METABOLISM CASE STUDIES (1)

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?
2. What is the clients most serious risk factor for peptic ulcer disease?
3. Why is smoking contraindicated for clients with peptic ulcer disease?
4. The clients practitioner prescribes an H2 receptor antagonist, an antibiotic, and a
cytoprotective agent. What is the rationale for administering these drugs to clients with
peptic ulcer disease?
5. List 3 priority nursing diagnoses for a client with peptic ulcer disease.
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 clients nasogastric
suction?
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?
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?
C. DUMPING SYNDROME
SITUATION: 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?

2. How does it benefit the client to eat a high-fat, high protein, low carbohydrate diet?
3. Why is it important for clients with dumping syndrome to lie down after a meal?
4. Why does postprandial hypoglycemia occur two to three hours after eating in clients
with dumping syndrome?
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 clients behavior over the holiday triggered exacerbations of ulcerative
colitis?
2. What role do diet, alcohol, and stress play in producing symptoms of ulcerative colitis?
3. What information can the nurse give this client that will help her prevent future attacks
of ulcerative colitis?
E. CROHNS DISEASE
SITUATION: A 25-year-old woman with an exacerbation of Crohns disease is
admitted to the emergency department with complaints of diarrhea, intermittent
abdominal pain, flatulence, abdominal distention, and severe fatigue. The clients
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 clients diarrhea and fever can create nutritional and hydration
problems. What should the nurse assess for and what nursing actions
should be taken?
2. The clients Crohns disease was apparently aggravated by recent
stressful events. How can the nurse help the client cope better with
stress?
3. What instruction can the nurse give this client that will help to
prevent another exacerbation of this disease?
E. CONSTIPATION

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

llong-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 clients 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 daughters description of the clients bowel history, what possible
complications should be of concern to the nurse?
2. How should the nurse assess the client for fecal impaction?
3. What nursing activities will help to correct the clients constipation following
admission?
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 clients laboratory findings?
2. What does the client need to be taught about her condition and prescribed medication.
3. How will the nurse know if the client is responding effectively to the prescribed drug
therapy?
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
clients 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-Fowlers position, and is supporting her
head and neck with pillows and sandbags. The nurse frequently checks the clients
vital signs, and assesses her suture line for strain and bleeding. Once the immediate
postope 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?
2. Why is it mandatory to have an emergency equipment and ampules of clacium
gluconate on hand following thyroidectomy?

3. Why is it important to support the clients head and neck with sandbags and pillows?
CUSHINGS 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 womans arms and legs.
1. What is the relationship between the womans chronic use of the steroid drug
prednisone and her physical appearance?
2. Why should the nurse cautioin the client not to stop taking her oral steroid deug
without consulting health practitioner first?
3. The nurse observes the nursing diagnosis risk for injury: fractures on the clients
nursing care plan. Why is the client at risk for fractures?
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 clients 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.
TYPES OF DM
TYPE 1

SIMILARITIES

DIFFERENCES

TYPE 2

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
B. Late clinical manifestations
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
SKELETAL MUSCLE
ADIPOSE TISSUE
OVERALL RESULT
Additiona 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 GHb (glycosylated hemoglobin) was elevated. Other
medications include 1 mg estradiol daily and OTC Advil (ibuprofen) for occasinal
headaches.
4. What does the clients elevated glycosylated hemoglobin level imply?
5. What is the relationship between the clients hypertension and her DM?
6. Is there reason for concern about the clients combination of prescribed and OTC
medications? Why or why not?
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 slef-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.
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?
9. Should the client be counseled regarding monitoring her blood glucose level? Why or
why not?
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.
11. What are the most common reasons why diabetic clients develop hypoglycemia?
12. Prioritize the following nursing diagnoses for this client, with 1 being the highest
priority. Support your reason for selecting your top three priorities.
______ Altered nutrition: less than body requirements
______ Risk for injury
______ Management of therapeutic management
______ Risk for infection
______ Sensory/perceptual alterations