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NURS 425 > Exam #1 Study Guide: GI Bleed And Acute Liver Failure/Liver Transplant > Flashcards

Exam #1 Study Guide: GI Bleed And Acute Liver Failure/Liver Transplant Flashcards

1
Q

Acute GI Hemorrhage

A
  • Bleeding in the upper or lower GI tract

- Medical emergency -> potentially life threatening

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2
Q

Acute GI Hemorrhage: Common Causes

A
  • Peptic Ulcer Disease
  • Stress-related mucosal disease (SRMD)
  • Esophagogastric varices
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3
Q

Peptic Ulcer Disease

A

Protective mechanisms cease to function and allow gastroduodenal mucosal breakdown.

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4
Q

Stress-related mucosal disease (SRMD)

A

Increased acid production and decreased mucosal blood flow

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5
Q

Esophagogastric varices

A

Portal hypertension

*Need more info, especially pathophysiology

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6
Q

Acute GI Hemorrhage: Pathophysiology

A

Acute massive bleeding -> hypovolemic shock -> multiple organ dysfunction syndrome

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7
Q

Why does a liver failure patient have hypovolemia?**

A

Liver can’t synthesize aldosterone and break it down. (You hold on to aldosterone -> Na retention -> water retention)

*Listen to recording on 5/15

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8
Q

Acute GI Hemorrhage: Clinical presentation

A
  • Hematemesis

- Hematochezia and Melena ?

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9
Q

Acute GI Hemorrhage: Lab Studies

A
  • Hemoglobin and hematocrit are poor indicators of severity of blood loss if bleeding is acute.
  • Platelet count and prothrombin time
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10
Q

Acute GI Hemorrhage: Diagnostic Procedures

A
  • Urgent endoscopy
  • Tagged RBC scan
  • Angiogram (not done as often, often use scopes)
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11
Q

Acute GI Hemorrhage: Medical Management

A
  1. Stabilize
  2. Control the bleed
  3. Surgical intervention
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12
Q

Acute GI Hemorrhage Management: Stabilization

A
  1. Restoration of adequate circulating blood volume: Administer crystalloids, blood and blood products
  2. Supplemental Oxygen Therapy: Intubation (d/t decrease in RBC’s = decreased oxygen carrying ability)
  3. Insertion of nasogastric tube: to confirm diagnosis and prepare site for endoscopic evaluation.
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13
Q

Acute GI Hemorrhage: Controlling the Bleeding for Peptic Ulcer Disease

A
  • Endoscopic injection therapy (inject medicine that causes vasoconstriction i.e epinephrine)
  • Endoscopic thermal therapy (with endoscope, burn the area)
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14
Q

Acute GI Hemorrhage Medical Management: Controlling the bleeding for stress-related mucosal disease

A
  • Intraarterial infusion of vasopressin

- Intraarterial embolization

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15
Q

Acute GI Hemorrhage Medical Management: Controlling the bleeding for Esophageal Varices

A
  • Intravenous vasopressin, somatostatin, or octreotide
  • Endoscopic variceal ligation
  • Transjugular intrahepatic portosystemic shunting (TIPS)
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16
Q

Acute GI Hemorrhage Medical Management: Surgical Intervention for PUD

A

Vagotomy (cuts vagal nerve = decrease in gastric acid production) and pyloroplasty

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17
Q

Acute GI Hemorrhage Medical Management: Surgical Intervention for stress ulcers

A
  • Total Gastrectomy

- Oversew of ulcers

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18
Q

Acute GI Hemorrhage Medical Management: Surgical Intervention for Esophageal Varices

A
  • Portacaval shunt
  • Mesocaval shunt
  • Splenorenal shunt (increases perfusion to the kidneys)

*Not going to be tested on shunt, but understand why its done

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19
Q

Acute GI Hemorrhage Nursing Management: Nursing priorities are directed toward

A
  1. Administering volume replacement
  2. Controlling the bleeding
  3. Providing comfort and emotional support
  4. Maintaining surveillance for complications such as hypovolemic shock and gastric perforation
  5. Educating the patient and family (how to prevent it in the future, treatment, what to look for)
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20
Q

Acute GI Hemorrhage Patient Education includes

A
  • Specific cause
  • Precipitating factor modification
  • Interventions to reduce further bleeding episodes
  • Importance of taking medications
  • Lifestyle changes
  • Stress management
  • Diet modifications
  • Alcohol and smoking cessation
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21
Q

Acute Liver Failure is characterized by:

A
  • Severe acute liver cell dysfunction
  • Coagulopathy
  • Hepatic encephalopathy
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22
Q

What is the definitive treatment for liver failure?

A

Liver transplantation is the definitive treatment

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23
Q

Acute Liver Failure Etiology

A
  • Infections
  • Drugs
  • Toxins (i.e wild mushrooms)
  • Hypoperfusion
  • Metabolic disorders
  • Surgery
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24
Q

Acute Liver Failure Pathophysiology: Occurs over

A

1-3 weeks

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25
Q

Acute Liver Failure Pathophysiology: Hepatic Encephalopathy occurs

A

Within 8 weeks.

Usually less than 2 weeks between liver failure and onset of encephalopathy

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26
Q

Acute Liver Failure Pathophysiology

A
  1. Hepatic encephalopathy occurs.
  2. Massive necrosis of hepatocytes.
    a. Impaired bilirubin conjugation (results in jaundice (a later sign))
    b. Decreased clotting factor production (results in bleeding)
    c. Depressed glucose synthesis (results in hypoglycemia)
    d. Decreased lactate clearance (results in metabolic acidosis)
    e. Many more *look up
27
Q

Acute Liver Failure: It is important to differentiate

A

Compensating versus decompensating chronic liver disease. (Does so by looking at previous liver function studies and comparing them to current liver function studies. Also by looking at symptoms present.)

28
Q

Acute Liver Failure: Signs and Symptoms

A
  • Headache (secondary to lactic acid build up in the brain, Hepatic Encephalopathy)
  • Hyperventilation (because they are acidodic, also d/t ascites which makes it harder to breathe)
  • Jaundice
  • Mental status changes (r/t hepatic encephalopathy caused by ammonia)
  • Palmer erythema (d/t inability to breakdown estrogen)
  • Spider nevi, bruises (d/t Low clotting factors)
  • Edema
  • Asterixis, or “liver flaps”
29
Q

Acute Liver Failure: Laboratory Studies **

A
  • Elevated serum bilirubin
  • Elevated aspartate aminotransferase (AST)
  • Elevated alkaline phosphatase
  • Elevated serum ammonia
  • Decreased serum albumin
  • Elevated coagulation studies (PTT)
  • Decreased platelet count
30
Q

Acute Liver Failure: Staging of Hepatic Encephalopathy ** (Need to know how to stage on exam)

A
  1. Euphoria or depression, mild confusion, slurred speech, disordered sleep rhythm; slight asterixis and normal EEG
  2. Lethargy, moderate confusion; marked asterixis and abnormal EEG
  3. Marked confusion, incoherent speech, sleeping but arousable; asterixis present and abnormal EEG
  4. Coma; initially responsive to noxious stimuli, later unresponsive; asterixis absent and abnormal EEG
31
Q

Acute Liver Failure: Medical Management

A
  1. Remove or decrease nitrogenous waste in large intestine (neomycin, lactulose)
  2. Prevent complications such as stress ulcers, metabolic disturbances (get ammonia level down and infection.
32
Q

Acute Liver Failure Medical Management: Treat acute bleeding

A
  • Vitamin K
  • Fresh frozen plasma (FFP)
  • Coagulation factor replacement
  • Blood transfusions
  • Platelets
33
Q

Acute Liver Failure: Multisystem organ involvement

A
  • Brain: cerebral edema
  • Kidneys: renal failure
  • Lungs: respiratory failure (d/t hyper/hypoventilation; can do paracentesis when patient is in respiratory distress)
  • CV: hemodynamics instability
34
Q

Acute Liver Failure: Nursing Management is directed toward

A
  • Protecting the patient from injury
  • Providing comfort and emotional support
  • Maintaining surveillance for complications (bleeding, Hepatic Encephalopathy)
  • Educating the patient and family
35
Q

Acute Liver Failure: Patient Education Includes

A
  • Specific cause
  • Precipitating factor modification
  • Interventions to reduce further episodes
  • Importance of taking medications
  • Lifestyle changes
  • Diet modification (lower protein diet)
  • Alcohol cessation
36
Q

GI Intubation: Nasogastric Suction Tubes are used to

A
  • Remove fluid regurgitated into the stomach
  • Prevent accumulation of swallowed air
  • Facilitate decompression of the bowel
  • Reduce risk for aspiration
37
Q

GI Intubation: Long intestinal tubes (Miller Abbot) are used to

A

Treat intestinal obstruction

38
Q

GI Intubation: Feeding tubes (dobhoff tube) are used to

A

Administer enteral feeding

Can give medication through it as well.

39
Q

Esophagastric Balloon Tampoonade Tube

A
  • Suction

* Check for more?

40
Q

Endoscopic Injection Therapy

A

Controls bleeding of varices and ulcers

41
Q

Complications of Endoscopic Injection Therapy

A
  • Esophageal perforation
  • Extravasation of the injective agent
  • Strictures of the esophagus
42
Q

Endoscopic Injection Therapy is contrainidcated in

A

Severe coagulopathies

43
Q

Endoscopic Variceal Ligation

A
  • Application of bands or metal clips around varices

- Induces venous obstruction and controls bleeding

44
Q

Complications of Endoscopic Variceal Ligation

A

Superficial mucosal ulcers

45
Q

Transjugular Intrahepatic Portosystemic Shunt (TIPS) (Don’t need to worry about)

A
  • Interventional radiology procedure
  • Decreases portal hypertension
  • Stent placed in liver parenchyma to connect portal vein and hepatic vein
46
Q

TIPS Complications

A

Bleeding
Hepatic or portal vein laceration
Inadvertent puncture of surrounding organs

47
Q

Liver Transplantation: Indication and selection

A

Considered for patient who suffers from irreversible acute or chronic liver disease that is progressive and has no therapy for established effectiveness

48
Q

Liver Transplantation: Contraindications

A
  • Not likely to survive major surgery
  • Patients who will not survive the effects of long-term immunosuppression
  • Disease is likely to recur quickly and fatally
  • Not willing to comply with long-term and sometimes difficult and demanding medical regimens
49
Q

Liver Transplantation: Recipient Evaluation

A
  • Determine the cause and severity of disease
  • Establish need for transplantation
  • Identify objective indications and contraindications
50
Q

Liver Transplantation: Pretransplant Phase

A

Is about preventing complications and getting them to the best level of health they can be we can until transplant

51
Q

Liver Transplant: Determining Donor Suitability

A

Rh match not HLA (human leukocyte antigen) match (for kidney not for liver TEST QUESTION)

52
Q

Liver Transplantation: Surgical Procedure (Not on test, just understand what is happening)

A
  • Recipient hepatectomy
  • Vascular anastomoses with a donor liver
  • Biliary anastomosis
53
Q

Liver Transplantation: Postoperative medical and nursing management immediate priorities include

A
  • Reestablishment of normal body temperature
  • Hemodynamic stabilization
  • Maintenance of adequate oxygenation and ventilation
54
Q

Liver Transplantation Post op: We look at

A
  1. Hemodynamics (BP, HR, UO)
  2. Pulmonary management
  3. Coagulopathy risk
  4. Neurological status
  5. Pain management
  6. Glucose control (want blood glucose ~150)
  7. Kidney function (UO at least 30cc/hr)
  8. Bile drains (monitor drains, suture lines)
55
Q

Liver Transplantation: Nutrition

A
  • They won’t be eating- so depend on when the physician think they will start to eat
  • They will have an NG tube, and stays in place until they are ready to eat, if they think it will take longer timethey won’t go more than 24hrs before giving them some type of nutrition
56
Q

Liver Transplantation: Liver Function Tests

A
  • Slowly decrease after 24hr, they might have a peak before they start to drop
  • After 24-48H, they go back up good indicator of liver rejection
57
Q

Liver Transplant graft nonfunction

58
Q

Liver Transplantation: Rejection Surveillance

59
Q

Liver Transplantation: Transfer out of critical care

A

Once off of the ventilator and awake will move to IMC to then be d/c from there.

60
Q

Liver Transplantation: Long-term follow up

61
Q

Liver Transplant: Pharmacological Agents

A
  • Antiulcer agents: H2-antagonists, Gastric PPIs, Gastric mucosal agents
  • Vasopressin
  • Somatostatin and Octreotide
62
Q

Vasopressin

A
  • Controls gastric ulcer and Variceal bleeding.

- Administered intraarterially or IV

63
Q

Somatostatin and Octreotide (does not care as much for these drugs)

A

Reduce splanchnic vasodilation and portal pressure

NURS 425 (19 decks)

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