Advanced GI: Hepatic & Pancreatic Disorders Flashcards
What are the vascular functions of the liver?
blood storage and filtrations
What are the secretory functions of the liver?
bile productions and bilirubin metabolism
What are the metabolic functions of the liver?
digests carbs/ fat/ protein, synthesizes all clotting except for Von Willebrands, aids in synthesis of albumin, prothombin, and fibrogen, detoxification, vitamin and mineral storage (A, D, E, K, iron, copper)
Liver ________ in size with aging.
decreases
decreased synthesis of enzymes which help metabolize drugs
liver aging
- Ask ?s in nonjudgmental manner
- Always ask about family hx of liver disease
- Any hx of drug use (IV or intranasal?)
- Hx of tattoos?
- Been in military?
- In prison? County jail? Healthcare worker?
- Hx of Hepatitis?
- Ask about employment hx (exposure to toxins?)
- Sexual Hx?
Assessment Questions for Liver Function
growth of the breast tissue in men related to hormonal changes during liver disease
gynecomastia
7 F’s for Abdominal Distention
fat, fetus, fluid, flatulence, feces, fibroid, fatal tumor
skin abnormality in liver disease in which red, spider-like clusters appear on chest, back or umbilicus…they blanche
spider angiomas
What should the nurse inspect on a patient with liver disease?
skin color (everywhere, look for jaundice), surface characteristics, surface movements
What is shifting dullness?
When the patient lies on their side, the top of abdomen will have tympany (high-pitched sound) because of gas rising up and the bottom of abdomen will have dullness b/c fluid will shift down
What is a fluid wave?
When the patient’s side is tapped, the abdominal fluid will cause a wave across the abdomen.
Liver patients are at a high risk for _________.
bleeding
hernia surrounding the umbilicus in which the blood vessels pop out
caput medusa
vascular changes in the hand that cause the palms to be red
palmar erythema
What do ultrasounds of the liver check for?
patency of blood vessels in liver, gallstones, cysts, tumors & fat
What can CT scans pick up on the liver?
exact size of the liver, small lesions, look at bile ducts closely
What is an MRCP?
MRI of the pancreas and bile ducts
Is the MRCP or the ERCP more invasive?
the ERCP is more invasive
What does liver nuclear testing check?
cystic duct disease
AST Normal Level
10-35 units/L
In acute liver injury, AST is __________.
elevated
In chronic liver disease, AST is ________ or _________.
decreased or normal
ALT Normal Level
4-36 units/L
In acute liver injury, ALT is __________.
elevated
In chronic liver disease, ALT is ________ or _________.
decreased or normal
AP Normal Level
30-120 units/ L
GGT Normal Level
8-38 units/ L
In acute liver injury, AP and GGT are __________.
elevated
Bilirubin Normal Level
0.3-1.0 mg/ dL
In chronic liver disease, bilirubin is ________.
elevated
Albumin Normal Level
3.5- 5 g/ dL
Total Protein Normal Level
6.4-8.3 g/ dL
In chronic liver disease, albumin and total protein are _______.
decreased
PTT Normal Level
11-12.5 seconds
LDH Normal Level
??
In chronic liver disease, PTT is ________.
prolonged
In acute liver disease or liver tumors, LDH is ________.
elevated
80% of liver function is gone once __________.
albumin is decreased and PTT is prolonged
Normal Bleeding Time/ Platelet Closure Time
64-120 seconds
Ammonia Normal Level
6-47 µmol/L
In chronic liver disease, bleeding time is ________.
increased
In chronic liver disease, ammonia is ________.
elevated
In chronic liver disease patient, CBC will show _________.
B12, Folic Acid and Iron Deficiencies Anemias
In chronic liver disease, platelets are ________.
low (thrombocytopenia)
Before a liver biopsy, _________ is tested.
bleeding time
Elevated ammonia causes _________ and __________.
agitation and confusion
The gold standard test for liver disease.
liver biopsy
liver biopsy obtained by cutting the abdomen
open liver biopsy
liver biopsy obtained by going through the jugular vein
closed liver biopsy
The labs prior to a liver biopsy are __________.
H&H, bleeding time, platelets, and PT
If PT is high or platelets are low prior to liver biopsy, what does the nurse do?
notify the surgeon
What does the nurse give if PT is high or platelets are low prior to liver biopsy?
Vitamin K or fresh frozen plasma
Patients are NPO how long prior to liver biopsy?
6 hours
What must the nurse check prior to liver biopsy?
vital signs, labs, and signed informed consent
During a liver biopsy needle insertion, the patient must __________ and ___________.
lie completely still and hold breath on exhalation
Post-liver biopsy, the patient must be on complete bed rest and right side-lying for _____ hours.
6-8 hours
For an open liver biopsy, the nurse must apply _________.
direct pressure
How long must a patient remain right side-lying after liver biopsy?
2 hours
accumulation of bilirubin in the skin and mucous membranes that causes a yellow-orange discoloration and icterus of the sclera
jaundice
Bilirubin is formed by the breakdown of ______.
hemoglobin
jaundice that comes from the liver itself due damage of the liver
hepatocellular jaundice
jaundice that results from impaired bilirubin transport and excretion in the biliary system and is caused by a tumor
intrahepatic obstructive jaundice
jaundice that results from impaired bilirubin transport and excretion in the biliary system and is caused by gallstones stuck in the bile duct or pancreatic mass
extrahepatic obstructive jaundice
type of jaundice that is the most dangerous and caused by transfusion of the wrong type of blood
hemolytic jaundice
A patient that is very jaundiced but has no pain most likely has _________.
pancreatic cancer
Why is stool clay-colored and urine dark tea-like colored in jaundiced patients?
because bilirubin is being excreted in the urine instead of the stool like it should
What are the symptoms of jaundice?
scleral icterus, tea-colored urine, clay-colored stool, pruritus, elevated conjugated bilirubin, fatigue, anorexia
What are the expected outcomes for impaired skin integrity?
regain integrity of the skin, report any altered sensation or pain, describe measures to protect and heal the skin
Jaundice usually starts to fade after _____ weeks.
4-6 weeks
What is the first sign that jaundice is improving?
urine will return to yellow and stool will return to brown
The liver will heal itself if the problem is ___________.
hepatitis or gallstones and not cirrhosis
Acute liver failure is also called ________.
fulminate hepatic failure
In acute liver failure, 75% of patients die within ______.
days of the symptoms
What is the main cause of acute liver failure?
acetaminophen overdose
What causes acute liver failure?
infection, acetaminophen overdose, mushroom poisoning, or heat stroke
What happens to the liver in acute liver failure?
massive destruction of hepatocytes
What are the signs of acute liver failure?
headache, jaundice, LOC change (ammonia), bruising (bleeding)
What is the characteristic lab test of acute liver failure?
elevated PT
Every patient that is jaundice needs what lab test?
PT
What is the treatment for acute liver failure?
decrease ammonia levels, prevent bleeding, liver transplant and life support
What should the nurse do for a patient in acute liver failure?
protect from injury, monitor neurological status, give blood products, continuous pulse ox, ABG’s, cardio fxn, renal fxn, coagulation fxn, monitor ICP, watch for sepsis and shock
benign liver tumor made up of a collection of blood vessels
hemangioma
What are the benign liver tumors?
hemangiomas, cysts, lesions, adenoma
What are the malignant liver tumors usually caused by?
viral hepatitis or metastatic disease
Why are mets common in the liver?
because it is highly vascular
Primary cancers of the liver can arise in ___________ or ________.
liver cell or bile duct cell
How is primary liver cancer diagnosed?
CT or alpha feto protien (AFP) in bloodwork
After liver resection, the nurse should do what?
monitor closely for bleeding, V/S q15 min, check dressings, I & O, continuously monitor cardiac and respiratory function, control pain
What is the major risk for liver resection?
bleeding
What herbs can cause toxic hepatitis?
Kava Kava and Ephedra
What supportive nursing care is needed for toxic hepatitis?
give fluids and watch for bleeding
acute inflammation of hepatocytes caused by a virus
viral hepatitis
What are the modes of transmission of viral hepatitis?
contact w/ blood, blood products, semen, saliva, percutaneously or direct contact
What is the most common type of Hepatitis?
Hepatitis A
Hepatitis A is eliminated in the _______.
feces
Hepatitis A is spread through the ingestion of __________.
contaminated food, water, or shellfish
Hepatitis A is a ___________ disease.
self-limiting
Recovery from Hep A occurs in about ____ weeks.
9
Hepatitis B is spread through contact with ___________.
blood, blood products, and body fluids (like semen)
Recovery from Hep B occurs in about ____ weeks.
16
Hep B may progress to __________ infection.
chronic
Groups at risk for Hep B infection are?
IV drug users, people who have unprotected sex, infants born to infected mothers, immigrants
Hepatitis C is spread through contact with ___________.
blood and bodily fluids
80% of Hep C+ patients have ________.
no symptoms
85% of Hep C+ patients have __________ infections.
chronic
The most common genotypes of Hep C are _______.
1, 2, 3, and 4
What is the leading indicator for liver transplant?
Hepatitis C
What are the causes of Hep C infection?
IV drug use, intranasal drug use, tattoos, needle-stick injuries, and blood transfusions prior to 1992
Hep C can survive on surfaces for ____ weeks.
6
Hep D always occurs in the presence of Hep ____.
B
Hep E is similar to Hep ____. It is caught the same way.
A
Hep F and G are similar to Hep ____.
C
Symptoms of Hepatitis C include?
anorexia, N/V, abdominal pain, fatigue, low grade fever, enlarged/ tender liver, joint pain, and jaundice in the icteric phase
What should the nurse include in the plan of care for a Hepatitis patient?
bed rest, control of nausea, and frequent rest periods
What medication should a Hepatitis patient avoid?
acetiminophen
What kind of diet should the Hepatitis patient eat?
high carb, high calorie, moderate protein and fat
What precautions should the nurse enact with a Hepatitis patient?
disposable patient care items, gloves, universal precautions
Who can a Hep C patient donate a liver to?
another Hep C patient
Can Hep C patients donate blood or body fluids?
No
Liver enzymes are _______ in Hep A and B.
elevated
Liver enzymes are ________ in Hep C.
slightly elevated
Hep A test that checks for acute infection
IgM anti-HAV
Hep A test that checks for immunity
IgG
Hep B test that, if positive, means the patient has chronic infection and is contagious
HBsAg antigen
Hep B test that, if positive, means the patient is immune to Hep B
HBsAb antibody
How is a patient tested for Hep C?
Hep C viral load and genotype
What is the treatment for Hep A?
none because it is self-limiting
What is the treatment for Hep B?
Lamivudine QD x 1 year and Interferon
What are the horrible side effects of Interferon?
flu-like symptoms, N/V/D, joint pain, severe psychiatric problems
What is the treatment for Hep C?
Interferon Pegs, Ribavirin, and Direct-Acting Antiviral
What is the bad side effect of Ribavirin?
bone marrow depression – severe anemia
Viekira Pak for Hep C is a combo drug of what 4 drugs?
Ombitasvir, Paritaprevir, Dasabuvir, and Ritonavir
Ombitasvir, Paritaprevir, Dasabuvir, and Ritonavir are ____________ anti-virals.
direct-acting
Ombitasvir, Paritaprevir, Dasabuvir of the Viekira Pak are taken when?
once daily in the morning
Ritonavir of the Viekira Pak is taken when?
twice daily in the morning and evening
How many weeks does a patient take Viekira Pak?
12- 24 weeks depending on sub-genotype
What are the minimal side effects of Viekira Pak?
pruritus, nausea, and fatigue
Viekira Pak has multiple ________.
drug interactions
Viekira Pak is _____% effective in Hep C genotype 1b without cirrhosis.
100%
For a co-infected HIV patient, Viekira Pak is 100% effective if they have Hep C genotype ____.
1b
Viekira Pak is _____% effective in Hep C genotype 1b with cirrhosis.
99%
Viekira Pak is _____% effective in Hep C genotype 1a without cirrhosis.
87-96%
Viekira Pak is _____% effective in Hep C genotype 1a with cirrhosis.
95%
For a co-infected HIV patient, Viekira Pak is 91% effective if they have Hep C genotype ____.
1a
What is the dose of Sovaldi (sofosbuvir)?
One 400 mg tablet once daily
What are the side effects of Sovaldi (sofosbuvir)?
fatigue and headache
Sovaldi (sofosbuvir) is used in combination with _________ and ________.
interferon alfa and ribavirin
For Hep C genotype 1 and 4, Sovaldi (sofosbuvir) is used with ________ and _________.
peg interferon and ribavirin
For Hep C genotype 1, 2 and 4, Sovaldi (sofosbuvir) is given for ______ weeks.
12
For Hep C genotype 2, Sovaldi (sofosbuvir) is used in combination with ________.
ribavirin
For Hep C genotype 3, Sovaldi (sofosbuvir) is used in combination with _________.
ribavirin
For Hep C genotype 3, Sovaldi (sofosbuvir) is given for ______ weeks.
24 weeks
The cost of Sovaldi (sofosbuvir) is $_____/ pill.
$1,000
What is the dose of Harvoni (ledipasvir/ sofosbuvir)?
one pill once daily
Harvoni (Ledipasvir/sofosbuvir) is given for _____ weeks.
12
Side effects of Harvoni (Ledipasvir/sofosbuvir) are?
fatigue and headache
Is Harvoni (Ledipasvir/sofosbuvir) given with any other drugs?
No
Hepatitis A vaccines
Havrix or Vaqta
Havrix or Vaqta is given as a 2 injection series ___ to ___ months apart
6 to 12
Havrix or Vaqta is given to what groups of people?
people w/ Hep B or C, people who travel to 3rd world countries, military, and illicit drug users
Havrix or Vaqta is not a ______ virus.
live
Why is Hep A pre-vaccination screening needed in certain populations?
because some people might already have immunity because they already contracted Hep A (common in southwest US)
Hepatitis B vaccine
HBV
HBV is recommended for what groups?
infants born to Hep B+ mothers, people who have unprotected sex, people w/ chronic liver disease, people exposed to blood or body fluids, people who live in close-quarters
combination Hep A and B vaccine given at 0, 1 and 6 months
Twin-Rix
Twin-Rix is contraindicated in people allergic to _____.
alum
Immunoglobulin is only effective as post-exposure treatment for Hep A if given within ____ weeks of exposure.
2
Immunoglobulin _____ or ______ be effective post-exposure treatment for Hep C.
may or may not
Hep B post-exposure treatment for un-vaccinated people is _____.
HBIG (Hep B Immunoglobulin) then initiate HBV vaccine series
Hep B post-exposure treatment for a previously vaccinated known responder is _____.
no treatment
Hep B post-exposure treatment for a previously vaccinated known non-responder is _____.
HBIG x 1 then revaccinate OR HBIG x 2 separated by 4 weeks
Hep B post-exposure treatment for a previously vaccinated person whose antibody response is unknown is _____.
If HBsAb are adequate, don’t treat. If HBsAb are inadequate, give HBIG x 1 and vaccine booster.
If HBsAb is inadequate prior to HBIG, what needs to be done?
Recheck titer in 3-4 months. If still inadequate, complete full second series of vaccine.
condition that occurs when the liver is damaged beyond its capacity to regenerate new cells
cirrhosis
Cirrhosis leads to _______.
fibrosis and nodule formation in the liver
In cirrhosis, the liver lobes become covered with _____.
fibrous tissue
In cirrhosis, ________ deteriorates in the liver.
parenchyma
In cirrhosis, the liver lobules are infiltrated with _____.
fat
Alcholic cirrhosis is also known as ______.
Laennec’s cirrhosis
type of cirrhosis induced by toxins that leads to necrosis of liver tissue
post-necrotic cirrhosis
type of cirrhosis that is auto-immune
biliary cirrhosis
type of cirrhosis that is fairly rare and caused by right-sided heart failure
cardiac cirrhosis
What is the #1 cause of cirrhosis?
alcohol
abnormal accumulation of iron in the blood that can lead to cirrhosis
hemachromatosis
abnormal accumulation of copper in the blood that can lead to cirrhosis
Wilson’s disease
type of cirrhosis that comes from the biliary system (bile ducts)
primary biliary cirrhosis
the stage of cirrhosis in which the liver is damaged but there are few, if any, symptoms
compensated disease
the stage of cirrhosis in which the liver can no longer perform vital functions and multiple manifestations occur throughout all body systems
decompensated disease
In early cirrhosis, liver enzymes are ______.
high or low
In advanced cirrhosis, liver enzymes are ________.
normal or low
In cirrhosis, bilirubin is _______.
elevated
In cirrhosis, protein and albumin are _________.
decreased
In cirrhosis, a patient is deficient in what vitamins?
Vitamin K, thiamine, and folic acid
In cirrhosis, what blood disorder is common?
anemia
In cirrhosis, PT will be _________.
elevated
What is the only definitive test for cirrhosis?
liver biopsy
Can blood work show cirrhosis?
Yes
How can cirrhosis be diagnosed?
X-ray, abdominal CT, blood work, and liver biopsy
Cirrhosis patient should avoid what hepatotoxic drugs?
acetaminophen, phenobarbital and alcohol
The cirrhosis patient should eat what kind of diet?
high protein (if compensated), low fat, low sodium, 2500-3000 cals/day, and small, frequent meals
What nursing interventions should be completed with the cirrhosis patient?
daily weights, strict I & O, antacids, anti-emetics, and vitamin supplements like thiamine (banana bags or IM QD x 3 days)
obstruction of the portal blood flow that increases portal venous pressure
portal hypertension
What can portal hypertension cause?
splenomegaly, ascites, esophageal varices, caput medusa, and severe hemorrhoids
What is the main risk of portal hypertension?
bleeding
If collateral circulation develops in portal hypertension, what is the patient at massive risk for?
upper GI bleed
What should the portal hypertension patient be taught?
no heavy lifting, avoid vigorous nose-blowing, no straining to have bowel movement, use a soft toothbrush/ foam toothbrush, and report any sign of bleeding ASAP
What medications are given to reduce portal vein pressure?
beta blockers like propranolol (Inderal)…even if the patient has asthma
High ammonia levels cause _______.
mental status changes
hepatic encephalopathy or hepatic coma
portal-system encephalopathy
What factors lead to portal-system encephalopathy?
high protein diet, infection, hypovolemia, hyperkalemia, constipation, GI bleeding, and medications like opiods, diuretics and hypnotics
How does a high protein diet lead to portal-system encephalopathy?
It leads to constipation and stool in the colon produces ammonia which circulates back into system to the liver.
first stage of portal-system encephalopathy in which driving could be impaired
sub-clinical stage
stage of portal-system encephalopathy in which behavior and handwriting changes
Stage 1- Prodomal
stage of portal-system encephalopathy including disorientation, confusion, and asterixis (flapping of hands “liver flap”)
Stage 2- Impending
stage of portal-system encephalopathy in which the patient becomes greatly confused, falls asleep, is hard to arouse, and has muscle twitching
Stage 3- Stuporous
stage of portal-system encephalopathy in which seizures and death occurs
Stage 4- Comatose
flapping of the hands often called the “liver flap”
asterixis
What is the dietary management of a patient with portal-system encephalopathy?
low protein
What medication is used in portal-system encephalopathy that decreases ammonia?
Lactulose
How does Lactulose decrease ammonia in the body?
It alters the acidity of the stool preventing the absorption of ammonia by the colon and also increases the number of stools per day.
How many stools per day should a patient have on lactulose?
3-4 loose stools/ day
How can Lactulose be given?
orally or by retention enema mixed w/ 75 mL of saline
How long must the lactulose retention enema be held in?
30 minutes
What is the first sign of altered mental status in portal-system encephalopathy?
changes in handwriting
For a patient with portal-system encephalopathy, the nurse should encourage _______.
fluids
The patient with portal-system encephalopathy should limit _______ until ammonia is decreased.
activity
sudden kidney failure for no reason in people with liver failure resulting from complete intrarenal vasoconstriction of normal kidneys
Hepatorenal Syndrome
A patient with Hepatorenal Syndrome will develop _____ and ______.
oliguria and azotemia
increase in BUN and creatinine
azotemia
What is the treatment for Hepatorenal Syndrome?
fluid administration, diuretic therapy, and hemodialysis
Nurses should address __________ decisions with Hepatorenal Syndrome patient and family.
end-of-life
accumulation of plasma-rich fluid within the peritoneal cavity secondary to portal hypertension, increased aldosterone, and decreased oncotic pressure
ascites
What happens to the kidneys in ascites?
Kidneys retain sodium and water increasing third-spaced fluid and anasarca
What is the most common cause of ascites?
cirrhosis
What are the treatment options for ascites?
Paracentesis, TIPS, or Peritoneal venous shunts
The two types of Peritoneal venous shunts are?
Denver and Leveen
What medications are given for ascites?
Aldactone (K+ sparing), Lasix (K+ depleting), and Bumex (K+ depleting)
If giving Lasix or Bumex, what needs to be checked?
potassium levels
What diet should a person with ascites follow?
low-sodium
What is given with a paracentesis to prevent shock?
albumin infusion
How much fluid can a patient with ascites have?
1 L/day or less
What should be done by the nurse prior to a paracentesis?
check weight and V/S, have patient void, position the patient upright, give albumin infusion
What should be done by the nurse during a paracentisis?
describe amount and appearance of fluid obtained
What should be done by the nurse after a paracentisis?
send specimen to the lab, check weight and V/S, put ostomy bag over site
Enlargement of collateral blood vessels in the esophagus that occurs due to portal hypertension
esophogeal varices
_____% of esophogeal varices patients will die the first time they bleed
50%
sign of a massive bleed in a patient with esophogeal varices
Hematochezia (bright red blood in stool)
What is the risk with Hematochezia?
shock
How often should the nurse monitor V/S in patient with bleeding esophogeal varices?
q 15 minutes
What should the nurse monitor in patient with bleeding esophogeal varices?
urinary output (foley), V/S, LOC, abdomen, labs
What procedure is done in patient with bleeding esophogeal varices?
endoscopy
What procedure is done in patient with non-bleeding esophogeal varices?
barium study
What medications are given to control hemorrhage in patient with esophogeal varices?
Vasopressin, Somatostatin/Octreotide, PPI’s, coagulants (FFP, platelets, clotting factors), or beta-blockers
hormonal peptide given subQ or on a drip to control hemorrhage that is much safer than vasopressin
Somatostatin/Octreotide
What are the bad side effects of Vasopressin?
systemic vasoconstriction including the heart which can cause dysrythmias and chest pain
What kind of monitoring needs to be done with a patient on vasopressin?
cardiac monitoring
temporary measure to stop bleeding in esophogeal varices that applies direct pressure to varices to control bleeding
Esophageal Varices Treatment Balloon Tamponade
Esophageal tamponade tube with 3 lumens
Sengstaken-Blakemore or Linton-Nachlas
Esophageal tamponade tube with 4 lumens and 2 ports
Minnesota
How long will a patient have a balloon tamponade tube?
24-48 hours
How often does the nurse deflate a balloon tamponade tube?
for 15 minutes every 4 hours
What is the biggest risk with a balloon tamponade tube?
aspiration
What should be monitored while a patient has a balloon tamponade tube?
aspiration, nasal necrosis, tube position
What should be kept at the bedside while a patient has a balloon tamponade tube?
scissors to cut the tube if needed
Medication that is inserted during endoscopy that has an inflammatory reaction producing fibrous bands to form around vessels
Ethanolamine
Medication that is inserted during endoscopy that causes localized vasoconstriction
Epinephrine
endoscopic procedure in which mall bands or metal clips are placed around base of varices
band ligation
endoscopic procedure done when a patient is actively bleeding in which the vessels are washed out with saline to see which one is bleeding and epinephrine or ethanolamine is shot into the vessel
sclerotherapy
procedure in which a shunt is placed into the internal jugular vein
Transjugular intrahepatic portosystemic shunting (TIPS)
TIPS has a high rate of _________.
re-occlusion
What is the nursing care for a patient post-TIPS procedure?
monitor for bleeding and hypovolemic shock
TIPS worsens encephalopathy in ___% of patients.
20%
type of shunt that is threaded down abdomen to collect fluid and shunt back into inferior vena cava
Le Veen Shunt
type of shunt that has hand-held pump that pt. pumps to get fluid back into circulation
Denver Shunt
What are porto-caval shunts used for?
malignant and nonmalignant ascites, alternative to paracentesis, for patients awaiting liver transplant
1 unit of PRBC will increase hemoglobin by _____ g/dL
1
liver transplant surgery lasts between ______ hours
8 to 18 hours
The most common conditions for liver transplant are?
Viral Hepatitis (C), Cirrhosis, Primary sclerosing cholangitis, and Genetic conditions
What are the contraindications for liver transplant?
Systemic disease (cancer), Uncontrolled extrahepatic bacterial or fungal infection, Advanced cardio or pulmonary disease, and Active alcoholism or drug abuse
What are the potential complications of liver transplant?
Infection, Rejection, Hemorrhage
Liver transplant patients are discharged within _____.
1 week
Liver transplant patients can resume normal life within _____.
3-4 months
Liver transplant survival rate is greater than ______% with close follow up and medication compliance.
85%
What should the nurse do post-liver transplant?
Monitor for signs of rejection and infection, Continue immuno-suppressive therapy (might be for life), Monitor labs, assess for Volume Overload, Monitor wound drains and bile drains, and Assess needs of family and significant others
What are the exocrine functions of the pancreas?
secretion of pancreatic enzymes
What are the endocrine functions of the pancreas?
secretion of insulin, glucagon, and somatostatin
What enzymes does the pancreas secrete that are essential in breaking down nutrients?
amylase, lipase, trypsin, chrymotripsin
What is ordered to best view the pancreas?
a spiral CT
Inflammation of the pancreas resulting in premature release of pancreatic enzymes causing auto-digestion of the pancreatic tissues
pancreatitis
In pancreatitis, usually enzymes are released into the __________ which is extremely painful.
small bowel
fat necrosis caused by premature release of lipase
Lipolysis
edema, necrosis & gangrene of the pancreas due to premature release of trypsin
Proteolysis
in pancreatitis, this is caused by release of elastase which dissolves fibers in blood vessels causing the patient to hemorrhage
Necrosis of the blood vessels
Early release of pancreatic causes what 4 pathologic conditions?
lipolysis, proteolysis, necrosis of blood vessels and profuse inflammation
What is the #1 cause of pancreatitis?
alcohol
What can cause pancreatitis?
alcohol, gallstones, opiates, sulfa drugs, birth control, and bacterial or viral infections
Discoloration around umbilicus (blue/gray color) in pancreatitis
Cullen’s sign
Discoloration on the flanks in pancreatitis
Turner’s sign
What position helps with the pain of pancreatits?
fetal position
What makes pancreatitis pain much worse?
eating
Pancreatitis pain is described as ______ and _______.
intense and radiating to the back
What are the symptoms of pancreatitis?
abdominal pain, N/V, diaphoresis, weakness, tachycardia, and steatorrhea
What are Ranson’s Criteria upon admission?
age > 55, WBC > 16,000, glucose > 200, LDH > 350, and AST > 250
What are Ranson’s Criteria 48 hours post-admission?
hematocrit decreased > 10%, fluid sequestreation > 6 L, hypocalcemia (Ca+ 5 after IV fluids, and base deficit > 4 mmol/L
Ranson’s Criteria score of 0 - 2 means _____% mortality.
2%
Ranson’s Criteria score of 3 - 4 means _____% mortality.
15%
Ranson’s Criteria score of 5 -6 means _____% mortality.
40%
Ranson’s Criteria score of 7 - 8 means _____% mortality.
100%
What are the systemic complications of pancreatitis?
massive hemorrhage (hypovolemic shock), pulmonary complications, and renal complications (acute renal failure)
What is the most definitive lab test for pancreatitis?
lipase
Normal Lipase Level
1 - 160
Pancreatitis Lipase Level
6,000 - 7,000
Normal Amylase Level
30 - 220
In pancreatitis, bilirubin is _______.
elevated
In pancreatitis, a CBC will show signs of _______.
bleeding
How is pain controlled in pancreatitis?
opiods (Dilaudid or Morphine) and Anticholinergics (dicyclomine)
How will pancreatitis patient receive nutrition?
J tube, feeding tube that bypasses the pancreas, or TPN
What does dicyclomine do in pancreatitis?
decreases vagal stimulation, motility and pancreatic flow
When is dicyclomine contraindicated?
in patients with a paralytic ileus
What should be checked prior to administration of dicyclomine?
bowel sounds
drugs that decrease gastric secretions given to patients with pancreatitis
Octreotides, H2 blockers and PPI’s
As pancreatitis patient begins to eat again, what diet should they follow?
bland food, moderate to high carb, high protein, low fat, no caffeine or alcohol
Chronic Calcifying Pancreatitis (CCP) is caused by _______.
alcoholism
Chronic Obstructive Pancreatitis is caused by ________.
gallstones
The key symptom in chronic panreatitis is _________.
abdominal pain
In chronic panreatitis, there may be a palpable mass in the ____.
LUQ
Chronic pancreatitis can cause possible manifestations of __________.
diabetes
What general symptoms can Chronic pancreatitis cause?
Weight loss, muscle wasting, and ascites
What GI symptoms can Chronic pancreatitis cause?
Nausea/Vomiting, Diarrhea, Steatorrhea
In chronic panreatitis, stool will be ______ colored and urine will be _______ colored.
clay; tea
What is the definitive test for In chronic panreatitis?
biopsy done through ERCP
What diagnostic tests are done for chronic panreatitis?
CT, MRCP, labs (lipase and amylase), and biopsy
What is the dietary management for pancreatitis?
low fat diet
What are the surgical management options for chronic panreatitis?
Roux-en-Y or Celiac plexus nerve block (pain control)
What can be given for pain control of chronic panreatitis?
NSAIDS, Tricyclics, and Opioids (must go to pain managment)
enzyme replacement that contains lipase, amylase and protease to aid in digestion of fats, proteins and starches
Pancrelipase
What is the dose of Pancrelipase?
oral 4,000 to 50,000 Units with each meal and snacks
everytime they eat
What are the adverse effects of Pancrelipase?
nausea, abdominal cramping, diarrhea (in large doses)
Pancreatic enzymes are made from ________.
pork
Pancreatic enzymes cannot be mixed with __________.
protein-containing foods
Pancreatic enzymes cannot be _______ or ________.
chewed
Do not _______ the Pancreatic enzyme capsule as it could cause asthma exacerbations.
open
When taking Pancreatic enzymes, avoid contact with the _____.
lips
What is the first sign that Pancreatic enzymes are working?
decrease in frequency of stools
condition of the pancreas in which an abscess arises from necrotic tissue that is bacterial in nature and can erode into surrounding tissue
pancreatic abscess
pancreatic abscess has a _____% mortality rate.
60%
What are the risk factors for pancreatic cancer?
People older than 60, History of smoking, Chronic pancreatitis, Diabetes mellitus, Cirrhosis, High intake of red meat ** Study released 1/13/12, Long term exposure to chemicals, Obesity, African American, Heavy alcohol use, Male gender, family history
What is the usual first sign of pancreatic cancer?
painless jaundice
What are the symptoms of pancreatic cancer?
Dull discomfort in RUQ, Fatigue, Rapid Weight loss, Nonspecific GI disturbances, Clay colored stool
How is pancreatic cancer diagnosed?
CEA and CA19-9 (tumor markers), spiral CT, ultrasound, ERCP w/ biopsy
What is the most useful test for pancreatic cancer?
spiral CT
What is the most definitive test for pancreatic cancer?
ERCP w/ biopsy
What is the treatment for pancreatic cancer?
palliative, internal or external radiation, chemotherapy (5-Fluorouracil (5-FU) and Gemcitabine)
What medication is given for pancreatic cancer symptoms?
Morphine, Hydromorphone, Fentanyl
What is surgical treatment is used to remove small pancreatic tumors?
Partial pancreatecotomy
What is a Radical pancreaticoduodenectomy?
Whipple procedure
What are the potential complications of the Whipple procedure?
Cardiovascular- MI, hemorrhage, heart failure, thrombophlebitis, Pulmonary- atelectasis, pneumonia, PE, ARDS, pulmonary edema, GI- paralytic ileus, gastric retention, bowel obstruction, pancreatitis, hepatic failure, thrombosis, Wound- infection, dehiscence, fistulas, Metabolic- diabetes, renal failure
After pancreatic surgery, how is pain controlled?
PCA pump
What position should the pancreatic surgery patient be placed after surgery?
Semi-fowlers
GI drainage from a wound should be _________.
sero-sanginous
Immediately report GI drainage fluid that appears _______, ________, ________, or ________.
Clear, Colorless, Bile-tinged, Bloody (bright red)
After pancreatic surgery, the nurse should monitor what levels?
fluid/ electrolytes, protein, albumin, and blood glucose
Protein and albumin losses after pancreatic surgery occur due to_________, _________, or __________.
blood loss, NGT, or drainage tubes
