01/26 Flashcards by Kelsey Klipfel

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

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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

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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

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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

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Vitamin deficiencies: cirrhosis:

A, C, E, K

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Vitamin deficiencies: Cholecystitis:

A, D, E, K; fat-soluble vitamins: need bile from gallbladder to digest fat

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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

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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

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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

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Transmitted via Blood (more likely) and body fluid
IV drug use major transmission factor - want get Hep panel

Hepatitis C

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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

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Transmitted via fecal oral route - poor hand hygience, contaminiated water; waste products in water supply

Hepatitis E

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Take out ¾ of abdominal contents and put all back together

Whipple procedure

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4.2-6.1 million cells/microL

RBC

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5,000-10,000 mm3
Tells us about infection
High - indicate might have infection
Low - indicate immunocompromised

White Blood Cell:

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12-18 g/dL
Carries oxygen around in body
Low: blood loss, anemic
High: excess of RBC

Hemoglobin:

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37-52%
Low: indication of hydration, fluid overload
High: more concentrated, more indicated that dehydrated

Hematocrit:

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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:

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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:

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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:

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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:

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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:

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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:

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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:

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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