Liver And Pancreas Flashcards
1
Q
Other than the skin, what is the largest organ in the body?
A
The liver
2
Q
Functions of the liver
A
Storage of glycogen (and many vitamins and minerals), protein metabolism, detox, and production of albumin, bile, and coagulation factors
3
Q
Byproduct of protein metabolism
A
Ammonium
4
Q
Ammonium is sent to the liver to be metabolized into ____ which is sent to the kidneys for excretion as urine
A
Urea
5
Q
A phagocytic cell which forms the lining of the sinusoids of the liver and is involved in the breakdown of red blood cells
A
Kupffer cell
6
Q
Functions of albumin
A
Attracts water, transports drugs, binds with calcium
7
Q
What are the two primary functions of bile?
A
- Transports waste out of the body (bilirubin (dead RBCs) and cholesterol) 2. Break down fats during digestion
8
Q
Purpose of coagulation factors
A
Formation of blood clots
9
Q
Extensive scarring of the liver caused by necrotic injury or chronic inflammation over a prolonged period of time
A
Cirrhosis
10
Q
End-stage liver disease that is characterized by irreversible destruction and degeneration of liver cells
A
Cirrhosis
11
Q
In cirrhosis, normal liver tissue is replaced with _____ tissue that lacks function
A
Fibrotic
12
Q
Cirrhosis can lead to
A
Liver failure (b/c scar tissue slows blood flow through liver)
13
Q
Cirrhosis causes
A
Postnectrotic, Laennec’s, Biliary
14
Q
Postnectrotic cirrhosis is caused by
A
Viral hepatitis, or some medications or toxins
15
Q
Laennec’s cirrhosis is most commonly caused by
A
Chronic alcohol use
16
Q
Biliary cirrhosis is caused by
A
Chronic biliary obstruction or autoimmune disease
17
Q
Gastrointestinal S/S of cirrhosis
A
N/V, anorexia, ascites, gray/tan stools, melena, hematemesis, bleeding esophageal and gastric varices (medical emergency)
18
Q
Musculoskeletal S/S of cirrhosis
A
Muscle wasting from poor nutritional status
19
Q
Respiratory S/S of cirrhosis
A
Dyspnea and hyperventilation (b/c of ascites), hepaticus (sweet, musty odor of breath caused by accumulated liver byproducts)
20
Q
Integumentary S/S of cirrhosis
A
Jaundice (yellowing of skin around eyes/mouth) and itching (d/t accumulation of salts under skin)
21
Q
Neurologic S/S of cirrhosis
A
Hepatic encephalopathy
22
Q
Early clinical manifestations of cirrhosis
A
Malaise, RUQ discomfort, GI disturbances (anorexia, indigestion, bowel habit changes)
23
Q
Late clinical manifestations of cirrhosis
A
Jaundice, esophageal varices, ascites, hepatomegaly, splenomegaly, edema, changes in mental responsiveness and memory, spider angiomas (face, neck, shoulder), anemia, thrombocytopenia
24
Q
Blood flows out of the liver through ___ hepatic veins into a big vein called the Inferior Vena Cava
A
3
25
Oxygen-rich blood flows into the liver through the
Hepatic artery
26
Nutrient-rich blood coming from the digestive tract, spleen, and pancreas flows into the liver through the
Portal vein
27
The liver received its blood supply from the hepatic artery and portal vein resulting in about _____ mL of blood flow through the liver every minute
1500
28
Bile flows out of the liver through the
Bile duct
29
High blood pressure in the portal vein resulting from an obstruction before, within, or after the liver
Portal hypertension
30
Portal hypertension most often results from an obstruction _____ the liver due to __________
Within; cirrhosis
31
S/S of portal hypertension
Ascites, splenomegaly, collateral vessels
32
Bloating or swelling due to fluid buildup in the abdomen and legs, and third spacing
Ascites
33
Portal hypertension is classified as > ___ mm Hg
10
34
_________ is caused by backup of blood into the spleen
Splenomegaly
35
Splenomegaly can cause
Thrombocytopenia and platelet destruction
36
Formation of new blood vessels that connect digestive organs directly to general circulation serving as alternate routes for blood to bypass the liver, reduce blood flow to portal vein, and relieving portal pressure
Collateral vessels
37
Complications of collateral vessels
Variceal bleeding and hepatic encephalopathy
38
S/S of hepatic encephalopathy
Confusion, drowsiness, tremor, and coma
39
A network of dilated veins surrounding the umbilicus caused by increased blood flow in the umbilical and paraumbilical veins and is often accompanied by Cruveilhier-Baumgarten murmur
Caput medusae
40
Audible venous hum over the umbilical vein
Cruveilhier-Baumgarten murmur
41
What is the root cause of caput medusae?
Portal hypertension
42
Paracentesis poses a huge risk for
Hemorrhage
43
Bile is made in the _____ and stored in the _________
Liver; gallbladder
44
Bile consists of
Waste products, cholesterol, bile salts
45
Bilirubin that is bound to a certain protein (albumin) in the blood
Unconjugated/indirect bilirubin
46
Bilirubin that is changed by the liver into a form that the body can get rid of
Conjugated/direct bilirubin
47
T or F: the liver makes all the cholesterol you need
True! (The remainder of cholesterol in the body comes from diet such as meat, poultry, and dairy)
48
Yellow discoloration of the skin and mucous membranes caused by an excess accumulation of bilirubin in the blood
Jaundice
49
Byproduct of red blood cell breakdown
Bilirubin
50
Jaundice becomes visible when the bilirubin level is approximately ___ - ___ mg/dL
2-3
51
What are the three main types of jaundice?
Prehepatic, hepatic, and posthepatic
52
__________ jaundice occurs when RBC lysis exceeds the liver’s capacity to conjugate bilirubin, resulting in large amounts of bilirubin to accumulate in the blood
Prehepatic (hemolytic)
53
Causes of Prehepatic jaundice
Transfusion reactions, sickle cell anemia, thalassemia, and autoimmune disease
54
__________ jaundice results from hepatocyte dysfunction which limits the uptake and conjugation of bilirubin, resulting in a rise in the levels of conjugated and unconjugated bilirubin in the blood.
Hepatic
55
Causes of hepatic jaundice
Hepatitis, cancer, cirrhosis congenital disorders, and drugs
56
_________ jaundice occurs when gallstones, inflammation, scar tissue, or tumors block the flow of bile into the intestines, resulting in water-soluble conjugated bilirubin to accumulate in the blood
Posthepatic (obstructive)
57
What type of bilirubin is water soluble?
Conjugated/direct
58
What type of bilirubin is lipid soluble?
Unconjugated/indirect
59
How to calculate total and indirect bilirubin
Total = direct + indirect; Indirect = total - direct
60
An enzyme found in the liver that helps convert proteins into energy for the liver cells. When the liver is damaged, this enzyme is released into the bloodstream and levels increase
Alanine transaminase (ALT)
61
ALT range
4-36 units/L
62
An enzyme found in the liver AND bone important for breaking down proteins
Alkaline phosphatase (ALP)
63
Elevated ALP may indicate
Liver damage/disease (such as blocked bile duct) or certain bone diseases
64
ALP range
30-120
65
An enzyme that helps metabolize amino acids, normally present in the blood at low levels. An increase in this enzyme may indicate liver damage, disease, or muscle damage
Aspartate transaminase (AST)
66
AST range
0-35 units/L
67
Bilirubin passes through the liver and is excreted in
Stool
68
Why is serum bilirubin elevated in liver damage/disease?
Due to the inability of the liver to excrete bile
69
Serum protein range
6.4-8.3 g/dL
70
Serum albumin range
3.5-5 g/dL
71
RBC range for males and females
Males: 4.7-6.1; Females: 4.2-5.4
72
Hematocrit range
12-16
73
Hemoglobin range
37-47%
74
Platelets range
150-400k
75
PT and INR range
PT: 11-12.5; INR: 0.8-1.1
76
The time it takes blood to clot is called
Prothrombin time (PT)
77
Ammonia range
6-47
78
Labs elevated with liver damage/disease
ALT, ALP, AST, bilirubin, PT/INR (prolonged), ammonia
79
Labs decreased with liver damage/disease
Protein, albumin, RBCs, H&H, platelets
80
Inflammation of the liver
Hepatitis
81
HAV transmission
Fecal-oral route
82
Symptoms of HAV
Loss of appetite, diarrhea, fever, nausea, malaise, jaundice
83
HAV recovery time
6 weeks
84
T or F: HAV does not result in permanent liver damage
True
85
HBV transmission
Via blood or bodily fluids (tears/saliva)
86
HCV transmission
Via blood or bodily fluids
87
HCV symptoms
Asymptomatic, flu-like symptoms
88
HDV transmission
Via blood or bodily fluids; Can only be infected with HDV if you have HBV already
89
HEV transmission
Fecal-oral route
90
HEV duration
2-8 weeks
91
HEV symptoms
Jaundice, nausea, fatigue
92
What types of hepatitis carry a greater risk of liver failure and cirrhosis?
HDV and HEV
93
What types of hepatitis have vaccines?
HAV and HBV
94
Symptoms of acute hepatitis
Yellowing of the skin and eyes, nausea, fever, and fatigue
95
Symptoms of chronic hepatitis
May be asymptomatic
96
Populations at risk for chronic hepatitis C virus
Those who had blood transfusion before 1992, those who have experimented with IV drugs or snorted cocaine, those who have gotten tattoos with a non-sterile needle, those who have had unprotected multiple sexual partners
97
Hepatitis phases
Preicteric, icteric, posticteric
98
Describe the preicteric (prodromal) phase of hepatitis
Flui-like symptoms: joint pain, fatigue, N/V, abdominal pain, change in taste; increasing levels of liver enzymes and bilirubin
99
Describe the icteric phase of hepatitis
Decrease in flu-like symptoms but will have jaundice, dark urine, clay-colored stool, enlarged liver and pain in this area
100
Describe the posticteric (convalescent) phase of hepatitis
Jaundice and dark urine start to subside and stool returns to normal brown color, liver enzymes and bilirubin decrease to normal
101
Populations at risk for HAV and HEV
Crowded conditions, poor hygiene of food handlers, poor sanitation
102
HAV incubation
15-50 days
103
Prevention of HAV
Good handwashing, HAV vaccine (need 2 doses at least 6 months apart)
104
Populations at risk for HBV and HDV
Health care workers, IV drug abusers, individuals who reside with persons who have HBV, individuals who undergo dialysis
105
HBV incubation
45-160 days
106
HBV and HDV prevention
Good handwashing, HBV vaccine, needle precautions, avoid unprotected contact with bodily fluids of infected persons, blood donor screening, testing of women who are pregnant
107
Populations at risk for HCV
Health care workers, IV drug users, high-risk sexual practices, blood transfusions administered prior to 1992
108
HCV incubation
14-180 days
109
HCV prevention
Good handwashing, blood donor screening, needle precautions, avoid unprotected sex with infection persons
110
HDV incubation
2-26 weeks
111
HEV incubation
15-64 days
112
Liver cancer risk factors
Older age, cirrhosis, male, gender, tobacco use
113
S/S of liver cancer
Abdominal pain, weight loss, weakness/fatigue
114
Liver cancer assessment
Enlarged liver, jaundice, ascites, pruritis, encephalopathy, bleeding/bruising
115
Liver cancer diagnosis
Biopsy
116
What is the most frequently occurring type of liver cancer?
Hepatocellular carcinoma (HCC)
117
Primary liver cancer can originate in the
Bile duct or liver vasculature
118
Cancers can be __________ tumors originating in the liver or __________ that spread from other organs to the liver
Primary; metastatic
119
Cancer that starts in the cells that line the small bile ducts
Intrahepatic cholangiocarcinomas
120
Rare cancer that starts in cells lining the blood vessels of the liver
Angiosarcoma/hemangioma
121
Rare liver cancer that develops in children, typically younger than 4 years old
Hepatoblastoma
122
An endoscopic procedure that allows the doctor to examine the esophagus, stomach and duodenum
Esophagogastroduodenoscopy (EGD)
123
EGD characteristics
Outpatient procedure, patient goes home the same day, takes approximately 30-60 min to perform
124
Priority for patient getting an EGD
Preventing aspiration (no food or drink until gag returns)
125
A procedure that combines upper gastrointestinal (GI) endoscopy and X-rays to treat problems of the bile and pancreatic ducts
Endoscopic retrograde cholangiopancreatography (ERCP)
126
A liver biopsy identifies
The progression and extent of cirrhosis
127
Liver biopsy is done under __________ for safety due to risk for bleeding
Fluoroscopy
128
Liver biopsy most common route
Percutaneous route
129
Describe the process of percutaneous liver biopsy
Patient supine with right hand resting above head, local anesthetic applied to biopsy site (expect burning), IV tube used for sedatives or pain meds during or after procedure, incision less than 1/4 in made on right side of chest wall between ribs, biopsy needle inserted, patient should exhale and hold breath while needle is inserted, several sample may be collected
130
Post percutaneous liver biopsy interventions
Patients must lie on right side for up to 2 hours to reduce risk of bleeding; patients monitored an additional 2-4 hrs after biopsy before being sent home
131
Why is transjugular liver biopsy not the preferred method of liver biopsy?
Because it provides small liver samples
132
Transjugular liver biopsy is reserved for patient with
Significant blood clotting disorders or ascites
133
Describe the process of transjugular liver biopsy
Patient supine, local anesthetic applied to right side of neck, small incision made on neck and sheath (hollow tube) is inserted into jugular vein, sheath is threaded down the jugular vein, along the side of heart, and into one of hepatic veins (located above liver). Contrast dye used to show proper location of sheath. Biopsy needle threaded through sheath and into liver. Liver sample is quickly withdrawn. Several samples may be collected.
134
Transjugular liver biopsy post-procedure care
Sheath is withdrawn and incision is closed with a bandage. Patient monitored for 4-6 hours for signs of bleeding
135
Percutaneous liver biopsy complications
Pain at biopsy site (most frequent), hemorrhage, puncture of other internal organs (lungs, bile ducts), leakage of bile inside the abdomen at biopsy site, spread of cancer cells (cancer seeding)
136
Indications for abdominal paracentesis
Used to relieve ascites
137
Abdominal paracentesis nursing care
Assist patient to void prior to procedure (safety), consent, position patient supine with HOB elevated, apply dressing over puncture site, measure fluid and document
138
A procedure used to reduce portal HTN and its complications, especially variceal bleeding. A stent is placed in the middle of the liver and connects the hepatic vein with the portal vein, which reroutes blood flow in the liver and helps reliever pressure in abnormal veins
Transjugular intrahepatic portosystemic shunt (TIPS)
139
Surgery to replace a diseased liver with a healthy liver from another person
Liver transplant
140
A nervous system disorder brought on by severe liver disease
Hepatic encephalopathy
141
Hepatic encephalopathy triggers
Infection, constipation, dehydration, GI bleeds, medications (sleep, pain, water pills), kidney disease, alcohol binge
142
Early symptoms of hepatic encephalopathy
Forgetfulness, confusion, and breath with a sweet or musty odor
143
Advanced symptoms of hepatic encephalopathy
Shaking of the hands or arms, disorientation, and slurred speech
144
Hepatic encephalopathy treatment
Removal of toxic substances from the intestine
145
Type ___ hepatic encephalopathy is brought on by acute liver failure (without underlying chronic liver disease)
A
146
Type ___ hepatic encephalopathy occurs in some people who have a shunt that connects two veins inside the liver without underlying liver disease
B
147
Type ___ hepatic encephalopathy results from chronic liver disease and cirrhosis
C
148
What are the four main parts of the pancreas?
Head, neck, body, tail
149
The widest part of the pancreas found in the right side of the abdomen, nestled in the curved of the duodenum
Head
150
The thin section of the gland between the head and the body of the pancreas
Neck
151
The middle part of the pancreas between the neck and the tail. The superior mesenteric artery and vein run behind this part of the pancreas
Body
152
The thin tip of the pancreas in the left side of the abdomen, in close proximity to the spleen
Tail
153
The _________ pancreas produces enzymes that help to digest food, particularly protein
Exocrine
154
The __________ pancreas makes the hormone insulin, which helps control blood sugar levels
Endocrine
155
Exocrine cells of the pancreas that produce and transport enzymes that are released into ducts and then passed into the duodenum where they assist in the digestion of food
Acinar cells
156
Small islands of endocrine cells in the pancreas that release hormones such as insulin and glucagon into the bloodstream, which maintain proper blood glucose levels
Islets of Langerhans
157
Sudden inflammation of the pancreas that is reversible if caught quickly and treated
Acute pancreatitis
158
Causes of acute pancreatitis
Gallstone, alcohol, infection, tumors, medications, trauma
159
S/S of acute pancreatitis
Sudden severe midepigastric pain, N/V, fever, tachycardia, hypotension, hyperglycemia, confusion/agitation, guarding abdomen, rigid abdomen, grey-turner’s sign
160
Bluish discoloration at the flanks
Grey-Turner’s sign
161
Irreversible inflammation of the pancreas
Chronic pancreatitis
162
Causes of chronic pancreatitis
Repeated acute pancreatitis, alcohol, cystic fibrosis
163
S/S of chronic pancreatitis
Chronic epigastric pain or NO pain, pain increases after ETOH or fatty meal, steatorrhea, weight loss, jaundice, DM, dark urine
164
Bluish discoloration of the umbilicus
Cullen’s sign
165
How does pain differ in acute versus chronic pancreatitis?
Individuals with an acute attack will have severe pain all the time. With chronic pancreatitis, the affected individual will not always have pain, but pain will be exacerbated after consuming alcohol or a fatty meal.
166
An autodigestion of the pancreas by pancreatic enzymes that activate prematurely before reaching the intestines
Pancreatitis
167
Inflammation of pancreatic tissue causes…
Duct obstruction
168
Pancreatitis can result in
Pancreatic inflammation, necrosis, and hemorrhage
169
Classic presentation of an acute pancreatitis attack
Severe, knifelike pain in the LUQ, midepigastric region, and/or radiating to the back
170
Chronic pancreatitis that is calcifying is often associated with
Alcohol abuse
171
Chronic obstructive pancreatitis is associated with
Cholethiasis
172
Pancreatitis risk factors
Biliary tract disease, alcohol use, older adults, GI surgery, metabolic disturbances, kidney failure, trauma, medication toxicity, viral infections, cigarette smoking
173
S/S of pancreatitis
Severe abdominal pain, board-like abdomen, ecchymosis (flank and/or umbilicus), N/V, hypotension
174
Elevated labs with pancreatitis
Serum amylase and lipase (lipase remains elevated longer), WBC, bilirubin, alkaline phosphatase, triglycerides, LDH/AST, Hct, glucose, PTT prolongation
175
Decreased labs with pancreatitis
Serum albumin and protein, calcium, potassium, Hgb
Note: potassium low with GI loss; potassium high secondary to tissue necrosis, acidosis, renal insufficiency
176
Pancreatitis urinalysis
Glucose, myoglobin, blood, and protein may be present
177
A disorder of motor control characterized by an inability to actively maintain a position and consequently irregular myoclonic lapses of posture affecting various parts of the body independently
Asterixis
178
Asterixis is a type of negative myoclonus characterized by a brief loss of muscle tone in _________ muscles followed by a compensatory jerk of the _________ muscles
Agonist; antagonist
179
Asterixis is most commonly associated with
Metabolic encephalopathies and structural brain lesions (unilateral Asterixis)
180
How to test Asterixis
Extend the arms, dorsiflex the wrists, and spread the fingers to observe the “flap” at the wrist
181
How to test for Asterixis at the hip joint
Keep patient supine with knees bent and feet flat on table, leaving the legs to fall to side (assess the knees)
182
Risks for pancreatic cancer
Genetics, age > 45, males, African American, Tobacco use, chronic pancreatitis, high intake of red meat, long-term gas and pesticide exposure, DM, family hx
183
S/S of pancreatic cancer
Pain that radiates to back, fatigue, anorexia, pruritis
184
Pancreatic cancer assessment
Weight loss, palpable abdominal mass, hepatomegaly, clay-colored stool, dark/frothy urine, ascites
185
Diagnosis of pancreatic cancer
Biopsy, ERCP
186
Characteristics of pancreatic cancer tumors
Usually adenocarcinoma, originate in pancreatic head, and grow rapidly in glandular patterns
187
A complex operation to remove the head of the pancreas, duodenum, the gallbladder, and the bile duct to treat tumors and other disorders of the pancreas, intestine, and bile duct
Whipple procedure (pancreaticoduodenectomy)
188
On average, the whipple procedure takes about ___ hours to complete and most patients stay in the hospital for ___-___ weeks following the surgery.
6; 1-2
189
Cirrhosis nursing interventions
Elevate HOB (respiratory), monitor skin integrity w/ scratching, I&Os, daily weights, measure abdominal girth
190
Cirrhosis diet
High carb, high protein, moderate fat, low sodium, vitamin supplements, fluid restriction
191
Cirrhosis medications
Diuretics, beta-blockers (for varices), lactulose
192
Medication used to promote excretion of ammonia from the body through the stool
Lactulose
193
Lactulose MOA
Lowers colon pH, converts ammonia to ammonium so it is no absorbed, and works as a laxative to eliminate stool
194
Medication that works by suppressing colon bacteria that convert ammonia in the gut
Neomycin/rifaximin
195
Nursing interventions for pruritis
Cool clothes, soft bedding, tepid baths, restrict activities that increase temp and sweating, cool environment, short nails, no drying soaps, administer cholestyramine, oatmeal bath, pat skin dry
196
Nursing interventions for ascites
HOB in semi-Fowler, measure and record abdominal girth, restrict sodium
197
Medications for ascites
Spironolactone, albumin
198
The presence of neurological symptoms caused by biochemical lesions of the central nervous system after exhaustion of B-vitamin reserves, in particular thiamine (B1)
Wernicke’s encephalopathy
199
Diet for client with wernicke’s encephalopathy IF they have signs of coma
High carb, low protein
200
Too little protein lead to __________, and too much protein can lead to __________
Muscle wasting; encephalopathy
201
Thiamine and folic acid deficiency lead to
Peripheral neuropathy
202
Components of a “banana bag” or “rally pack”
100 mg thiamine, 1 mg folic acid, multivitamins in NS or DW, 1-2 g of Mg
203
How to measure abdominal girth
Client supine, measure at level of umbilicus, mark client’s abdomen along sides of tape on flanks and midline prior to removal of tape to ensure later measurements are taken in same place
204
Drain placed in pleural cavity for the treatment of ascites
PleurX drain
205
Hepatitis diet
High carb, high calorie, low-mod protein, small frequent meals, avoid alcohol
206
Nursing interventions for hepatitis
Prevent transmission to others (priority!), hand washing
207
Prevention of hepatitis A
Handwashing, education on proper preparation of shellfish, immunization (including post-exposure), educate day care workers
208
Proper shellfish preparation education
Steam 90 sec or boil 4 min at 185-195 degrees; only buy from reputable source
209
DTs related to alcohol withdrawal typically occur ___-___ hours after last drink and peaks at ___-___ hours
30-120; 24-48
210
S/S of DTs
Increase HR, BP, and Temp, shaking, vomiting, sweating
211
Medications for DTs related to alcohol withdrawal
Ativan, Valium, Librium
212
Nursing interventions for hepatic encephalopathy
Administer lactulose, monitor potassium d/t hypokalemia related to lactulose (GI losses), assess LOC, watch for Asterixis (indicates worsening encephalopathy) and fetor hepaticus, bed rest (exercise produces ammonia)
213
Nursing interventions for pancreatitis
NPO (until pain free), NGT, TPN (severe), NO alcohol, IV fluids/electrolyte replacement, antiemetics, pain management, limit stress
214
Pancreatitis diet after recovery
Bland high protein, low fat with no stimulants (caffeine), small frequent meals
215
Pancreas labs
ELEVATED: amylase, lipase, glucose, triglycerides, DECREASED: calcium
216
Normal blood amylase
23-85 units/L, although some lab ranges may go up to 140 units/L
217
Normal lipase levels
0-160 U/L
218
__________ is one of the components of Ranson’s scoring system done to assess the severity of pancreatitis
Hypocalcemia
219
Medication indicated for chronic pancreatitis and cystic fibrosis that aids in digestion of fats and proteins when taken with meals and snacks
Pancrelipase
220
How to take pancrelipase
Can sprinkle on foods, drink a full glass of water
