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Adult nursing II > Biliary, Exocrine & Hepatic Disorders (Day 2) > Flashcards

Biliary, Exocrine & Hepatic Disorders (Day 2) Flashcards

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1
Q

Hepatitis: Inflammation of the Liver

A

Causes:
Viral (most common)
Alcohol
Medications
Chemicals
Autoimmune diseases
Metabolic problems

Widespread inflammation
Acute infection:
Lysis/necrosis of infected hepatocytes
Proliferation & enlargement of Kupffer cells

Cholestasis: Inflammation of peri-portal areas interrupt bile flow

Liver cells can regenerate
Systemic Side-effects
Rash
Angioedema
Arthritis
Fever, Malaise

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2
Q

Hepatitis A Virus (HAV)

A

RNA virus
Transmission: Fecal-oral route; Contaminated food or drinking water
Increased risk: Illicit drug users, MSM, travel to developing countries
Mild to acute liver failure; Not chronic
Incidence decreased with vaccination
Acute onset; Mild, flu-like symptoms
Frequently occurs in small outbreaks
Prevention: Hepatitis A Vaccine & Handwashing

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3
Q

Hepatitis B Virus (HBV)

A

DNA virus
Transmission: Perinatal, percutaneous, small cuts on mucosal surface, exposure to infectious blood, blood products, or other body fluids
Increased risk: MSM, contact with chronically infected, hemodialysis health care & public safety workers, IV drug users, blood product transfusion
Acute or chronic; 30% asymptomatic
Incidence decreased with vaccination
Prevention: HBV Vaccine (Recommended for all, routine for children)
3 IM Deltoid injections
0, 1 & 6 months

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4
Q

Hepatitis C (HCV)

A

RNA virus
Transmission: Percutaneous
Increased risk; IV drug use, high-risk sexual behavior, occupational exposure, perinatal exposure, blood transfusions before 1992
Acute HCV 80% asymptomatic
Highly persistent
Can lead to chronic liver damage

Prevention: Personal protection similar to HBV
No vaccine

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5
Q

Health Promotion
Hep A

A

Hepatitis A
Personal & environmental hygiene
HAV Vaccine
1-year of age
Adults at risk
Post-exposure prophylaxis:
HAV vaccine
Immune globulin (IG)
Special precautions for health care personnel

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6
Q

Health Promotion
Hep B

A

Hepatitis B
General measures
Vaccines
Recombivax HB
Engerix-B
3 IM injections
All children
At-risk adults
Post-exposure prophylaxis:
Vaccine
Hepatitis B immune globulin (HBIG)

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7
Q

Health Promotion
Hep C

A

Hepatitis C
No vaccine
General measures
Screen those born between 1945 -1965
No post-exposure prophylaxis
Baseline & follow-up testing

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8
Q

Pathophysiology
Hep

A

Acute infection
Many hepatocytes destroyed
Liver cells can regenerate normally after infection
Chronic infection
Can cause fibrosis
Progress to cirrhosis
Antigen-antibody complexes activate complement system
Many asymptomatic; Symptoms intermittent or ongoing
Anorexia
Malaise, fatigue, lethargy
Myalgia, arthralgia
Right upper quadrant tenderness

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9
Q

Pre-icteric Phase (1 - 21 days)Period of Maximal Infectivity for HAV

A

Acute phase
Maximal infectivity
Symptoms during incubation
Nausea, vomiting
RUQ tenderness
Reduced sense of smell
May find food repugnant
Distaste for cigarettes

Anorexia
Constipation
Diarrhea
Malaise
Headache
Low-grade fever
Arthralgia
Skin rashes

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10
Q

Icteric Phase (Jaundice & Pruritis)1 – 6 months

A

Not all patients will have jaundice (Anicteric Hepatitis)
Acute phase
Hepatomegaly
Lymphadenopathy
Splenomegaly
With jaundice, patient can also have
Dark urine
Light or clay-colored stools
Pruritus

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11
Q

Jaundice

A

Symptom
Alteration of bilirubin metabolism
Flow of bile into hepatic-biliary systems
Bilirubin approximately 3x normal
Hemolytic
Hepatocellular
Obstructive

Yellow sclera
Yellow-orange skin
Clay-colored feces
Tea-colored urine
Pruritis
Fatigue
Anorexia

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12
Q

Post-Icteric (Convalescence) Phase

A

Begins as jaundice disappears
Lasts weeks to months (Average 2 – 4 months)
Major problems
Malaise
Easy fatigability
Hepatomegaly persists
Splenomegaly subsides

Most patients recover completely with no complications
Most cases of acute HAV resolve
Some HBV & most HCV result in chronic hepatitis

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13
Q

Complications
Hep

A

Acute Liver Failure
Encephalopathy d/t livers inability to remove toxins – especially Ammonia
Potentially life-threatening spectrum of neurologic, psychiatric, & motor disturbances
GI bleeding
Fever with leukocytosis
Renal manifestations
Liver transplant usually the cure
Portal Hypertension
Liver Cancer

Chronic Hepatitis
Some HBV, most HCV
Chronic HBV more likely in infants & those < 5 YO
< 50% immunocompromised adults with HBV progress to chronic infection

Cirrhosis
Male sex
Alcohol use
Fatty liver disease
Excess iron in liver

Ascites; Accumulation of fluid in peritoneum d/t reduced protein in blood (reduces plasma oncotic pressure)

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14
Q

Hepatitis: Diagnostic Studies

A

Specific antigen / antibody for each type of hepatitis
Liver function tests
Viral genotype testing
Physical assessment findings
Liver biopsy
FibroScan
FibroSure (FibroTest)

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15
Q

Hepatitis: Collaborative Care

A

Overall goals:
Relief of discomfort
Return to normal activities
Return of normal liver function without complications

Expected outcomes:
Adequate nutritional intake
Increased activity tolerance
Able to “Teach back”
Follow-up care
Methods of transmission & prevention

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16
Q

HAV: Collaborative Care

A

No specific treatment
Most managed at home
Symptom management
Promethazine (Phenergan)
Ondansetron (Zofran)
Diphenhydramine (Benadryl)
Rest
Assess degree of jaundice
Follow-up for at least 1-year

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17
Q

HBV & HCV: Collaborative Care

A

Medications for HBV:
LT treatment with Nucleoside / Nucleotide analogs; Inhibit DNA replication & decrease viral load
Lamivudine (Epivir)
Adefovir (Hepsera)
Used in higher doses to treat HIV

Interferon; Anti-viral, anti-proliferative, immune-modulating
SQ injection
Side effects make adherence challenging
Use limited d/t better tolerated, more effective treatments

Medications for HCV:

Ledipasvir 90 mg / Sofosbuvir 400 mg (Harvoni)
1 tablet, once / day

Clinical studies of HARVONI demonstrated cure in 96 – 99% adults with HCV
Genotype1 & no prior treatment
12-weeks of therapy

Provider determines length of treatment

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18
Q

Nutritional Therapy
Hep

A

No special diet needed; Emphasis on well-balanced diet patient can tolerate
Adequate calories (2500 – 3000 / day) important during acute phase
Frequent small meals
Anorexia worse during day; Concentrate efforts to take in calories at breakfast
Fatty foods may need to be reduced to decrease nausea

Vitamins B-complex & K

IV glucose or enteral nutrition

Protein 75 – 100 g/day; Decreased with encephalopathy to prevent ammonia build-up

Restrict sodium / fluids with edema

Thiazide diuretics; Increase food sources with K+

Avoid alcohol

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19
Q

Cholelithiasis (Gallstones)

A

10% Americans; More common in women
Multi-parous (gave live birth) & > 40-years old
Native American (Navajo & Pima)
Familial tendency
Obesity
Other risk factors:
Estrogen therapy
Sedentary lifestyle

20
Q

Cholelithiasis: Clinical Manifestations

A

Pain: Upper midline, radiating to:
Back
Right shoulder
Sub-sternal

Cholecystitis: Block cystic duct

Cholangitis: Block common duct

Inflammation & Pancreatitis
Jaundice = obstruction

Differential Dx:
Pain of CAD / Angina

21
Q

Cholecystitis: Etiology & Pathophysiology

A

Most often associated with obstruction from stones or sludge

Inflammation confined to mucous lining or entire wall

Gallbladder is edematous & hyperemic

May be distended with bile or pus

Cystic duct may become occluded

Scarring & fibrosis after attack

Acalculous Cholecystitis:
Older adults & critically ill

Prolonged immobility, fasting, prolonged parenteral nutrition, diabetes

Biliary stasis

Adhesions, cancer, anesthesia, opioids

22
Q

Cholelithiasis/Cholecystitis: Clinical Manifestations

A

Severe to none at all
Pain increased when stones move or obstruct
Steady, excruciating
Tachycardia, diaphoresis
RUQ; Referred to right shoulder, scapula
3 - 6 hours after high-fat meal or when supine

With total obstruction:
Dark amber urine
Clay-colored stools, Steatorrhea
Pruritis
Intolerance to fatty foods
Bleeding tendencies

In addition to pain
Indigestion
Fever, chills
Jaundice
Nausea/vomiting
Restlessness

Inflammation
Leukocytosis
Fever

Physical examination findings
RUQ or epigastrium tenderness
Abdominal rigidity

23
Q

Diagnostic Studies
Cholelithiasis/Cholecystitis

A

Increased WBC
Increased serum bilirubin
Increased urinary bilirubin
Increased liver enzymes
Increased serum amylase
Ultrasound
ERCP
Percutaneous transhepatic cholangiography

Complications of Cholecystitis
Gangrenous cholecystitis
Subphrenic abscess
Pancreatitis
Cholangitis
Biliary cirrhosis
Fistulas
Gallbladder rupture leads to peritonitis
Choledocholithiasis

24
Q

Collaborative Care
Cholelithiasis/Cholecystitis

A

Analgesics
Anti-cholingergics (Atropine; Anti-spasmotic)
Fat soluble vitamins
Bile salts
H2 Blockers or PPI’s
Anti-emetics
Anti-biotics
Cholestyramine (Questran)
Bile salt binder
Treats pruritis, loose stools

NPO – Advance as tolerated

IV fluids

NG to LIS

ERCP

Extracorporeal shock wave lithotripsy (ESWL)

25
Q

Cholecystectomy

A

Excision of gall bladder from posterior liver wall
Ligation of cystic duct, vein & artery
T-tube ensures adequate bile drainage during duct healing (with Open procedure)

Laparoscopic
Contra-indicated with stones in common bile duct

26
Q

Laparoscopic Cholecystectomy

A

Monitor for complications & provide analgesia
Referred pain to shoulder pain from CO2
Sims’ position
Deep breathing, ambulation
Clear liquids 1st day; Light meals for a few days

Discharged same day
Remove bandages POD#1 and can shower
Report signs of infection
Gradually resume activities; Return to work in 1 week

Patient teaching
Teach what to report & Follow-up care
May need low-fat diet for several weeks
Weight reduction if needed
Fat-soluble vitamin supplements

27
Q

Open-incision Cholecystectomy

A

Maintain adequate ventilation, prevent pulmonary complications
General postoperative nursing care
Maintain drainage tubes (T-tube, Penrose, or J-P)
Replace lost fluids and electrolytes
CL, the ADAT once bowel sounds have returned

Patient Teaching:
No heavy lifting for 4 - 6 weeks
Usual activities when feeling ready
May need low-fat diet for 4 - 6 weeks
Weight reduction if needed
Fat-soluble vitamin supplements
What to report & Follow-up care

28
Q

T-Tube

A

Inserted into Common Bile Duct during Open Cholecystectomy; Drains bile while duct heals & small intestine adjusts

29
Q

ERCP with Sphincterotomy

A

Endoscope passed to duodenum then retrograde up into duct
Visualization & dilation
Placement of stents
Open sphincter of Oddi, if needed
Stones removed with basket or allowed to pass in stool

Extracorporeal shock-wave lithotripsy (ESWL)
If stones cannot be removed via endoscope
High-energy shock waves disintegrate gallstones
Takes 1 - 2 hours
Used in conjunction with bile acids

30
Q

Medications for Gallstones

A

Oral dissolution therapy
Ursodeozycholic acid (Ursodiol or Actigal)
300 mg tablets; 600 mg / day; 300 mg two times/day
Therapy takes average of 1-3 months; up to 12 months (https://www.rxlist.com/actigall-drug.htm#description)

Bile Acid Sequestrants; Given for pruritus or loose stools
Colestipol (Colestid): 2000 mg tablets PO 1 – 2 times/day
Cholestyramine (Questran) 4 to 8 grams 1 – 2 times/day (Max 24-grams/day)
Powder, mixed with milk or juice
Monitor N/V, diarrhea or constipation, skin reactions
Check drug-to-drug interactions

31
Q

Trans-hepatic Biliary Catheter

A

Preoperative or palliative
When endoscopic drainage fails
Inserted percutaneously and attached to drainage bag
Replace fluids lost with electrolyte-rich drinks
Skin care important

32
Q

Cirrhosis

A

End-stage of liver disease; Extensive degeneration & destruction of liver cells
Replacement of liver tissue by fibrous & regenerative nodules
Chronic, progressive; Usually happens after decades of chronic liver disease
Alcoholic (Laennec’s)
Chronic HCV
Post-necrotic
Macro-nodular
Toxin-induced
Biliary and/or Cardiac

Portal Vein Hypertension
Bleeding varices
Ascites
Increased ammonia (encephalopathy)
Incomplete clearing of protein waste

Jaundice

Skin Lesions; Increase in circulating estrogen d/t inability of liver to metabolize steroid hormones
Spider angiomas (telangiectasia or spider nevi)
Palmar erythema

33
Q

Cirrhosis: Other Complications

A

Peripheral neuropathy
Common in alcoholic cirrhosis
Dietary deficiencies of thiamine, folic acid, & cobalamin
Sensory & motor symptoms

Hepato-renal syndrome
Renal failure with azotemia, oliguria, and intractable ascites
No structural abnormality of kidneys
Portal hypertension leads to vasodilation which leads to renal vasoconstriction
Treat with liver transplantation

34
Q

Hepatic Encephalopathy

A

Hepatic encephalopathy (Neurotoxic effects of ammonia); Liver unable to convert increased ammonia to urea, Ammonia crosses blood-brain barrier

Changes in neurologic and mental responsiveness
Impaired consciousness
Inappropriate behavior
Sleep disturbances, trouble concentrating, coma
Asterixis
Flapping tremors; Most common in arms & hands
Impairment in writing; Difficulty in moving pen left to right
Fetor hepaticus
Musty, sweet odor of patient’s breath

35
Q

Diagnostic Tests for Cirrhosis

A

Liver enzyme tests
(Alkaline phosphatase, AST, ALT, GGT)
Total protein, albumin levels
Serum bilirubin, globulin levels
Cholesterol levels
Prothrombin time
Ultrasound elastography (Fibroscan)
Liver biopsy

36
Q

Cirrhosis: General Nursing Management

A

Assess response to altered body image
Supportive listening

Rest
Prevent complications
Modify schedule

Minimize or avoid:
ASA
Acetaminophen
NSAIDs

Monitor color of urine & stools
Daily weights, accurate I & O
Extremities measurement
Abdominal girth
Monitor for fluid & electrolyte imbalances
Hypokalemia
Water excess (hyponatremia)
Observe for bleeding tendencies

37
Q

Cirrhosis: Nutritional Therapy

A

Diet for patient without complications
High Carb / Calorie (3000 cal/day)
Moderate to low fat
Protein restriction rarely needed
Oral hygiene
Between-meal snacks
Offer preferred foods
Explanation of dietary restrictions

Seasonings to make food more palatable
Administration of B-complex vitamins
Avoidance of alcohol
Protein supplements for protein-calorie malnutrition
Low-sodium diet for patient with ascites & edema
Dietitian referral / consult

38
Q

Nursing Interventions for Jaundice / Pruritus

A

Assess for jaundice
Measures to relieve pruritus
Cholestyramine or hydroxyzine
Baking soda or Alpha Keri baths
Lotions, soft or old linen
Antihistamines
Temperature control
Short, clean nails; Scratch with knuckles rather than nails
Control of temperature

39
Q

Management of Esophageal & Gastric Varices

A

Prevent bleeding/hemorrhage
Avoid alcohol, aspirin, & NSAIDs
Screen for with endoscopy
Nonselective β-blocker

If bleeding occurs, stabilize patient, manage airway, start IV therapy & blood products

Drug therapy
Octreotide
Vasopressin

Support for acute bleed
FFP, PRBCs
Vitamin K
PPI’s
Lactulose (Cephulac) & Rifaximin (Xifaxan)
Antibiotics

Sclerotherapy

Balloon tamponade; Mechanical compression (Scissors at bedside)
Sengstaken-Blakemore tube
Minnesota tube
Linton-Nachlas tube

LT Management
Nonselective Beta-blockers
Repeated band ligation

40
Q

Portosystemic Shunts

A

Shunting Procedures
Done more after second major bleeding episode

Nonsurgical: Transjugular Intrahepatic Portosystemic shunt (TIPS)

Surgical: Portacaval or Distal Splenorenal shunt

41
Q

Interventions for Ascites

A

Relief of dyspnea
Semi- or high Fowler’s position

Skin care
Special mattress
Turning schedule, at least every 2 hours

ROM exercises

Coughing/deep breathing exercises

Elevate lower extremities (and scrotum PRN)

Sodium restriction
Diuretics, fluid removal
Albumin
Tolvaptan (Samsca)
Paracentesis
Transjugular intrahepatic portosystemic shunt (TIPS)
Peritoneovenous shunt
Rarely used
High rate of complications

42
Q

Assisting with Paracentesis

A

Have patient void immediately before
High Fowler’s position or sitting on side of bed
Monitor for hypovolemia & electrolyte imbalances
Monitor BP & heart rate
Monitor dressing for bleeding/leakage

43
Q

Management of Hepatic Encephalopathy

A

Treatment of precipitating cause
Control factors known to precipitate encephalopathy
Lower dietary protein intake
Control GI bleeding & remove blood from GI tract

Maintain safe environment; Assess:
LOC & neuro status every 2-hours
Sensory & motor abnormalities; Prevent falls & injuries
Fluid & electrolyte imbalances; Acid-base imbalances
Response to treatment measures

Reduce ammonia formation
Lactulose (Cephulac), traps ammonia in gut, expelled with stool
Rifaximin (Xifaxan) antibiotic
Prevent / minimize constipation
Encourage fluids

44
Q

Patient Self-Management / Ambulatory Care

A

Supportive measures:

Rest, Maintain adequate nutrition; Proper diet
Reduce or eliminate risk factors
Abstinence from alcohol and/or treat alcoholism
Bariatric surgery for morbidly obese
Avoiding potentially hepatotoxic OTC drugs

Community support programs

Patient education re: symptoms of complications & when to seek medical attention

Written instructions with adequate explanations for patient/family

Referral to community or home health nurse

45
Q

Hepatic Cancer

A

Primary (Benign or Malignant):
Can originate from hepatocytes, connective tissue, blood vessels, bile ducts

Benign: 90% are women taking BCP’s
Metastatic:
GI tract (Colon), breasts, lungs
Resection only method of cure & only if confined to one lobe

Poor prognosis; 6 - 12 months
Most common d/t hepatic encephalopathy or blood loss from GI bleeding

Adult nursing II (7 decks)

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