01/26 Flashcards
What is the paramount worry of a ruptured appendix?
A. bowel obstruction
B. peritonitis
C. elevated CBC
D. elevated temp
Answer: B
Rationale: most concerned about/priority = paramount; peritonits most/main concerned about with ruptured appendix - part GI tract - if any part GI tract ruptures leaks poo/GI contents - full bacteria - lot bacteria supposed be there because aids digestion - only supposed be inside gut not outside but once outside get peritonitis but can quickly lead to sepsis: outcomes with sepsis not great - extended hospital stays and death
Bowel obstruction - can also lead to peritonitis - backs up and colon/gut gets stretched too far and tears leaking into abdominal cavity resulting in peritonitis
Elevated CBC - part of CBC most worried about WBC elevated - shows have active infection - sign but not biggest worry for pt - help make decisions - point in right direction; CUE
Elevated temp - CUE - something going on with pt; sign have an issue; not biggest concern
Biggest concern: what kill pt first
Which of the following is NOT a cause of peritonitis?
A. ruptured appendix
B. abdominal stab wound
C. peritoneal dialysis
D. paralytic ileus
Answer: D
Rationale: NOT; peritonitis can cause a paralytic ileus - GI tract loses ability to push food bolus forward get paralytic ileus - gut is not moving food bolus/waste product (depending on part) forward and holding still - can cause bowel obstruction and goes further downhill; other things besides peritonits result in paralytic ileus; acid-base metabolic issues out of balance - can get more acidic than norm gut - excess H ions affect ability of muscle contraction gradients and gut to push forward causing paralytic ileus; besides peritonitis may have delayed GI motility through tract: post-op surgery (time for GI tract wake up)
Ruptured appendix - cause peritonitis
Abdominal stab wound - lot squishy areas; odds piercing organs is high; if part GI tract punctured have gut flora that should be inside now outside GI tract leading to peritonitis; potential cause peritonitis
Peritoneal dialysis - diff than hemodialysis; for pts with renal failure; involves GI cavity; have sys installed and have inflow and outflow out abdomen; pt do own dialysis at home; benefits: not go to dialysis clinic and have sit there for longer periods of time, feel lot better compared to hemodialysis - nightly basis so not as big buildup waste products in blood and still fluid shift but not as drastic fluid shift; good option for many pts with renal failure before hemodialysis; two ports into peritoneal cavity - anytime break into skin have risk for infection; is a sterile procedure; train pts to be sterile technique when doing instilling dialsate and doing outflow; some pts more compliant and cleaner than others; screening - see if can handle this on own and if can candidate; if develop peritonitis from lack sterile technique or sites infected, let by once (learning experience), second time - go to hemodialysis; each time get peritonitis (inflammation - lead to long-term scarring/scar tissue build up: not work well) - once scar tissue builds up not work same as normal tissue: not perform same functions
What enzymes cause anutodigestion in pancreatitis?
A. amylase and lipase
B. aspartate aminotransferase and alanine aminotransferase
C. blood urea nitrogen and creatinine
D. entecavir and tenofovir
Answer: A
Rationale: what enzymes made in the pancreas; digestion of cells; blockage leading to pancreatitis - cannot get out - digest tissue around them - autodigestion; pancreatitis - pancreas eating self: number one complaint: pain - pain control - NEVER/not priority - pay attention to pain control for pt - go straight to dilaudid - lot pain; not tolerate much PO
Amylase digests carbs - also made in salivary glands
Lipase digests fats
Fats and carbs have issues
AST and ALT - liver enzymes; liver failure - look at these; elevated when damage to cells of liver with cells that normally contain enzymes when cells lyse/contain inflammation - enzymes leak out and detected in blood stream - so elevated; go with liver issues
BUN and creatinine - kidneys; BUN - affected with liver issues: urea nitrogen produced by liver and filtered by kidneys; Cr - part muscle tissue break down: filtered by muscles - and broken down and filtered by kidneys
Entacavir and Tenofovir - meds and anti-virals because ends in -vir; both used for Hep B; Tenofovir - also used for HIV
What manifestation of cirrhosis of the liver would be equated with decreased level of consciousness?
A. portal hypertension
B. jaundice
C. hepatic encephalopathy
D. vitamin deficiencies
Answer: C
Rationale: elevated ammonia (NH4) in bloodstream; brain not func if issues with high ammonia; med: lactulose - better to get off sooner; induces diarrhea - ammonia excreted via stool - if have diarrhea - acid base imbalance: bicarb (metabolic acidosis), K, Na
Portal HTN: elevated pressure in portal veins - portal vein connects blood flow from GI tract into liver; body not like fighting against high pressure all time - leads to comps; get back up blood into lower esophagus (esophageal varices - extended periods portal HTN can lead to varices) and GI tract; what happening in liver: liver is getting harder because fibrosis/scar tissue: lead to it: alcohol (#1), any Hep viruses (esp Hep B/C), genetics; scar tissue cause excess pressure; varices - rupture and bleed - very high mortality rate - big vessels - lose lot blood quickly in abdominal cavity quickly
Vitamin deficiencies: cirrhosis:
A, C, E, K
Vitamin deficiencies: Cholecystitis:
A, D, E, K; fat-soluble vitamins: need bile from gallbladder to digest fat
Over dosage of Acetaminophen is classified as what type of liver disorder?
A. non-viral hepatitis
B. hepatitis C
C. cirrhosis
D. hepatitis B
Answer: A
Rationale: non-viral hepatitis - inflammation of liver - frequently caused by viral issues but not always; max 24 hr dose: 3-4g/day
Hepatitis C and B - viral hepatitis
Cirrhosis - hepatitis can lead to cirrhosis but not due to tylenol
Vaccines
Travel vaccine
Transmitted via fecal oral route - issues with water-sanitation and not have health inspectors - high risk for contracting for Hep A
Transmitted via fecal oral route - poor hand hygience, contaminiated water; waste products in water supply
Hepatitis A
Vaccines
Transmitted via Blood (more likely) and body fluid
IV drug use major transmission factor - want get Hep panel
Not everybody who has Hep B gets Hep D
Hepatitis B
Transmitted via Blood (more likely) and body fluid
IV drug use major transmission factor - want get Hep panel
Hepatitis C
Transmitted via Blood (more likely) and body fluid
Not get unless already have Hep B - go together; not everybody who has Hep B - everyone has Hep D has Hep B
Hepatitis D
Transmitted via fecal oral route - poor hand hygience, contaminiated water; waste products in water supply
Hepatitis E
Take out ¾ of abdominal contents and put all back together
Whipple procedure
4.2-6.1 million cells/microL
RBC
5,000-10,000 mm3
Tells us about infection
High - indicate might have infection
Low - indicate immunocompromised
White Blood Cell:
12-18 g/dL
Carries oxygen around in body
Low: blood loss, anemic
High: excess of RBC
Hemoglobin:
37-52%
Low: indication of hydration, fluid overload
High: more concentrated, more indicated that dehydrated
Hematocrit:
150,000-400,000 mm3
Big in clotting
Low: patient could have much higher risk for bleeding because do not have enough could bleed easier
High: could be at risk of blood clot
Platelets:
3.5-5 mEq/L
Biggest electrolytes
Has sig impacts on heart if high or low; can have sig cardiac dysrhythmia; affects electrical activity of heart - muscle and K+ has huge impact on muscle
Potassium:
136-145 mEq/L
Sig impacts on fluid volume; abnormalities with fluid volume
high/low indicated fluid volume imbalance; also huge impact on neurological func; high/low dehydrated or overloaded fluid wise
Sodium:
8.4-10.5 mg/dL
Sig impacts on cardiac but also gen musculature; muscle hypertonia where it is really high tone muscle or muscle weakness
Calcium:
0.5-1.2 mg/d:
Very common lab look at
Very rare see low: indicate nutritional deficiencies because related to protein
High: key factors someone having renal/kidney probs
Creatinine:
10-20 mg/dL
Nitrogenous wastes
Low: sometimes fluid overload
High: indication of dehydration
BUN and creatinine high tell us renal issue but sometimes dehydrated concentration nitrogenous waste higher and so have higher BUN and try giving fluids
BUN:
70-110 mg/dL (fasting)
Big lab look at for diabetic patients
Too low: hypoglycemic: could also be our diabetic patients
High: hyperglycemic: could be diabetic
Glucose:
11-12.5 sec
Telling you how long takes for blood to clot
Higher number takes longer for blood to clot and increased risk for bleed
Prothrombin Time (PT):
0.76-1.27
Very sim to PTT just normalized
Diff labs run norm ranges diff
INR norm range is always same regardless of location in world is because certain meds given to clients that are given based INR and clotting factor so if they were traveling and had to have lab drawn want to have normalized so know same and not adjusting meds
International Normalized Ratio (INR):
60-70 sec
Another coag factor
Looked at commonly
Base certain meds on it
How long blood takes to clot
Higher number is increased risk of bleed because longer takes body to clot
Flip side if any low means increased risk of clotting because does not take long for blood to clot so that they could clot easily because bleeding a lot is bad but acculding a blood vessel and clotting is bad as well
Partial Thromboplastin Time (PTT):
21-35 seconds
aPTT
Inflammation of Appendix resulting in increased pressure causing edema/obstruction of orifice.
If untreated high risk of rupturing and becoming Peritonitis
Most often caused by blockage from kinking or occlusion from stool
Key points - Appendicitis
Elevated WBC and neutrophils
CT scan will show inflammation
Urinalysis to rule out kidney stones or UTI
Pregnancy test to rule out ectopic pregnancy
Sig labs/diagnostics - Appendicitis
Rebound tenderness at McBurney’s Point (let up of the abdomen is worse than the push down; located diagonally between umbilicus and anterior iliac crest)
Severe, steady pain in right lower quadrant
Low grade fever/nausea
Hallmark: big rebound tenderness
Assessment findings - Appendicitis
Administer pain medications
Administer IV fluids
Educate patient on surgery
Prevent complication post surgery through use of TCDB/IS, ambulation, assess bowel sounds, position in high fowlers
Nursing care - Appendicitis
Inflammation of peritoneum can be result of
Bacterial infection
Extension sources such as abdominal surgery or trauma
Peritoneal dialysis
Inflammation of other organs
Inflammation peritoneal space - leak hydrochloric acid from stomach and cause autodigestion of tissues
Key points - Peritonitis
Elevated CBC
Abdominal x-ray
*C&S of aspirate
Electrolyte disturbances eg potassium, sodium and chloride.
Blood culture
Sig labs/diagnostics - Peritonitis
Fever
Severe pain
rigid muscles/ distention of the abdomen
nausea, vomiting
Can cause a paralytic ileus
hypovolemia caused by the movement of fluid
Rigid muscle - abdominal muscles; because being eaten by hydrochloric acid or other substance - start contracting; rigid, boardlike abdomen - have peritonitis/gastric contents leaking
Affect organs in abdominal cavity: GI tract and kidneys - not passing flatus - clue - not urinating - kidneys damaging; decrease UO and flatus
Assessment findings - Peritonitis
*Administer medications
*Monitor; Assessment/Vital signs
*Intensive care for septic shock
*Focus on Bowel sounds
*Advance diet as tolerated
N&V huge issue for pts - Zofran admin, NG tube insertion
Nursing care - Peritonitis
Inflammation of the gallbladder
Affects more women than men
Four F’s: Fat, Fertile, Female, (Greater than) Forty
Acute (May have stones )
Chronic (No stones)
Key points - Cholecystitis
Right upper quadrant abdominal tenderness (radiates shoulder and back)
Nausea
Fever
Vomiting
Urine is dark and stool is putty/clay colored stool
If obstruction occurs can cause jaundice
Labs that are affected are Vitamins Deficiences (A, D, E, and K (fat soluble))
Positive murphys sign
Bile duct blockage - pt can turn colors - jaundice and have increased bilirubin; symp complain if elevated bilirubin - puritis (itchy); as climbs higher - skin tone higher and turn very yellow
Assess for jaundice: eyes first
Murphy’s sign - below ribcage and feel inflamed - inflamed gallbladder; is elicited in patients with acute cholecystitis by asking the patient to take in and hold a deep breath while palpating the right subcostal area. If pain occurs on inspiration, when the inflamed gallbladder comes into contact with the examiner’s hand, Murphy’s sign is positive
Chest pain - start with EKG; complain of chest pain with full gallbladder because looks like non-STEMI; cardiac workup first before gallbladder; if do procedure laparoscopy prefer less risk for infection, less pain, less invasive, outpt procedure
Assessment findings - Cholecystitis
Abdominal X-Ray
Ultrasonography
ERCP
Increased Bilirubin
Sig labs/diagnostics - Cholecystitis
-Low fat diet, high fiber, high carbohydrates, high proteins
-Treat nausea and vomiting (leads to electrolyte deficits)
-Promote skin integrity due to potential biliary drainage from surgical incision
-Educate to avoid strenuous activity
-Encourage fluid intake
Nursing care: Post-op - Cholecystitis
Autodigestion of the pancreas (self-digestion)
Why?
Gallstones –> obstruction –> backflow of amylase and lipase to pancreas
Excessive Alcohol use – viscous secretions block pancreatic ducts –> enzyme backflow
Autoimmune – body attacks itself (autodigestion)
Excessive alcohol use number 1 reason; can be due to blockages or autoimmune issues
PPN feedings - drop NG tube - suction - parenteral feeding through IV - TPN/PPN - monitor BG
Key points - Acute pancreatitis
Pain in the abd and back - guarding
Breathing pattern, altered
Nausea, rigid abd
Bruising around flank/umbilicus
Fever
Jaundice -> obstruction and biliary build up
Hypotension/hypovolemic shock
ABCs - kill pt first; encourage TCDB - hurts
Has central line - do TPN or PPN - draw blood off of it - stop TPN or PPN for at least 2 min before draw blood
Assessment findings - Acute pancreatitis
CBC; elevated WBC and H&H
Inc serum amylase and lipase
Hyperglycemia, glycosuria
Elevated bilirubin
Diagnostics through abd x-ray & ultrasound
Sig labs/diagnostics - Acute pancreatitis
Parenteral feedings - NPO
NG suction
Pain management
Resp care (inflammation of pancreas & proximity to lungs causes breathing difficulties)
Biliary drainage (watch for obstruction)
Nursing care: Post-op- Acute pancreatitis
(adenocarcinoma - super aggressive)
Highly invasive
Fast growing
Metastasis through venous and lymphatic system
Diagnosed late
Includes all part of the pancreas
Key points - Pancreatic cancer
Fatigue
Abdominal pain
Jaundice
Clay-colored stool
Dark urine
Weight loss/Anorexia
N/V
Assessment findings - Pancreatic cancer
Increased amylase + lipase
Increased alkaline phosphatase
Increased Bilirubin
Definite Test: ERCP
Sig labs/diagnostics - Pancreatic cancer
Admin Pain Medication
NPO/NG
IV Fluids
Monitor BG (TPN has D50)
Assess for bleeding, infection, abscess formation
Nursing care: Post-op- Pancreatic cancer
Inflammation and necrosis of the liver cells
Can be viral (A,B,C,D,E) or non-viral (Acetaminophen, anticonvulsants)
Hepatitis A and E are transmitted the fecal oral route
Hepatitis B, C, D are transmitted by blood and bodily fluids
Key points - Hepatitis
Jaundice- yellowing of the skin and the sclera of the eyes
Malaise and weakness
Nause and heartburn
Enlarge liver
Abdominal tenderness
Assessment findings - Hepatitis
*Increased liver enzymes
-ALT (4-36 iu/L)
-AST (0-35 u/L)
-Serology testing- Checks for the presence of antibodies
*Liver biopsy
Sig labs/diagnostics - Hepatitis
Administer antivirals: Entecavir & Tenofovir
Administer alpha-interferon injections 3x weekly for 16-24 weeks
Educate patient about prevention
Care for post-op liver transplant patients and monitor labs
Diet: fruits & vegetables, lean protein, whole grains, low-fat dairy products
Nursing care: Post-op - Hepatitis
Chronic inflammation of liver tissue → diffuse fibrosis of liver
Liver becomes nodular; blood and lymph flow are impaired
Disrupts structure and function
Men>Women; 40-60 y/o
3 types:
-Alcoholic (most common)
- Post-Necrotic (late result acute viral Hepatitis)
- Biliary (scarring around bile ducts)
Key points - Cirrhosis
Cognitive status
Impaired testicular atrophy/Gyno
Round abd or small hard
Rash (Petechiae/Spider angiomas)
Hepatomegaly/Edema
Skin (pallor/Jaundice)
Impaired Mm (Atrophy)
Skin Excoriation (Scratching)
Jaundice
Muscle atrophy
Edema
Petechiae
Enlarged liver or small/hard
Bleeding risk huge - see petechiae - ascites might develop
Assessment findings - Cirrhosis
Decreased serum albumin levels
Increased serum globulin levels
Increased AST, ALT, and GGT levels
Increased serum Bilirubin
Liver biopsy to confirm diagnosis
Sig labs/diagnostics - Cirrhosis
Promoting rest
Reducing risk of injury
Monitoring and managing potential complications
Improving nutritional status
Frequent Neuro exams/monitoring neuro status
Nursing care: Post-op - Cirrhosis
Primary:
Chronic Hep B and C
Cirrhosis (hep B and C can lead to cirrhosis)
Secondary:
Metastases: particularly digestive system, breast, and lung
Key points - Liver cancer
Ascites
Jaundice
Loss of strength
Weight loss
Possible palpable hepatomegaly
Pain
Assessment findings - Liver cancer
Elevated ALT and AST and bilirubin
Elevated levels of alpha-fetoprotein (AFP) in the blood
Liver biopsy
CT
MRI
Ultrasound
Sig labs/diagnostics - Liver cancer
Maintain sterile technique for biliary draining-and all other procedures (high risk for infection)
Bleeding precautions (especially after liver biopsy because it is highly vascularized)
Education on possible imbalanced nutrition, the risk for falls, bleeding risk
Go with specialized drains/tubes - responsibility: keep them clean - not sterile dressing changes; monitor still working - need know how contact medical/nursing staff; basic assessment if still draining and who contact if not; not their responsibility to get it to drain again but need to do assessment
Nursing care: Post-op - Liver cancer
- End stage liver disease, Hepatitis, Liver cancer
Total removal of diseased liver & replacement of healthy liver from cadaver/right lobe from live donor (same location)
Successful immunosuppression is needed to maintain transplant
Key points - Liver transplant
Symptoms of ESLD: enlarged spleen and liver, ascites, jaundice , abdominal pain
Monitor for signs of infection after the procedure such as: A high fever, Jaundice, pain in the abdomen, vomiting and shortness of breath.
Monitor for signs of rejection that include having a fever greater than 100F, yellowing of the skin and eyes, fatigue and increased liver function tests.
Assessment findings - Liver transplant
BUN and Creatinine
ALT, AST
CBC, especially WBC
Sig labs/diagnostics - Liver transplant
PT must stop drinking
Post-op complications
Immunosuppression (education on medication compliance)
Education on signs of organ rejection
Education on how to live with a weakened immune system
MED COMPLAINCE WITH ANY TRANSPLANT
Go with specialized drains/tubes - responsibility: keep them clean - not sterile dressing changes; monitor still working - need know how contact medical/nursing staff; basic assessment if still draining and who contact if not; not their responsibility to get it to drain again but need to do assessment
Nursing care: Post-op - Liver transplant
Splanchnic hypoperfusion leads to…
Hepatic ischemia —–>
Coagulopathy —–>
Intra-abdominal bleeding
OR
Splanchnic hypoperfusion leads to…
Gut mucosal acidosis —->
Bowel edema
Key points - Intra-abdominal HTN
Abdominal Distention
Wheezing, Difficulty Breathing
Cyanosis
Displacement of the Diaphragm
Abdominal Pain
Assessment findings - Intra-abdominal HTN
Pressure transducer
Daily weight
Girth measurement
Remember for how measure for non-ICU pts: girth measurement and daily weight
Sig labs/diagnostics - Intra-abdominal HTN
Albumin to pull fluid back into the vascular space
Maintenance of Skin Integrity
Monitor Oxygenation
Blood Pressure Management
1 priority nursing diagnosis: ineffective tissue perfusion - cause cascade of probs
Nursing care: - Intra-abdominal HTN
