exam 4 Flashcards
9 functions of liver
Bile formation and excretion
Metabolism of bilirubin (a by-product of breakdown of old RBCs)
Production of protein for blood plasma
(albumin) - albumin holds water in vascular space
Metabolism of carbohydrates, proteins, and fats
Conversion of ammonia to urea – ammonia
comes from breakdown of protein
Coagulation and anticoagulation
Metabolic detoxification
Metabolizing medications
Storage of minerals and vitamins
heptocytes
functional cell of the liver, secretes bile, performs metabolic functions
sinusoids
specialized vascular beds
lined with Kupffer cells
very permeable endothelium
kupffer cells
phagocytic
detoxify toxins
Produce vasoactive mediators
severity of alc withdrawal symptoms
are dose and time dependent
3 things that cause more serious alc withdrawal
Previous withdrawal, liver dysfunction, and other substance use
1st Q to ask when assessing alc withdrawal
when was the last drink
s/s of alc withdrawal and when do they start
- 4 early signs
- 5 moderate
- 5 severe
Symptoms: start 6-12 hours after last drink
Psychomotor agitation
Anxiety
Autonomic hyperactivity (tachycardia, sweating, HTN, fever) (EARLY SIGNS)
Increased hand tremor
Insomnia
Nausea or vomiting
hallucinations (severe)
Tonic-clonic seizures (severe)
delirium tremens(severe)
fluid, electrolyte imbalances (severe)
wernick-korsakoff syndrome (severe)
CIWA assessment cateogries 8
Nausea and vomiting
Tremor
Sweating
Anxiety
Agitation
Headache
Disorientation
Tactile, visual, and auditory disturbances
gold standard of tx for alc withdrawal
benzos (lorazepam)
how is blood supplied to the liver
most blood comes from GI tract via portal vein
who is at higher risk of seizures
people with previous hx of withdrawal
if pt having seizures, nurse should 4
implement seizure precautions ,
one-to-one observation,
monitor fluid and electrolyte status, and glucose monitoring.
when do hallucinations start to occur
12-24 hours
what 2 symptoms distinguish delirium tremens
disorientation and global confusion
nurse actions for alc withdrawal 4
Monitoring vital signs,
pulse oximetry
Assessment using the CIWA Scale q 4
Administration of (benzodiazepines) based on ciwa
how do benzos work
increases GABA = mimics depressive effects
therapeutic goal of benzo use
light somnolence (patient sleeps when not stimulated but is easily arousable).
Treatment of AWS Seizures, DTs and Refractory DTs vs AWS and what is goal
infusion of benzos + phenobarbital + BB
goal: reduce autonomic activity
wernickes encephalopathy
confusion, abnormal gait, and paralysis of eyes muscles caused by nutritional deficiency (especially thiamine (vitamin B1) deficiency) and NOT caused by AWS.
korsakoff syndrome
selective memory disturbances and amnesia that occurs commonly in AWS and with Wernicke’s encephalopathy.
how to treat wernicke korsakoff
thiamine for 3 days through IV infusion
how does nurse maintain and monitor fluid and electrolyte levels 9
what do electrolyte imbalances cause
weight
vital signs
I&O
BUN
creatinine
electrolytes (low K+, Mg, Phosp)
skin and mucous
edema
lung sounds
DYSRHYTHMIAS
all patients should have what consult
nutritonist
nurse action to counteract hypoglycemia
thiamine then IV glucose (cannot do glucose by itself)
most common cause of acute liver failure
alcohol
5 questions
to assess in overdose
1 question:Intent – is the ingestion intentional or unintentional? If an attempt to commit suicide, suicide precautions and a psychiatric consultation are indicated.
Dose
Pattern – single or repeated
Time of ingestion
Coingestants
labs to monitor in acetaminophen overdose 6
ABGS -ph
creatinine - bc renal damage
Pt/inr - rises 24-72 hours after ingestion
bilirubin
actaminophen levels
ASt/alt - greater than 1000 is toxicity
acetaminophen antidote
N-acetylcysteine (NAC)/Mucomyst
N-acetylcysteine (NAC)/Mucomyst
when to give
how to give
how it works
give 8-12 hours after ingestion to reduce hepatic injury
if alert and oriented can give orally
It limits formation/accumulation of toxic metabolite,
digoxin antidote
digibind
MgSo4 antidote
Ca gluconate
heparin antidote
protamine sulfate
warfarin(coumadin) antidote
Vit K
iron lead antidote
chelation
Lavage 3
insertion tube with Nacl
within 2-4 hours
Contraindicated in ingestion of caustic agents, sharp objects.
high priority in overdose is
AIRWAY
when to give activated charcoal
1 hour of ingestion
cirrhosis leads to
portal hypertension
-> ascites
ascites development
hypoalbuminemia -> leakage from plasma from the lymph -> Changes in capillary permeability and hydrostatic/oncotic pressure gradients
Release of nitric oxide causes vasodilation of the splenic artery, -> decreasing SVR and MAP, -> activating the renin-angiotensin-aldosterone (RASS holds onto water and salt), -> SNS and ADH causing water and sodium retention, the inability to excrete water causes dilutional hyponatremia, and renal blood flow is reduced resulting in hypoperfusion and decreased GFR.
8 assesments for ascites
For shifting dullness in the abdomen with percussion
For peripheral edema (often pitting in the legs and feet)
Daily weight and I&O
For difficulty breathing and lung sounds
Abdominal discomfort and pain
For skin breakdown and jaundice
Orthostatic vital signs
5 tx of ascites
alcohol abstinence
Sodium restriction of 2000 mg/day
Diuretic therapy
Fluid restriction
Paracentesis
nursing resp for paracentesis
BEFORE
(time-out),
reassure the patient,
maintain sterile field
monitor hemodynamic status,
infuse albumin to replace protein as ordered.
AFTER
monitor hemodynamics
assess for pain,
assess fluid withdrawn and process any specimens,
maintain I&O,
monitor dressing for leaking,
monitor for complications.
most serious complications of cirrhosis and portal hypertension.
bleeding varices - results from collateral circulation that develops to bypass the abnormally high pressure in the portal system
assesment focus for bleeding varices 3***
hemodynamic status
fluid volume status.
somatostatin
prophylactic antibiotics for 7 days
somatostatin
a hormone that inhibits vasodilator hormones and decreases portal pressure. Administered by IV bolus dose, followed by a continuous infusion for 3-5 days. – assess H and H
endoscopic therapy
for bleeding varices tx
- sclerosing or banding to ligate the vessel. - repeated every 2-4 weeks until varices are eliminated
- surveillance every 6-12 months.
TIPS
done to treat repeated or uncontrolled variceal bleeding.
A stent placed to decrease portal pressure thus reducing re-bleeding and formation of ascites.
if someone has balloon tamponade what should be at bedside
scissors to cut balloon
hepatic encephalopathy
is neuropsychiatric manifestations from ammonia resulting from a disturbance in the CNS because of liver failure.
s/s confusion to coma
5 treatment for hepatic encephalopathy
Assessment of neurological status
Maintenance of the patient’s airway and preventing aspiration
Maintaining safety by preventing falls
Administration of lactulose or oral antibiotics (rifaximin).
TEMP restriction of protein intake from veg sources
6 long term effects of burns
Temp regulation
Increased susceptibility to UV injury (wear sunscreen)
Decreased vitamin D synthesis (need vit D supplement/need osteoporosis screening younger)
Hypermetabolic state- increased HR and temp (need increased nutritional needs)
Prolonged immunosuppression
PTSD, anxiety etc
percents of body burn
Head and neck – 9%
Arms – each 9%
Anterior and posterior trunk – 36%
Anterior and posterior legs – each 18%
Perineum – 1%
burn that extends to subcut, muscle or bone
4th
superficial/1st degree
epidural only
Skin is pink to red in color and slightly edematous.
These burns heal in 3-6 days.
TBSA not used
painful.
superficial 2nd degree
epidermis and part of dermis
bright red in color, moist, with fluid-filled blisters
increased sensation and pain
21 days
little scaring
deep 2nd degree
involve the epidermis + entire dermis.
white/waxy,
capillary refill is decreased.
less pain and decreased sensation.
3 weeks
scarring
full thickness/3rd degree burns
all layers
Wound color ranges
no capillary refill
wound is dry, firm, leathery
no sensation to pressure, no pain
need skin grafting.
major burn area percent
> 20%
which burns for which zones
Zone of inflamm: superficial
Zone of stasis: superificial or deep 2nd
Zone of coag: 3rd
most common cardiac change with burns
hypovolemic burn shock.
2 components of burn shock
The cellular component results from damage to cells in the burn itself.
The CV component=Release of inflammatory mediators suppress myocardial contraction
systemic edema ->
massive decrease in circulating blood->
hyperviscosity of blood (can lead to dvt)
->and slowed capillary circulation
critical nursing function for burn shock
fluid and electrolytes!!!
gold standard for fluid monitoring after first 24 hours
urine output
burn resuscitation fluid is successful when
0.5-1.0 mL/kg/ HOUR achieved after 2 hours of maintence fluids
fluid resuscitation required when
burns involving > 20% TBSA
fluid amount resucitation determined by
The Parkland Formula is commonly used: (4 mL/kg) * % of TBSA burned administered in the first 24 hours.
After the first 24 hours, fluids are given at a maintenance rate with urine output guiding replacement
preferred fluid for resuscitation
Lactated Ringer’s solution
Burns that extend around the circumference of the neck, chest, abdomen, and extremities (think tourniquet) are at risk for
compartment syndrome
For patients with burns around the abdomen,
bladder pressure (measured through the indwelling urinary catheter WITH A PRESSURE SENSOR) to measure intra-abdominal pressure (> 30 mmHg indicate abdominal hypertension)
tx for compartment syndrome
escharotomy
what is escharotomy
provider uses a scalpel or electrocautery to cut through the eschar, releasing tension and permitting blood flow to the area.
nurse responsibilties for escharotomy
sterile guaze for 24 hours
monitoring for blood loss/edema
if Patients with singed scalp or facial hair, changes in the mucosal lining of the oropharynx, including presence of soot, hoarseness, edema, or blisters
evaluate for inhalation injury
monitoring resp function include 6
vital signs,
ABGs,
lung sounds,
chest x-ray,
bronchoscopy
carboxyhemoglobin levels.
respiratory support interventions 4
elevating the HOB,
turning and repositioning,
administration of humidified O2,
suctioning as needed.
intervention for inhalation injury
Early intubation
NG/OG tube- to decompress the stomach/ enteral nutrition.
patient with suspected CO poisoning
high-flow O2 at 90-100% or hyperbaric O2 therapy.
GI changes in burns 6
hypermetabolic state
Urea and creatinine levels in urine increase.
Body weight drops quickly.
Delayed healing,
muscle wasting
bone loss
GI assessments in burns 4
bowel sounds,
bowel movements,
presence of nausea/vomiting,
abdominal distention and tightness (remember abdominal compartment syndrome)
lab values 3 and other assessments 2
to monitor for blood loss from ulcers
h and h
nitrogen- 24 hour urine collection
gluoce checks
I and O
dly weights
renal chnages in burn 4
GFR decreased
urine output decreased
BUN and Cr rise
dark brown urine
how to monitor urine output for burns
catheter
foundation of burn wound management
early exicision to remove eschar and debris
how long are dressings on burns
3 days
silver sulfadiazine
topical medication for bacteria
Application is painless
does not penetrate eschar.
If a rash occurs, the medication is discontinued
madenide acetate
bacterial cream
NOT ANTI FUNGAL
penetrates eschar and application can be painful.
MONITOR FOR FUNGAL INFECTION
discontinuing if a rash develops.
portal vein supplies
75% of blood flow and 50% of oxygen from nutrient-rich blood in the entire GI tract
