

ORGAN/TISSUE CONSEQUENCES
LIVER Increased glucose output
 Increased basal hepatic glucose production
SKELETAL MUSCLE Decreased insulin-stimulated glucose
uptake
ADIPOSE TISSUE Gastrointestinal absorption of glucose
Increased breakdown of fats throughout the
body
OVERALL RESULT HYPERGLYCEMIA

(Hinkle, Cheever, 2014) p. 1419

Additional Information: The client visits her health care practitioner yearly unless
she experiences problems. Two years ago she was diagnosed with hypertension
secondary to her DM and was placed on the drug metoprolol (Lopressor) 50 mg bid
and a low-salt diet to control her blood pressure. Her daily insulin dose was also
adjusted because her HbA1c (glycosylated hemoglobin) was elevated. Other
medications include 1 mg estradiol daily and OTC Advil (ibuprofen) for occasional
headaches.

4. What does the client’s elevated glycosylated hemoglobin level imply?]

o Glucose molecules attach to haemoglobin in RBC which implies high glucose
concentration in the blood.
(Hinkle, Cheever, 2014) p. 1427

5. What is the relationship between the client’s hypertension and her DM?
 The presence of one increases the risk of having other. They have same risk
factors
(Hinkle, Cheever, 2014) p. 1417

6. Is there reason for concern about the client’s combination of prescribed and OTC
medications? Why or why not?
 Some OTC drugs may contain carbohydrates that may affect the blood
glucose levels of the patient
 (Hinkle, Cheever, 2014) p. 1417-1435

SITUATION: The client has self-administered 35 units of NPH human insulin and
20 units of regular human insulin at 7:30 AM each morning since her last visit to the
clinic, which she feels is controlling her DM well. She inconsistently monitors her
blood glucose levels because she dislikes pricking her own fingers and believes that
she can “feel” when her blood glucose is not within normal limits. The client intakes
between 1300 and 1400 calories each day per the American Diabetic Association
exchange system, which includes an evening snack.

7. While this client has self-administered her own insulin for years, many clients need to
be taught the skill. Cite at least four principles a newly diagnosed diabetic should be
taught about insulin and its administration.
  Blood glucose targets are 140-180 mg/Dl
 Insulin (IV or SQ) is preferred to oral antidiabetic agents to manage
hypoglycaemia
 Hospital insulin protocols or order sets should minimize complexity, ensure
adequate staff training, including standardized hypoglycaemic treatment,
and make guidelines available for glycemic goals and insulin dosing
 Appropriate timing of blood glucose checks, meal consumption, and insulin
dose are all crucial for glucose control and to avoid hypoglycaemia

(Hinkle, Cheever, 2014) p. 1435

8. What is the underlying principle supporting the American Diabetes Association

exchange list and how does the client use it to calculate her daily dietary intake?
 Exchange list of meal planning
 Breads
 Starch
 Vegetables
 Milk
 Meat
 Fat
 Food within one group contain equal numbers of calories and approximately
equal in grams of protein, fat, and carbs.

(Hinkle, Cheever, 2014) p. 1423

9. Should the client be counselled regarding monitoring her blood glucose level? Why or
why not?
 Of course, to monitor the client’s condition , promote healing process and
prevent complications
10. Cite at least 5 signs and symptoms that should be taught to diabetic clients and their
significant others, because they indicate the presence of hypoglycemia.
 CNS effects ( Mental confusion, blurred vision, diplopia, slurred speech,
fatigue and seizures
 Adrenergic effects ( Nervousness, pallor, weakness, diaphoresis, tremor,
tachycardia, hunger)
(Hinkle, Cheever, 2014) p. 1441

11. What are the most common reasons why diabetic clients develop hypoglycemia?
 Too much insulin or hypoglycaemic agents
 Too little food
 Excessive physical activity

(Hinkle, Cheever, 2014) p. 1441

12. Prioritize the following nursing diagnoses for this client, with “1” being the highest
priority. Support your reason for selecting your top three priorities.
___2___ Altered nutrition: less than body requirements (Impaired carbohydrates, fat,
protein metabolism/)
_____5_ Risk for injury
___1 Management of therapeutic management( Unfamiliar with disease process, and
proper managmenet, misinterpretation)
____3_ Risk for infection ( Decreased leukocyte function, circulatory changes due to
high glucose levels)
___4_ Sensory/perceptual alterations

(Hinkle, Cheever, 2014) p. 1417-1439