Exam #5 (chp 58-59) Flashcards
What is cirrhosis?
Cirrhosis is extensive, irreversible scarring of the liver; characterized by fibrotic (scarred) bands of connective tissue
A chronic reaction to hepatic inflammation and necrosis- results in extensive degeneration and destruction of hepatocytes (liver cells).
Develops slowly and is progressive- results in end stage liver disease.
What are common causes of Cirrhosis?
The most common causes of cirrhosis are:
- chronic alcoholism
- chronic viral hepatitis
- autoimmune hepatitis
- NonAlcoholic Steatohepatitis (NASH) (fatty liver)
- Drug and chemical toxins
- Gallbladder disease
- Metabolic/genetic causes
- Cardiovascular disease
What is the pathophysiology of cirrhosis?
As cirrhosis develops, the tissues becomes nodular, the nodules can block bile ducts and blow flow. Impairments in blood flow and lymph flow result from compression caused by excessive fibrous tissue. (Scarring)
Early- the liver is enlarged, firm and hard. Over time the liver shrinks resulting in decreased liver function- results in elevated liver enzymes (AST/ALT)
What are complications associated with cirrhosis?
Compensated cirrhosis: the liver is scarred but can still function.
Decompensated cirrhosis: liver function is impaired, obvious manifestations of liver failure
- portal hypertension
- ascites and esophageal varices
- coagulation defects
- jaundice
- Portal Systemic Encephalopathy (PSE) with hepatic coma
- hepatorenal syndrome
- spontaneous bacterial peritonitis
What is portal hypertension?
(Associated with decompensated cirrhosis)
Portal hypertension is a persistent increase in the portal vein pressure, greater than 5mm/Hg
It results from increased resistance or obstruction of the blood flow through the portal veins and it’s branches.
Can result in ascites, esophageal varices, prominent abdominal veins, and hemorrhoids.
What is splenomegaly?
Spleen enlargement caused by blood flow backing up into the spleen.
Destroys platelets, causing thrombocytopenia (low platelets) and increased r/f bleeding
THROMBOCYTOPENIA is the first sign of liver dysfunction
What is ascites?
Ascites is a collection of free fluid within the peritoneal cavity caused by increased hydrostatic pressure from portal hypertension.
plasma protein collects in the perineal fluid– decreases circulating plasma protein in the blood– in addition, the liver cannot produce albumin properly– the colloid pressure decreases= shift of vascular fluid to the abdomen “third spacing”
Pt may present: hypovolemia and edema
Massive ascites: causes renal vasoconstriction — triggers renin angiotensin system= results in sodium and water retention. (Causes hydrostatic pressure, and more ascites)
What is esophageal varices?
Esophageal varices occurs when fragile, thin-walled esophageal veins become distended and tortuous from increased pressure.
The bleed depends on their size
Occurs most often in the distal esophagus= LIFE THREATENING EMERGENCY
Severe blood loss can occur, leading to hypovolemia shock
Hematemesis- vomiting blood
Melena- black, tarry stools
No precipitating factor, heavy lifting, vigorous physical activity, chest trauma, or dry hard food increase likely hood of bleed
What is portal hypertensive gastropathy?
Portal hypertensive gastropathy is slow gastric mucosal bleeding, which results from chronic slow blood loss, occult positive stools, and anemia.
In patients with cirrhosis, why does biliary obstruction occur?
In patients with cirrhosis, bile production in the liver is decreased
– prevents absorption of fat soluble vitamins (D, E, A, K)
–lack of vitamin K, clotting factors 2,7,9,10 are insufficient
= increase r/f bleed and bruising
Confirmed by coagulation studies (PT/INR, PTT)
What is Jaundice? And how is it caused?
Jaundice is yellow discoloration of the skin, is caused by biliary obstruction.
Patients often report itching (pruritus)
2 types:
Hepatocellular- develops because the liver cells cannot effectively excrete bilirubin
Intrahepatic- results from edema, fibrosis, or scarring of the hepatic bile ducts and channels
What is hepatic encephalopathy? What are early and late Signs and Symptoms?
Hepatic encephalopathy aka Portal-systemic encephalopathy (PSE) is a complex cognitive syndrome that results from liver failure and cirrhosis.
-reversible with early intervention
EARLY: sleep disturbances, mood disturbances, mental status changes, and speech problems
LATE: altered LOC, impaired thinking processes, and neuromuscular problems
What is the proposed mechanism of action for hepatic encephalopathy?
Shunting of the portal venous blood into the central circulation to bypass the liver, substances absorbed by the intestine are not broken down or detoxified and
= cause metabolic abnormalities
ELEVATED AMMONIA AND GABA (gamma-aminobutyric acid)
What are STAGE 1 Hepatic encephalopathy signs and symptoms?
- Subtitle manifestations that may not be recognized immediately
- personality changes
- behavior changes: agitation, belligerence
- emotional Labile: euphoria, depression
- impaired thinking
- inability to concentrate
- fatigue, drowsiness
- slurred or slowed speech
- sleep pattern disturbances
What are signs and symptoms of STAGE 2 hepatic encephalopathy?
- continuing mental changes
- mental confusion
- disorientation of time, place, or person
- Asterixis (hand flapping)
What are STAGE 3 hepatic encephalopathy signs and symptoms?
- progressive deterioration
- marked mental confusion
- stuporous, drowsy but not arousable
- abnormal EEG
- muscle twitching
- hyperreflexia
- Asterixis (hand flapping)
What are signs and symptoms of STAGE 4 hepatic encephalopathy?
- unresponsiveness, leading to death
- Unarousable, obtunded
- No response to painful stimuli
- NO Asterixis
- Positive Babinski’s sign
- Muscle rigidity
- fetor hepaticus (characteristics of liver death– musty, sweet odor)
- Seizures
What are factors that can lead to hepatic encephalopathy in patients with cirrhosis?
High protein diet
Infection
Hypovolemia (decreased fluid volume)
Hypokalemia (decreased potassium)
Constipation
GI bleeding (causing large protein load in the intestines)
Drugs (hypnotics, sedatives, opioids, analgesics, diuretics, illicits)
What is hepatorenal syndrome (HRS)?
Hepatorenal syndrome indicates a poor prognosis for a pt with liver failure, can cause death
Manifested by:
- a sudden decrease in urine output (<500ml/24hr)
- elevated BUN and Cr levels with decreased urine Na+ levels
- increased urine osmolarity
Usually occurs after clinical deterioration following a GI bleed or hepatic encephalopathy
What is Spontaneous Bacterial Peritonitis (SBP)?
Spontaneous Bacterial Peritonitis is a result of bacteria in the ascites fluid and low concentrations of protein
Patients with cirrhosis and ascites may develop acute SBP
Patients with very advanced liver disease have increased susceptibility
Clinical manifestations:
Fever, chills, abdominal pain, and tenderness.
Increased Jaundice and loss of appetite
Dx with ascitic fluid via paracentesis, leukocyte count > 250 need Tx.
QUINOLONES- norfloxacin (Noroxin) drug of choice!
If allergic, use combo-drug Bactrim.
What is the etiology and genetic risks for Hepatitis C?
Second leading cause of cirrhosis and liver failure in US.
Hepatitis C is an infectious blood borne illness, causing inflammation leading to progressive scarring of the liver.
In combination with alcohol, progression speeds up
What is Nonalcoholic Fatty Liver Disease (NAFLD)?
Nonalcoholic Fatty Liver disease is associated with obesity, diabetes type 2, and metabolic syndrome.
Most common cause of liver disease in the world.
Genetic link to: Patatin-like phospholipase domain-containing 3 (PNPLA3)
Hispanics more like to have.
May cause cirrhosis, liver cancer, or liver failure.
What are the statistics of liver disease, according to the American Liver Foundation?
> 30 million have liver disease, 1 in 10 Americans
4 million Americans have Hepatitis C and >1 million have Hepatitis B
12th most common death in US; 28,000 die per year.
What are EARLY assessment findings associated with cirrhosis?
Fatigue
Significant change in weight
GI symptoms, anorexia and vomiting
ABDOMINAL pain and liver TENDERNESS
What are LATE assessment findings associated with advanced cirrhosis?
GI bleeding
Jaundice
Ascites
Spontaneous bruising
(All indicate poor liver function and complications of cirrhosis)
How would you assess the patient for liver dysfunction or failure? And what are interventions associated to these findings?
Jaundice (yellowing skin) or Icterus (yellowing sclera)
Dry skin ; Rashes
Petechiae or ecchymoses
Warm BRIGHT RED palms
Spider angiomas (vascular lesions on the nose, cheek, thorax, and shoulders)
Ascites ; abdominal distention= measure ABDOMINAL GIRTH, measure in supine position, around largest diameter on exhalation. DAILY WTs
Peripheral Edema- extremities and scrotum
Vitamin deficiency (especially fat soluble D,E,A,K)
Hepatomegaly (liver enlargement)
Occult stools or emesis- FOBT or HEMA-CULT
Fetor Hepaticus- fruity or musty distinctive breath odor (CLF/HE)
Amenorrhea or Gynecomastia or Impotence
Asterixis- “Hand flapping” course tremor, rapid nonrhythmic extensions and flexions of wrists and fingers
Agitation ; insomnia ; emotional lability ; euphoria ; depression
Question: A client previously diagnosed with liver cirrhosis visits the medical clinic. What assessment findings does the nurse expect in the client? Select all that apply: A. Ecchymoses B. Soft abdomen C. Moist, clammy skin D. Jaundice E. Ankle edema F. Fever
A. Ecchymoses
D. Jaundice
E. Ankle Edema
What are LAB findings associated with liver disease?
ELEVATED:
- AST/ALT and LDH (due to inflammation)
- Alkaline phosphatase and GGT (caused by bile obstruction)
- Bilirubin, present in the urine (urobilinogen)
- Prolonged PT/INR (decreased prothrombin)
- Ammonia (with advanced Liver disease)
- Creatinine (with deteriorating kidney function)
DECREASED:
- Protein and Albumin (decreased synthesis by liver)
- platelet count (thrombocytopenia)
- RBCs and H&H (anemia)
- WBCs
- Hyponatremia (caused by ascites)
Clay colored stools (cause bile obstruction & decreased bilirubin in urine)
What is assessment IMAGING indicative of liver disease?
Ultrasound of liver: 1st assessment suspected of liver disease to detect ascites, hepatomegaly, and splenomegaly
X-ray: hepatomegaly, splenomegaly, massive ascites
CT scan
MRI
Liver Biopsy- At risk for bleeding
EGD- esophagogastroduodenoscopy of upper GI (complications: esophageal varices, stomach irritation, and ulceration
ERCP- endoscopic retrograde cholangiopancreatography contrast dye into sphincter for stone removal and biopsies.
What are NANDA diagnoses associated with liver disease?
Excessive Fluid volume r/t third spacing
Potential for hemorrhage r/t portal hypertension
Potential for hepatic encephalopathy r/t shunting and increased ammonia
What are interventions related to cirrhosis and liver disease?
Prevent fluid accumulation- fluid restriction, treat ascites-
paracentesis and diuretics- monitor DAILY WT, I/O, abd. Girth, peripheral edema, and electrolyte levels. (Loop diuretics- decreased K and Na)
LASIX and SPIRONOLACTONE
Prevent scratching/itching skin- use COOL water and minimal soap, use lotion
DIET: Low Sodium diet < 2gm, high carb. moderate fat, high protein. Vitamin supplements (with late stage cirrhosis) Banana Bag IVF (thiamine, folate, and multivitamins)
What is Hepatopulmonary syndrome? And what are some interventions to conduct?
Hepatopulmonary syndrome is caused by excessive fluids caused by ascites
Caused dyspnea, as result of intra-abdominal pressure, limiting thoracic expansion
DO:
-Auscultate lungs every 4-8hrs for crackles
-Continuous Pulse Ox
-Elevate HOB to 30 degrees, elevate feet = decreased ankle edema to relieve dyspnea
- Assess BUN, H&H, protein, and electrolytes
(Elevated BUN and hematocrit and decreased protein indicate hypovolemia)
What are cares associated with a Paracentesis?
Ensure Informed consent is received and answer any questions
Obtain VS and Weight and have pt VOID BEFORE procedure
Position with HOB elevated
Measure the drainage- send fluid analysis
Apply dressing to site and assess leakage
Maintain bedrest and Weigh the pt POST-PROCEDURE
What is TIPS?
TIPS is a Transjugular Intrahepatic Portal-systemic Shunt
Is a nonsurgical procedure used to control long-term ascites and to reduce variceal bleeding
heavy IV sedation or general anesthesia
needle through sheath on jugular vein and pushed through liver into the portal vein
Balloon inflated, shunt to keep open.
Doppler to assess blood flow through stent
Question: The nurse is providing teaching for a client scheduled for a paracentesis. Which statement by the client indicates the teaching has been successful?
A. I must not use the bathroom prior to the procedure
B. I must lie on my stomach while the procedure is performed
C. I will not be allowed to eat or drink anything the night before surgery
D. The physician will likely remove 2-3 liters of fluid from my abdomen
D. The physician will likely remove 2-3 liters of fluid from my abdomen.
What are interventions to PREVENT a bleed? What are interventions if bleeding occurs?
best outcome: pt expected to be free of bleeding.
PREVENT bleed and infection:
- screen for esophageal varices
- nonselective Beta blocker: Propanolol (Inderal)
- Prophylactic ABX on admission (infection is a common cause of AVB)
If bleeding occurs: EMERGENCY
-Vasoactive drugs: Vasopressin and Octreotide acetate (Sandostatin)
-monitor VS q 1 hr, check coagulation studies (PT/INR, PTT and platelets)
What are endoscopic procedures used to control a bleeding veins?
Endocscopic Variceal Ligation (EVL): “banding” - apply a small “O” band at the base of the varices to decrease blood supply
Endoscopic sclerotherapy (EST) aka injection therapy - inject sclerosing agent via a catheter, complication mucosal ulceration
What are RESCUE therapies if rebleeding occurs?
Second endoscpoy or TIPS procedure if possible; if not:
balloon tamponade and esophageal stents using a Sengstaken-Blakemore tube
- place through the nose into stomach, balloon inflated, pressure to stop bleed
- pt intubated and on ventilation
- life threatening complications: aspiration, asphyxia, esophageal perforation.
What are interventions for hepatic encephalopathy?
goal: slowing or stopping accumulation of ammonia
Diet changes: moderate protein and fats, simple carbs.
-give brief, simple dietary do and dont
Drug therapy: used sparingly (no opioids, sedatives, or barbiturates)
Lactulose or lactitol: eleminate ammonia via stools, it is sweet, viscous, sticky liquid given PO or NG
- desired laxative effect, 2-3 soft stools per day and decreased confusion
- may report intestinal bloating and cramping
- dehydration and hypokalemia for stools
Nonabsorbable ABX:
Neomtcin or rifaximin - broad spectrum for intestinal antiseptic- destroys normal flora, decreases protein breakdown and ammonia production. Maintenance dose PO or retention enema- potential kidney toxicity, do not use for pts with kidney disease.
Metronidazole (Flagyl) - similar to neomycin, can cause peripheral neuropathy
Vancomycin - long-term use can lead to resistance
ASSESS: LOC and orientation frequently, asterixis (liver flapping) or fetor hepaticus (liver breath).
thiamine supplements and benzos if at risk for alcohol withdrawal.
What is the goal of community-based care for patients with cirrhosis?
Optimize comfort, promote independence, support caregivers, prevent rehospitalization.
End-stage may need hospice
What are home care management for patients with cirrhosis?
Nutrition:
- follow strict diet, low sodium
- small frequent meals with supplement if needed.
Drugs:
- avoid fat soluble vitamins, iron, and niacin.
- diuretics, may need K+ supplement
- Med to reduce Acid Reflux
- beta blocker (report weakness, irreg. HR, or dizziness)
- lactulose to maintain 2-3 soft stools daily
- avoid OTCs, including NSAIDs and TYLENOL
- daily maintenance ABX if SBP
Alcohol:
-do not consume, seek supportive services
Question: Which intervention will the nurse include in the plan of care for a client with severe liver disease?
A. Encourage low protein, high carb diet.
B. Admin Kayexalate
C. Instruct high protein, low carb diet
D. Teach participation in frequent, vigorous physical activities
A. Encourage the client to eat a low-protein, high-carbohydrate diet.
What is hepatitis?
Hepatitis is widespread inflammation of the liver cells.
Viral hepatitis is most common.
Edema can cause obstructive jaundice
What is hepatitis C? And how is it commonly spread?
Hepatitis C is an enveloped, single-stranded RNA virus, Transmitted blood to blood, incubation period is 7 weeks.
-associated with cirrhosis and liver cancer
Common causes:
- illicit IV drug needle sharing
- blood, blood products, or organ transplants
- Needle stick injury
- Unsanitary tattoo equipment
NOT transmitted via common contact!!
Advise NOT to share razors, toothbrushes, or earrings
NO VACCINE FOR HEP C!!
What are prevention measures for Hepatitis in health care workers?
- Use standard precautions
- Use a needleless system, decrease presence of sharp instruments
- Vaccinations, Hep B is a series of 3 injections
- Prevent Hep B to prevent Hep D
- Postexposure prevention of Hep A, seek medical attention immediately
- Report all cases of hepatitis to local health department
What are health practices to prevent VIRAL Hepatitis?
- Maintain adequate sanitation and personal hygiene.
- Wash your HANDS
- Drink purified water or bottled water
- Avoid foods prepared with tap water in undeveloped countries
- Do NOT share personal items, linens, or eating utensils.
- Do NOT share needles or piercings
- Use a condom
- Cover cuts/sores with bandage
- If infected, NEVER donate blood, organs, or tissues.
What is the initial diagnostic test for Hep C? And which test is used to confirm Hep C?
The initial test: ELISA test (Enzyme-linked immunosorbent assay) for those suspected to be infected and screen for antibodies (detected within 4 weeks of infection)
Confirming test:
RIBA (recombinant immunoblot assay) which is more specific in showing exposure to and development of antibodies than ELISA
Additional test:
OraQuick HCV rapid antibody test- approved by FDA in 2010, used for quick diagnosis as a point-of-care test.
What are common signs and symptoms of Hepatitis?
ABD. PAIN Changes in skin or sclera (icterus) Arthralgia (joint pain) Myalgia (muscle pain) N/V/D/C Dark urine and clay-colored stools Fever Lethargy Malaise Pruritus (Itching) RUQ pain with jarring movements
What are lab assessments associated with Hepatitis C?
Elevated AST/ALT
Elevated Bilirubin
Elevated Alkaline Phosphatase
What are complementary and alternative therapies for Hep C?
Mind-body medicine
- prayer
- deep breathing
- mediation
To promote well-being and relieve tension and anxiety- promote health and improve Quality of life
What are some medications used for chronic Hep C?
Telaprevir (Incivek)-monitor CBC for anemia
Boceprevir (Victrelis)- combo with HIV med, monitor Chem panel for kidney and liver function
PegIFN/RBV (interferon/ribavirin)- given SubQ, cannot miss a dose!
What are interventions associated with Hepatitis?
Aimed at REST, is essential to reduce metabolic demand, promote regeneration, and increase blood supply.
DIET: high carb, high calorie diet with moderate fats and proteins.
SMALL FREQUENT MEALS, eat foods that are appealing
Antiemetic to relieve nausea
Community-based care: Primarily to PREVENT spread of infection, good hygiene and hand washing. EDUCATION is key.
What is patient education associated with Hepatitis?
AVOID OTC drugs, including Tylenol Avoid Alcohol Rest frequently, get adequate sleep Small frequent meals Avoid sex until antibody testing is negative Prevent transmission via MEDICATIONS
What is Fatty Liver (Steatosis)? What are some interventions associated with Fatty Liver?
Fatty liver is caused by the accumulation of fats in and around the hepatic cells, may be caused by alcohol.
Additional causes:
- diabetes mellitus
- obesity
- elevated lipid profile
LABS: elevated ALT and AST or normal ALT and elevated AST
Pt is asymptomatic
MRI, US, nuclear med to diagnose. Percutaneous biopsy to confirm.
Intervention aimed to remove underlying cause of infiltration.
What is liver trauma?
Most common organ to be injured
Suspected with upper abdominal or lower chest trauma (steering wheel)
OBSERVE for early signs of HYPOVOLEMIC SHOCK due to potential massive blood loss
What are assessment findings associated with Liver Trauma?
RUQ pain with abd. Tenderness Abd distention and rigidity Guarding of the abdomen Increased abd pain with deep breathing or refers to the right shoulder (Kehr's sign) Hemorrhage or hypovolemic shock: -Hypotension -tachycardia -tachypnea -pallor -diaphoresis -cool, clammy skin -confusion or alter LOC -decreased Hematocrit
What are interventions for liver cancer?
Chemotherapy and radiation therapy
What patients are NOT considered candidates for a liver transplant?
Those with:
- Severe cardiovascular instability
- Severe respiratory disease
- Metastatic tumors
- Inability to follow instructions regarding drug therapy and self-management
What are some considerations regarding liver transplant?
Liver transplanted and preserved in solution for up to 8 hours.
Transplant list ran by UNOS.
Monitor for clinical manifestations of rejection:
- tachycardia
- fever
- RUQ or flank pain
- decreased bile pigment
- increased jaundice
- elevated bilirubin, ALT/AST, alkaline phosphatase
- prolonged PT/INR
DO:
- Vaccines and Prophylactic ABX
- Broad spectrum ABX during and after surgery
- Monitor Temp and neuro status frequently
- report clotting problems (bleeding)
- immunosuppressants and anti-rejection med
What are common post-op complications associated with liver transplant?
Acute graft rejection: 4-10th post-op day
- tachycardia, fever, RUQ or flank pain, diminished bile drainage or change in color of bile, increased jaundice
- Prevent: Prophylactic immunosuppressants (cyclosporine) and anti-rejection meds
Infection: occurs at any time
-fever, foul smelling drainage
Common infection- PNA, wound infection, UTI
Opportunistic infection-develop after the 1st month, include: cytomegalovirus, mycobacterial or parasitic infections
-Prevent: Prophylactic ABX and vaccinations. Frequent cultures, good hand hygiene, organism specific anti-infectives
Hepatic Complications: (bile leakage, abscess, hepatic thrombosis)
- decreased bile drainage, increased RUQ pain with distention and guarding, N/V, increased jaundice and Carly-colored stools. Increase bilirubin and transaminases
- Prevent: t-tube in dependent position, secure to patient, empty frequently, record appearance and amount. May need surgery
Acute Renal Failure:
- caused by hypotension, ABX, cyclosporines, Acute liver failure, or hypothermia
- Hypothermia Sx: shivering, hyperventilation, increased cardiac output, vasoconstriction, and alkalemia
- early indicators of renal failure: changes in urine output, increased BUN and Cr, electrolyte imbalance
- Prevent: monitor drug levels with nephrotoxic side effects, report early side effects immediately.
What does the biliary system do?
Liver, gallbladder (biliary system) and pancreas secrete enzymes to promote food digestion in the stomach and small intestine.
What is cholecystitis?
Cholecystitis is inflammation of the gallbladder, either acute or chronic.
What are the 2 types of Acute cholecystitis?
Calculous Cholecystitis- most common
- chemical irritation and inflammation result in gallstones (cholelithiasis) that cause obstruction (mostly cystic duct)
- trapped bile is reabsorbed and causes irritation leading to ischemia and infection. May eventually perforate (can cause peritonitis)
- Impaired motility causes stone formation by delaying bile emptying and causing stasis.
Acalculous Cholecystitis: inflammation without gallstones, associated with bile stasis. (Decreased blood flow, anatomical problems, twists/kinks)
Occurs in patients with: sepsis, severe trauma/burns, long term TPN, multiple organ failure, major surgery, hypovolemia.
What is chronic Cholecystitis? What are some key features associated with chronic Cholecystitis?
Chronic Cholecystitis occurs with repeated obstruction of cystic duct.
-gallbladder becomes fibrotic and contracted = decreased motility and absorption.
Common complications: pancreatitis and cholangitis
Jaundice and icterus (sclera) Pruritus (itching) or burning sensation Clay colored stools Tea colored foamy urine (kidneys try to excrete bilirubin) Epigastric or vague upper abdominal pain pain with large meals N/V Dyspepsia (indigestion) Eructation (belching) Flatulence (gas) Abdominal fullness Rebound tenderness (Blumberg's sign) Fever Steatorrhea (fatty stools)
What are risk factors for Cholecystitis?
4 F's: Female Forty Fat Fertile (Flatus)
Pregnancy or obesity Athletes Rapid wt loss - affects normal absorption Crohn's disease, sickle cell Hormone replacement therapy
American Indian, Mexican American, or Caucasian are more likely to develop Cholecystitis
What are presenting signs of Cholecystitis in older adults With diabetes?
NO pain or fever
Only Localized tenderness and acute confusion (delirium)
Check O2 sat
What is biliary colic? And what are symptoms of biliary colic?
Biliary colic is severe pain caused by obstruction of cystic duct caused by moving stones
tachycardia
Pallor
Diaphoresis
Prostration (extreme exhaustion)
CALL RRT!
Stay with pt and keep the HOB flat!
What are contributing factors to Cholecystitis?
Increased fatty foods
Increased calories
Increased refined white carbs
Decreased fiber
S/Sx when these foods consumed:
-gas, indigestion, belching, anorexia, N/V, abdominal pain or discomfort.
What are diagnostic imaging and labs associated with Cholecystitis?
Increased WBCs (inflammation)
Elevated Alkaline phosphatase, AST, and LDH
Elevated Bilirubin
If pancreas involved, elevated amylase and lipase
X-ray: see calcified gallstones
Ultrasound of RUQ: initial diagnostic test
Hepatobiliary scan (HIDA scan)- decreased bile flow = disease with obstruction, NPO before procedure
ERCP MRI (contrast gadolinium does not contain iodine)
What are treatment options for Cholecystitis?
Tx of choice: laparoscopic cholecystectomy
Short recovery time, inexpensive, less pain, minimal scaring
What are nonsurgical interventions for Cholecystitis?
NPO diet if N/V occur
IV fluids
NG tube
Acute pain: opioids: morphine or Dilaudid
Ketorolac (Toradol) for mild to moderate pain (NSAID)
Antiemetics for N/V
IV ABX - depending on cause of Cholecystitis
Bile acid dissolution: ursodiol (Actigall) and chenodiol (Chenodal) may be given for up to 2 years to dissolve or stabilize gallstones.
- report diarrhea, vomiting, severe abd pain, especially if radiates to shoulders
- take with food or milk
Lithotripsy (extracorporeal shock wave lithotripsy) - used for normal weight, cholesterol based stones, and good gallbladder function. Lay on a water-filled pad, shock breaks up stones. Spasms occur- ursodeoxycholic acid (UDCA) used after procedure to dissolve remaining fragments.
What is a Laparoscopic Cholecystectomy? What are interventions and education associated with a “lap Chole”?
Aka “Lap Chole” is the gold standard of Minimally Invasive Surgery
- complications uncommon
- death rate low
- bile duct injuries are rare
- recovery is quicker
- pain less severe
AMBULATE same day as surgery, review pain management, deep breathing, incision care, and leg exercises.
IV ABX given immediately before or during surgery
Air (carbon dioxide) 3-4 liters to inflate abdominal cavity, post-op will rise to chest and shoulders - elevated HOB, HEAT, void and early ambulation to get rid of air.
Offer food and water when fully awake, monitor for N/V
ASSESS O2 sat and deep breathing q 1 hour.
-Given antiemetic PRN
Maintain IV line
Sterl-strips or adhesive comes off after 10 days
Education: Ice and oral opioids for incisional pain. Bath or shower next day post-op. Rest for 24 hours then resume usual activities as tolerated. Avoid high fat foods- causes diarrhea and abd pain. Introduce fatty foods one at a time.
What is a traditional cholecystectomy?
Open surgical procedure for severe biliary obstruction and to explore duct patency.
Use has declined greatly
JP drain to prevent fluid accumulation- Seriosanginous fluid and stained with bile for 24 hours after surgery- ABX to prevent infection.
Post-op incisional pain: control with PCA pump, TCDB exercises, and incision splinting.
Antiemetic for N/V- give early to prevent retching and decrease muscle strain.
Post-op care for incision and surgical drain– surgeon removes dressing and drain within 24 HR of surgery
NPO until fully awake, advance to liquids then solid foods. Low fat diet, eat nutritious meals and avoid fatty foods.
Document LOC, VS, pain, and signs of infection. Early ambulation and D/C home within 2 days.
What is Post Cholecystectomy Syndrome?
Post cholecystectomy syndrome: severe Vomiting or Diarrhea with abdominal or epigastric pain for several weeks to months after surgery.
What is acute pancreatitis? What are the 4 major pathophysiologic processes that occur?
Acute pancreatitis is serious and life-threatening inflammation of the pancreas, caused by premature activation of excessive pancreatic enzymes that destroy ducal tissue and pancreatic cells, resulting in auto digestion and fibrosis of the pancreas.
4 processes:
- lipolysis
- proteolysis
- necrosis of blood vessels
- inflammation
The majority of deaths in patients with acute pancreatitis result from irreversible shock.
What are complications of acute pancreatitis?
jaundice occurs from swelling of the head of the pancreas
Compression of bile duct by calculi (stones)
Pancreatic shock (causes septic shock)
Hemorrhage (necrotizing hemorrhagic pancreatitis [NHP])
Acute Kidney failure
paralytic ileus
Hypovolemic shock
Acute Respiratory distress syndrome (ARDS)
Decrease release of insulin
Total distraction of the pancreas, leading to DM type 1.
Left lung pleural effusion, atelectasis, and PNA
Multiple organ failure
Disseminated intravascular coagulation (DIC)
DM type 2
Question: The nurse is providing discharge instructions for a client who has undergone a laparoscopic cholecystectomy. Which instruction will the nurse include in the discharge teaching?
A. Keep dressings in place for 4 weeks
B. Report bile-colored drainage from the incision
C. Expect dark, tarry stools after surgery
D. Be aware that no dietary changes will be necessary
B. report bile-colored drainage from the incision
Question: The nurse closely monitors the client with acute pancreatitis for which complication? A. Duodenal ulcer B. Infection C. Pneumonia D. Heart Failure
C. Pneumonia
What are common causes of acute pancreatitis?
Result from trauma from surgical manipulation, or complication of diagnostic procedures
Trauma-external source
Pancreatic obstruction-tumor, cysts, abscess
Metabolic disturbances-hyperlipemia, hyperparathyroidism, hypercalcemia
Renal disturbances-failure or transplant
Familial, inherited pancreatitis
Penetrating gastric or duodenal ulcers
Viral infections-coxsackievirus B and HIV
Alcoholism
Toxicity of drug-opioids, sulfonamide, thiazides, steroids, oral contraception
Cigarette smoking
Cystic Fibrosis
Gallstones
Abdominal surgery
What are assessment findings associated with Acute pancreatitis?
Severe and consistent abdominal pain, mid-epigastric or LUQ
Sudden onset and radiates to the back, left flank, or left shoulder.
Intense boring, worse when lying in supine position, relief in Fetal position or sitting upright and bend forward.
generalized jaundice
Gray-blue discoloration of abdomen (Cullen’s) or flanks (Grey Turner’s)
Absence of bowel sounds
Abdominal tenderness, rigidity, and guarding with light palpation
Palpable mass
Pancreatic ascites- dull sound
Respiratory Compromise
Steatorrhea or clay-colored stools
Wt loss
Dark Urine
Polyuria, polydipsia, polyphagia (DM)
Assess: elevated temp, tachycardia, and decreased BP. Auscultate lung fields.
What are labs findings associated with acute pancreatitis?
Elevated:
- amylase
- lipase
- trypsin
- elastase
- glucose
- Bilirubin
- ALT/AST
- leukocyte count (WBCs)
- BUN and triglycerides
- CRP present
Decreased:
- Calcium for 7-10 days, stay below 8 is poor prognosis
- Magnesium
- Potassium
- platelets (thrombocytopenia)
- Albumin (caused by cytokines)
What are Diagnostic imaging associated with acute pancreatitis?
Abdominal ultrasound- most sensitive to Dx
CT scan- with contrast, more reliable imaging
Abdominal X-ray: reveal gallstones
ERCP: best Dx pancreatic stones
What are interventions associated with acute pancreatitis?
Priority: ABCs!! Provide Oxygen Control Pain Hydration with IVF - isotonic fluids NS or LR Replacement Ca and Mg via IV Foley catheter for accurate I/O
NG tube and suctioning for severely ill with continuous vomiting and biliary obstruction (due to paralytic ileus)
-may need to be prolonged therapy, passing gas or BM is most reliable indicator of peristalsis return.
Fasting and rest!! Withhold food and fluids (NPO) during acute period.
Drug therapy:
- Opioids via PCA (morphine or Dilaudid), IV or transdermal Fentanyl
- —NO Demerol, can cause seizures
- H2 receptor antagonist (ranitidine [zantac])
- Proton pump inhibitor (omeprazole [prilosec])
- ABX for acute necrotizing pancreatitis.
Frequent oral and nasal hygiene measures to keep mucosa moist, may have dry mouth
manage anxiety and reduce pain.
Daily weight
Small frequent meals; moderate to high carbs, high protein, low fat meals. Bland foods, avoid caffeine (tea, cola, chocolate) and alcohol.
Nutrition supplement as needed, and fat-soluble vitamins and minerals.
Wound care and ADL assistance, activity to one floor.
Support groups: AA and Al-Anon for family members
What is chronic pancreatitis? What are the different types of pancreatitis?
Chronic pancreatitis is a progressive, destructive disease of the pancreas that has remissions and exacerbations
Alcoholism is primary risk factor for Chronic Calcifying Pancreatitis (CCP) (Predominant in men).
- early: insoluble proteins plug pancreatic ducts and flow of pancreatic juices
- late: ducts change and ulcerated, causes fibrosis. Introduction calcification and marked pancreatic destruction (necrosis). Organ is hard and firm.
Chronic Obstructive Pancreatitis: inflammation, spasms, and obstruction of sphincter of Oddi, often gallstones
Autoimmune Pancreatitis: chronic inflammation process in which immunoglobulins invade the pancreas. Can infiltrate the lungs and liver.
Idiopathic and Hereditary Chronic Pancreatitis: SPINK1 and CFTR gene mutations
What is PERT? What is education regarding pert?
PERT- pancreatic enzyme replacement therapy: standard of care to prevent malnutrition, malabsorption, and excessive weight loss.
- Pancrelipase: capsule or tablet containing amylase, lipase, and protease.
- –do NOT chew or crush delayed capsules and enteric coating
- –Take with all meals and snacks
- –admin after antacids and H2 blockers
If difficulty swallowing, pierce capsule and give with applesauce
do NOT mix with protein-containing foods
Wipe your lips after taking to prevent skin irritation
Follow-up labs (can cause increased Uric acid levels)
Record number of stools per day, if effective stools become less frequent and less fatty.
How can you prevent exacerbations of chronic pancreatitis?
Avoid things that worse symptoms, i.e. Caffeine
Avoid alcohol ingestion and nicotine
Eat bland, low-fat, high-protein, and moderate-carb meals; avoid gastric stimulants (spices)
Eat small meals and snacks high in calories (4000-6000calories/day)
Take Pancreatic enzymes as prescribed with meals
Rest frequently, restrict activity to one floor until regaining strength
Question: Which foods will the nurse teach the client with chronic pancreatitis to avoid? Select all that apply. A. Blueberries B. Green beans C. Bacon D. Baked fish E. fried potatoes
C. Bacon
E. Fried potatoes
What is a pancreatic abscess?
A pancreatic abscess is a serious complication of acute necrotizing pancreatitis.
recurrence rate is high, purulent liquification of necrotic pancreas.
Spiking temp, high to 104 degrees
Drainage via percutaneous method or laparoscopy to prevent sepsis. ABX alone not effective. May require multiple drainage
What are Pancreatic Pseudocysts? And what are the risk factors for Pseudocysts? What are symptoms? What are complications? Interventions?
AKA false cysts, do not have epithelial lining. Encapsulated saclike structures.
Pseudocysts wall becomes inflamed, vascular, and fibrotic.
Straw-colored or dark brown viscous fluid
Risk factors: Acute pancreatitis, abdominal trauma, and chronic pancreatitis.
Primary symptoms: Radiating epigastric pain to the back. Also abdominal fullness, N/V, and jaundice
Complications: Hemorrhage, infection, Obstruction, Abscess, Fistula formation, and Pancreatic ascites.
Interventions: Surgery if does not resolve within 6-8 weeks. Sump drainage tube to remove pancreatic secretions and exudate.
What is pancreatic cancer? And treatment? Symptoms?
leading cause of cancer deaths, 5 year survival rates are low. Originate from epithelial cells of the pancreatic ducal system.
Most often discovered in late stage and be a well-defined mass
primary or metastasis from lungs, breasts, thyroid, kidney, or skin.
treatment: Chemotherapy and radiation therapy. 5-FU. High dose opioids- morphine.
Biliary stents
Complete surgical resection
Whipped procedure
Symptoms:
Jaundice, clay colored stools, dark urine, abdominal pain (dull, vague, radiates to back), wt loss, N/V/A, glucose intolerance, splenomegaly, gas, GI bleeding, ascites, leg or calf pain, weakness and fatigue.
LAB VALUES TO KNOW:
Ca+ 9.0 - 10.5 K+ 3.5 - 5.0 Albumin 3.5 - 5.0 ALT 4 - 36 AST 0 - 35 Alkaline phosphatase 30 - 120 Bilirubin 0.3 - 1.0 Conjugated bilirubin 0.1 - 0.3 Unconjugated 0.2 - 0.8 Ammonia 10 - 80 Xylose 20 - 57 (60min) 30 - 58 (20min) Amylase 30 - 220. (Wendy 50-180) Lipase 0 - 160. (Wendy 31-186) Cholesterol <200 Carbohydrate antigen19-9: <37 Carcinoembryonic antigen <5
What are key features of a GI bleed?
Bright red blood (upper) coffee ground emesis (lower) Melena stools (dark, tarry) Decreased BP Weak peripheral pulses Confusion, vertigo, lightheaded Decreased H&H
What is Peptic Ulcer Disease?
Most common infection: H. Pylori
-NSAIDs breakdown mucosal layers
Most common reported complication: Indigestion (dyspepsia)
- left of midline pain
- aggravated by food consumption
Pain occurs 1.5-3 hours after eating
No eating before bed
Foods to avoid- Onions, alcohol, caffeine, NSAIDs
Tx:
Proton Pump Inhibitors (Protonix, Prilosec, Nexium)
-Protonix: use IV filter, and use separate line to admin
-Prilosec: give PO 30 minutes before meals
-Nexium: Don’t stop abruptly to prevent rebound secretions.
ABX for H. Pylori
H2 Antagonist: Zantac, Pepcid, Axid
Antacids (no wintergreen) give 1 HR before or 2 HR after meals & HS
Pepto: do NOT give with ASA
When do you seek medical attention with Peptic Ulcer disease?
Sharp, sudden, persistent, severe epigastricor abd pain
Bloody/black tarry stools or vomiting
What are ways to manage GI bleeds?
PRIORITY: ABC’s
Provide O2
2 large bore IVs
Monitor VS and Hematocrit
Gastric lavage (NG tube) done by the physician
What is gastric Cancer? What are risk factors? What are treatment options?
Occurs in the glands of the stomach, spreads via the lymphatic system– carries tumor deposits to the lymph nodes.
Risk factors:
- infection with H. Pylori (#1)
- pernicious anemia
- gastric polyps
- pickled foods
- nitrates
Treatment: Chemotherapy and radiation (causes N/V and bone marrow suppression- give Zofran)
PREFERRED: Surgical resection of the tumor
Metastasis- lymph nodes most common, Resection not available.
Whipped procedure- very severe option.
Monitor CBC, RBC, and WBC (leukopenia)
What is dumping syndrome?
Small frequent meals
Avoid drinks with meals
Do not consume food that causes discomfort
NO alcohol
may need B12 injections (loss of intrinsic factor)
Lie flat after meal to decrease motility
What are Esophageal tumors?
Grows rapidly, no aerosol layer to limit extension
Spreads rapidly to the lymph nodes
Risk factors:
Smoking, alcohol, tobacco, gender (males), untreated GERD, pickled foods, obesity, genetic factors
Assess: Dysphagia, Odynophagia (with cold liquids, painful swallowing), vomiting, halitosis, chronic hiccups
Wt loss is concern for nutrition
Dx: Barrium Swallow (1st) esophageal ultrasound with aspiration to examine tissue EGD to inspect tissue and collect sample PET/CT scan identifying metastasis
Tx: Surgery, chemo or radiation
Education:
Remain upright after meals
HOB >30 degrees to prevent reflux
Semi soft foods and thickened liquids, TPN may be needed at first
To promote swallowing: head forward in flexed position, place food at back of mouth, check for pocketed foods
Fam Education: S/Sx of aspiration
Pre-op: no smoking 2-4 weeks prior to increase resp. Status Nutrition therapy Good oral care and dental visit TCDB + A Chest physiotherapy
Post-op: AIRWAY, Respiratory care essential MIS procedure: less time to heal/short hospital stay, small incision Do not irrigate NG tube-physician does Mechanical ventilation Report weight loss of 5 lbs or more 6-8 small meals, give fluids between Caution: resp infection and hand washing Diarrhea occurs 20mins-2hrs after eating- give Imodium before Tube feeds at first Fatigue and weakness long lasting Avoid large crowds
What is colon cancer? What are risk factors for colon cancer? What are signs and symptoms of colon cancer?
Most common adenocarinoma from granular epithelial cells
Risks: >50 Personal or family Hx Crohn's Disease Ulcerative Cholitis 1st degree relative increase change by 3-4 X for this individual H. Pylori, Strep Bovis, HPV Long-term smoking Obesity, sedentary lifestyle Long, heavy alcohol consumption Hx: If personal Hx of breast, ovarian, and endometrial cancers = increased risk for!!
More common in African Americans, and their survival rate is lower
Education: Diagnostic screening Modify diet Stop smoking and drinking Encourage physical activity
Ask if change in bowel elimination
Pt may report: fatigue, abdominal fullness, vague abd pain, and unintentional wt loss, rectal bleeding (later), changes in stool shape and size, small/micro spots of blood in stool (early), straining to pass stools, narrowing of stools, dull pain.
What are Labs and Diagnostic that are associated with colon cancer? What are nursing Dx associated with Colon Cancer? What are Tx and interventions for Colon cancer?
Labs:
Decreased H&H
Positive Occult blood
Dx:
Double contrast barium enema
Colonoscopy
Sigmoidoscopy
Nursing Dx:
R/F cancer metastasis
Grieving r/t cancer Dx.
Tx:
Remove tumor
radiation and chemotherapy
Interventions: Stool softeners Colostomy- 1st sign of acceptance is starting to watch colostomy cares -side lying in bed -no air rings or donuts -NO gas causing foods/drinks
4-6wks to establish foods on a bowel pattern.
Avoid moisturizing soaps- interfere with adhesive dressing
What are characteristics of a new colostomy?
Yellow, green fluid drainage
Functioning to produce BM in 2-3 days post op
Pain is controlled with analgesics
Absorbent dressing is placed post op (not a surgical dressing)
JP drain in wound- Seriosangiuaous drainage
What are some gas causing foods? gas preventing? Odor preventing?
gas causing:
Cauliflower, cucumber, mushrooms, peas, broccoli, beans, chewing gum, asparagus, cabbage, onions, spicy foods, and Brussels sprouts
gas preventing:
Crackers, toast, yogurt
Odor preventing:
Buttermilk, cranberry juice, parsley, yogurt
