Med-Surg 2: GI/Hepatic/Pancreas Disorders Flashcards
0
Q
Some risk factors for IBS?
A
- High fat diet
- Alcohol
- Smoking
- Carbonated beverages
- Caffeine
- Stress
- Women more than men
1
Q
Functional disorder of motility of the intestines =
A
Irritable Bowel Syndrome.
2
Q
Clinical Manifestations of IBS:
A
- Abdominal pain/cramping
- Often after meals
- Bloated feeling
- Flatulence
- Diarrhea and/or constipation
- Relief after defecation: hallmark usually
- Mucus in the stool
3
Q
What is the Rome II symptom-based criteria for IBS?
A
- Abdominal pain/discomfort for at least 3 consecutive months within 12 months
- Symptom relief with defecation
- Change in frequency/appearance of stool
- mucous or ribbon-like
4
Q
How do you diagnose IBS?
A
- No specific test
- Diagnosis of exclusion
- Rule out lactose intolerance
- Colonoscopy: more of a rule-out thing
- Rome III symptom-based criteria
- Abdominal pain x 3 months
- Symptom relief with defecation
- Change in frequency/appearance of stool
- mucous or ribbon-like
5
Q
How do you manage IBS?
A
- Stress reduction: walking dog, warm bath, whatever reduces stress; even a glass of wine
- Avoid food triggers
- Fiber- 20 gms/day (plus hydration!)
- proceed with caution!! Do gradually.
- avoid gas producing foods: cabbage
- Bulking agents- Metamucil
- Probiotics: healthy bacteria; in certain yogurts, etc.
- Meds- Loperamide (Imodium)–for diarrhea; slows GI motility, Lotronex (severe IBS) Anticholinergics (Bentyl, Levsin)–may make sleepy, dizzy so may need to lie down when first taking.
6
Q
What are some meds to take for IBS?
A
- Bulking agents- Metamucil
- Probiotics: healthy bacteria; in certain yogurts, etc.
- Meds- Loperamide (Imodium)–for diarrhea; slows GI motility, Lotronex (severe IBS) Anticholinergics (Bentyl, Levsin)–may make sleepy, dizzy so may need to lie down when first taking.
7
Q
What do you need to tell the patient about Levsin and Bentyl?
A
It may cause dizziness and somnolence so they may need to lie down after they take it.
8
Q
What quadrant would appendicitis be in?
A
RLQ
9
Q
What are some things that can cause appendicitis?
A
Fecalith (a fecal calculus or stone) that occludes the lumen of the appendix; kinking/twisting of appendix; occlussions; infection; fibrous conditions; etc.
10
Q
What are three complications of Appendicitis?
A
Rupture/perforation; Peritonitis; gangrene.
11
Q
Clinical Manifestations of Appendicitis?
A
- Nausea/vomiting
- Acute abdominal pain
- Positive McBurney’s test: Push down on RLQ and lift up; pain when lifting up–rebound tenderness
- Pain can start in epigastric/periumbilical
- Progression to RLQ pain
- Guarding
- Sometimes only slight leukocytosis: unless ruptured appendix
- May have a low grade fever
12
Q
Would you put ice or heat on the painful spot caused by appendicitis?
A
ICE. Heat could cause rupture.
13
Q
Do you do a bowel prep pre-op for appendicitis?
A
NO bc it could cause rupture.
14
Q
What kind of diet should a person with IBS have?
A
High-fiber, low-fat, well-balanced; avoid problematic foods, carbonated beverages, limit smoking/alcohol
15
Q
Which test can you perform to test for appendicitis?
A
McBurney’s: press down on the RLQ and will have pain when lifting up (rebound tenderness)
16
Q
Post-op care for Appendicitis:
A
- Risk for infection- Perforation
- Risk for decreased fluid volume related to vomiting
- NGT (to decompress stomach bc of n/v), monitor I/O, Diet?–still gonna be NPO for a couple days because of no peristalsis; will do TPN after a while–try to hold off until they really have to (have to have central line, it’s expensive); may do J-tube–enteral feeding preserves gut integrity (“don’t use it, you lose it”).
- Pain management: PCA pump or IV meds usually
- Up first post day
- Restrict lifting for 3-4 weeks post-op
- Other usual post-op care for abdominal surgery patient
- Common complaint after Lap surgery is the pain in the shoulder from the CO2 traveling upwards; can apply warm blanket to shoulder.
- All other rules for post-op abdominal surgeries applies.
17
Q
After an appendectomy, restrict lifting for ____
A
3-4 weeks
18
Q
S/S of Peritonitis:
A
- Sudden onset
- Fever
- Increased pain
- Guarding, spasms
- Vital signs? Increase in BP/Tachy/RR in beginning because of pain; increased RR, but depth of respirations will be shallow because it hurts to breathe in–risk for atelectasis/pneumonia later on; if they go into sepsis, BP may drop because of fluid shifts
- Bowel sounds? decreased.
- N/V
- Rigid board-like abdomen*
- Elevated WBC: because of infection.
19
Q
Management of Peritonitis:
A
- Prevent with early dx of abdominal infection, meticulous abd. assessment!
- Bowel rest (NPO)/ NGT to LWS (low wall suction)
- Dressing changes/drains: often large dressing changes; wet-to-dry; wound vac maybe; may need Penrose or JP drain–make sure to label drains (right side/t-tube/whatever it is); make sure to record drainage
- IV antibiotics
- F&E balance
- Analgesics
- Prevent complications of immobility
20
Q
Crohn’s is more common in the ___ intestines (terminal ileum); thus, the ___ &__ quadrants would be involved. However, the ___ can also be involved.
A
small; RUQ & RLQ; ascending colon.
21
Q
Crohn’s appearance?
A
Cobblestone, skipped lesions.
22
Q
Ulcerative Colitis affects ____; it starts in the ___ and spreads ____; Therefore, it starts on the ___ side. There are distinct ___ between healthy and diseased colon.
A
entire length of colon; rectum; upward; left; demarcations;
23
Q
Diarrhea can be in both Crohn’s and Ulcerative Colitis, but it is more frequent in ____.
A
UC
24
With Crohn's, the ___ is involved which results in altered ___ metabolism which results in _____.
ileum; fat metabolism; steatorrhea (fat in stool).
25
Clinical Manifestations of IBD (Crohn's and Ulcerative Colitis):
* Diarrhea in both– but, more frequent with ulcerative colitis
- Stool characteristics? Can be up to 20/day (especially in ulcerative colitis)
- Crohn’s-ileum is involved, altered fat metabolism: ileum normally absorbs fat; steatorrhea (fat in stool).
* Cramping: in both
* Weight loss
* Nutritional deficits
- Decreased iron binding capacity, malabsorption (A,D,E,K--fat soluble vitamins)
* Abdominal assessment/ and pain
* Dehydration: high risk
* Rectal bleeding: especially with UC
26
How long can TPN hang?
24 hours
27
What do you need to do/think about when using TPN?
We don't have to spike tubing; pharmacy does it; Can only hang for 24 hours and then you change it; lipids may be hung separately; Do accuchecks with pt because there's high concentrations of glucose (insulin may be put into it); has lots of stuff in it; Will need to monitor electrolyte levels (because TPN has a lot of stuff in it); Physician has to order it; Daily weights will need to be done
-Do you check residuals and/or placement with J-tube? NOPE. You do with G-tube/PEG.
28
Management of Ulcerative Colitis and Crohn's?
* Fluid & electrolyte balance
- Manage diarrhea
- Anti-diarrhea meds- immodium
- Labs, monitor weight, I&O
- Bowel rest: NPO
- What about nutrition? Enteral or TPN
- Preferred route of nutrition if possible? Enteral preferred; surgeon has to insert J-tube, though.
- Elemental diets
- TPN may be necessary (total parenteral nutrition): increases risk for sepsis from breaking down of gut integrity
29
Nutrition for IBD?
* Follow My Pyramid guidelines if they are able.
* No smoking- increases GI motility
* Small frequent meals
* Individualize diet plan
- Food diary to ID “problem” foods
* Reduce high fat foods esp. if large portion of ileum removed/diseased
* Evaluate for lactose intolerance
* Low-fiber, low-residue often recommended
- Easily digested foods-what are they? Clear liquids, broth, mashed potatoes, refined flours, baked meats (no fried shit); NO cabbage/broccoli
Supplementation
* B12 if ileum inflamed or removed
- Lack of B12 prevents RBC maturation=anemic; may need injections of B12
* Folic acid (folate)- especially if on Azulfidine--causes folate deficiency even more.
* Multivitamin
- Malabsorption of fat soluable vitamins
* (A,D,E,,& K) **decreased Vit K= Bleeding potential
* Supplement iron if anemia present
* Monitor for electrolyte deficiencies
* Calcium
30
Azulfidine causes ___ deficiency.
folate.
31
Decreased Vitamin K = potential for _____
bleeding.
32
People with a lack of B12 may be _____
anemic.
33
With Azulfadine, monitor for allergy to _____
sulfa; it's a combo of ASA & sulfa.
34
Remicade is an IV drug used for _____
Crohn's.
35
What adverse reactions do you have to worry about with Remicade (infliximab) and Humira (adalimumab)--(Tumor Necrosis Factor Inhibitors)?
Risk of allergic Rx/transfusion reaction (chills, aching, diaphoresis, trouble breathing, possibly back pain), infections, reactivating TB, hepatitis/liver damage, lymphoma, & Bone marrow suppression.
36
First-line meds for IBD =
Anti-tumor necrosis factor
37
Azulfidine is used for ______
Ulcerative Colitis
38
Asacol and Colazol are used for ____ and have less side effects than Azulfidine.
Ulcerative Colitis.
39
Comes in a suppository form, used for distal IBD disease.
Rowasa.
40
Imuran may take ____ months to work.
6
41
What is a risk for Imuran?
allergic IV reaction.
42
What is an immunosuppressive med given for IBD?
Imuran.
43
Removing the diseased portion of the intestines for a patient with _____ may provide a cure.
Ulcerative Colitis.
44
Clinical Manifestations of Diverticulosis:
- Diverticulitis: inflammation of diverticuli
- Crampy abdominal pain
- Nausea
- Alternate between diarrhea and constipation
- Flatus
- Low grade fever
45
Risk factors for diverticulosis:
Low fiber diet; congenital predisposition.
46
Prevention of Diverticulitis:
- Prevent constipation
- High fiber diet – foods? 20 grams a day
- Hydration: drink lots of water with fiber! Constipation will be worse if they don't; Whole grains, whole wheats, veggies; they ARE able to eat nuts/tomatoes/popcorn, unlike some people think.
- Monitor for systemic symptoms: signs of infection--fever, malaise, etc.
- Monitor for abdominal pain
47
Diverticulitis can be dangerous bc they can rupture and lead to ______
Peritonitis.
48
Management of Diverticulitis:
* Colon rest
- Bed rest
- NPO or liquid diet
- NG tube if vomiting
* Antibiotics
* Pain management
* Some will require surgery
- Colon resection
- Temporary colostomy until healing
* Dietary modifications
* High Fiber Diet-regulates bowel function
* Water intake-Best if have 6-8 glasses of 8 oz of water per day
49
The part of the intestines that is important in the absorption of nutrients and fats:
ileum (small intestines)
50
The large intestine reabsorbs __&___
water and sodium
51
What will stool from an ileostomy look like?
semi-formed, liquidy/mushy
52
What are the benefits of a Kock Pouch over an Ileostomy?
Ileostomy has bag and KP doesn't (internal pouch--will have feeling of fullness). Risk for skin breakdown with Ileostomy. Ileostomy is continually leaking and may have to empty it 4-5 times a day.
53
The Kock Pouch and J-pouch are contraindicated with _____
Crohn's.
54
The J-Pouch is used for _____
Ulcerative Colitis.
55
How is the J-Pouch different from the Kock Pouch?
able to defecate thru rectum with J-Pouch.
56
Diarrhea is common after a Bowel Resection for ____ weeks.
6
57
What are some risks with a Bowel Resection?
Dumping Syndrome, Paralytic Ileus (distended abdomen, n/v, no bowel sounds/hypoactive), Anemia; decreased absorption of B12 & digestion of fat, glucose, and protein; Peritonitis; Peforation; F&E imbalance; hemorrhage; obstruction.
58
When do you irrigate an ileostomy?
NEVER!
59
When should you empty an ileostomy bag?
When it's about 1/3 full.
60
Necrosis of a stoma is most common within the first ______
48-72 hours.
61
What type of meds should you avoid with an ileostomy?
Enteric-coated.
62
How much fluid should you drink when you have an ileostomy?
2-3 L: risk for dehydration bc of constant output
63
What diet recommendations should you give a person with an ileostomy?
LOW fiber; high protein/carb/calorie; supplement fat-soluble vitamins and b12; chew food well; lots of fluids.
64
What is the stool like with a J-Pouch?
loose bc colon is removed.
65
What can happen in 30% of patients with a J-Pouch?
Pouchitis.
66
What are some symptoms of Pouchitis?
pain in area, increase in diarrhea, bleeding, fatigue, fever, etc.
67
J-pouch carries a risk of possible _______
sexual dysfunction.
68
Risk factors for Colorectal Cancer:
*Personal or family hx of colorectal polyps or cancer
–Age consideration >50 y/o: everyone
–Genetic abnormalities have been identified
*Life style
–Obesity, smoking, ETOH
–High fat, low fiber diet (animal-- red meat sources)
-Mediterranean diet best for us & veggies, whole wheat, etc
69
What is the Gold Standard screening for Colorectal Cancer?
Colonscopy!
70
What are the recommendations for colonoscopies for prevention of colorectal cancer?
–Colonoscopy Q 10years age 50 y/o, AA age 45
§If have 2 primary relatives (mother, father, sister, brother, but also think about 1st set of grandparents) with CRC before 60, begin screening at age 40
§Or 10 years before the dx was made in the family member (mom was diagnosed at 35, then you need to be screened at 25)
–repeat every 5 years if polyp is found
71
What are some screening methods for colorectal cancer other than colonscopy?
–FOBT (fecal occult blood test), DRE (check for low polyp in sigmoid) and Stool for DNA markers
–Double contrast BE (barrium enema)--what is this procedure, Flexible Sigmoidoscopy--while awake, stick tube up rectum into sigmoid, uncomfortable--might as well just get a colonoscopy
–Virtual colonoscopy: swallow pill and can see stuff
§What are the disadvantages ? Can't remove anything during it
72
Clinical Manifestations of Colorectal Cancer:
*General changes
*Weight loss, weakness, anorexia, nausea, vomiting
*More specific
–Abdominal pain, cramping
–Palpable mass
*Change in stool size, color, frequency
§Left side vs. right side symptoms? Left side=change in shape/size; ribbon-like; more in left than right side
–Blood in stool
-May have constipation
73
Pre- and Post-op care for Bowel surgery:
--Pre-op: bowel prep (Go-Lightly or Magnesium Citrate); need to be able to see through the stool (should be clear pretty much); some people may have trouble with Go-Lightly so may have to get enema (nursing assistant can do regular cleansing enemas but we have to monitor the patient); Patient can get dizzy/pass out because they are depleted. If you send them down to endoscopy and they are not cleansed, MD will be pissed. Antibiotics for 24-48 hours beforehand.
--Post-op: give Versed, Morphine, etc; will be out of it; Monitor LOC and airway--put on left side (empties air and prevents cramping)--tell patients to pass gas even if they don't want to; NG tube with suction until peristalsis returns; Rectal drainage (may need undies); monitor stoma (should be red and moist)--dark/dusky=call surgeon immediately.
74
With a double-barreled colostomy, the proximal end will have ___ coming out while the distal end will have ___ coming out. The ___ end may not even need a pouch and can be covered with a gauze dressing.
feces; mucous; distal.
75
___ colostomies are usually permanent while __ &___ ones are usually temporary.
Single-barrel; Double-barrel & Loop
76
With a 2-piece ostomy, they should change the pouch/faceplate every ___ days.
4-7 (or when leakage occurs).
77
Which stomas should be irrigated?
Pt's with end sigmoid colostomies
78
What is the criteria for colostomy irrigation?
**Criteria for irrigation:
–Descending colon or sigmoid colostomy
–Patient able and interested in learning to irrigate
–Absence of stomal hernia or prolapse
–Better if had regular bowel habits prior to colostomy
–Encourage patient with retracted stoma to irrigate
–Need to have running water (indoor plumbing): clean water source
79
How much water do you use when irrigating a stoma?
500-1000 mL.. 1500 max
80
What kind of water do you use when irrigating a stoma?
luke warm tap water.
81
How long do you instill the water when irrigating a stoma?
About 5 minutes.
82
How long do you wait for return when irrigating a stoma?
30-45 minutes.
83
The nurse evaluates the client’s stoma during the initial postoperative period. Which of the following observations should be reported immediately to the MD?
a. The stoma is slightly edematous
b. The stoma is dark red to purple
c. The stoma oozes a small amount of blood
d. The stoma does not expel stool
B is the answer; A&C are normal post-op; B is correct bc it could mean necrosis; D can be normal INITIAL post-op
84
Risk factors for GERD:
Alcohol, Overweight, Pregnancy, Smoking.
85
Clinical Manifestations & Complications of GERD:
*Heartburn
–Pain radiation: To shoulder, neck, jaw or back; sometimes hard to tell the difference between cardiac and GERD pain.
-Usually 30-60 mins after meal.
*Acid regurgitation
*Belching
*Long term effects: Risk for Barrett's Esophagus after long-term--cells change and become pre-cancerous
86
What are some ways of diagnosing esophageal complications of GERD?
EGD (Esophagogastroduodenoscopy); Esophageal Manometry (measures pressure in the esophagus); Barium Swallow/x-ray
87
Foods to avoid with GERD:
```
–Chocolate
–Citrus fruits
–Caffeine
–Fried and fatty foods
–Garlic and onions
–Mint
–Tomato based foods
```
88
Lifestyle and Diet changes for GERD:
–Avoid food triggers
–Small meals
–No eating or drinking 3 hours before sleeping
–Elevate HOB--not just pillows but elevate frame of bed--Reverse Trendelenberg
–Lose weight if overweight
–Avoid tobacco
–Avoid meds that irritate esophagus: NSAIDS, Anticholinergics, CCB's, BB's, Bisphosphonates (Fosamax, Actonel) -Delay gastric empty
89
When do you take antacids?
1 hour before meals or 2-3 hours after.
90
Meds for GERD:
*Antacids: Gaviscon
*Take 1 hour before meals or 2-3 hours after
*H2 receptor blockers (Zantac, Pepcid)
-Decrease gastric acid secretion
*Cholinergics (Metoclopramide/ Reglan)
-Increase gastric empty time (enhance GI motility)
*Proton Pump Inhibitors
–Lansoprazole (Prevacid) or Esomeprazole (Nexium) and Prilosec
–Suppress gastric secretions
–Promote/Increase healing time of ulcers
91
Risk factors for Hiatal Hernias:
- Women more than men
- Obesity
- Pregnancy
- After 60
- Trauma
92
Clinical Manifestations of Hiatal Hernias:
*Varies with type of Hiatal Hernia
*Nocturnal heartburn
*Sub-sternal pain, feeling of fullness
*dysphagia
*Pain worse: (like GERD)
–After meals
–Lying down
–ETOH
–smoking
*Complications: esophagitis; eso. cancer; GERD; strangulation of stomach/esophagus
93
Management of Hiatal Hernia:
```
Conservative; same as GERD
–Small meals
–Don’t lie down after eating
–Antacids
–H2 receptor blockers
–Reglan-major action? Increases GI motility
```
94
What is the Nissen Fundoplication surgery for?
GERD. It involves suturing the fundus around the esophagus to make a valve-like substitute sphincter. Will have a chest or abdominal incision (depends on approach).
95
What types of foods/drinks should a client that just had fundoplication surgery avoid?
Carbonated beverages or gas-producing foods.
96
Chronic GERD can lead to a serious complication called _______
Barrett's Esophagus: cells are altered and turn pre-cancerous and may become cancerous.
97
Risk factors for Esophageal Cancer:
smoking, alcohol, hot foods and drinks, foods high in nitrosamines (smoked meats), Barrett's esophagus.
98
Clinical Manifestations of Esophageal Cancer:
-Usually no symptoms until too late
*Few symptoms until advanced disease
–Early spread to lymph nodes and adjacent structures
*Dysphagia
*Odonyphagia (burning upon swallowing)
*Eventual esophageal obstruction
*Diagnostic procedures
*Aspiration (late symptom)
99
What should the head of bed be for a patient on tube feedings?
>30 degrees
100
Stridor=
high-pitched wheezing sound caused by airway obstruction
101
After an Esophagectomy, the patient will have an NGT for about ____ hours. What should the nurse do with the NGT?
8-12; nothing--the surgeon put it in so they usually are the first to mess with it
102
After an Esophagectomy, leakage at the site of anastomosis may appear about ____ days after surgery.
5-7
103
The causal factor in more than 90% of all peptic ulcers has been attributed to _____
H. pylori
104
Risk factors for Peptic Ulcer Disease:
- H. pylori
- Stress
- Brain injury
- Hospitalization
- Certain Meds (NSAIDS)
- Excess gastric acid secretion
- Foods
- Smoking
- Vagus Nerve Activity
- Gastric Mucosal Changes
105
How is the pain different between Gastric and Duodenal ulcers?
With Gastric, food increases pain/vomiting relieves it; With duodenal, food decreases pain.
106
After an EGD, what do you need to tell the patient?
They will be NPO for about 2 hours after until their gag reflex returns (their throat is numbed before the procedure).
107
What is the treatment for an H.pylori ulcer?
2 anti-infectives (Amoxicillin, Flagyl, or Biaxin) and a Proton-pump inhibitor (Nexium, Prilosec, etc) for 10-14 days.
108
What's the BRAT diet?
Bananas, Rice, Applesauce, & Toast; used for GI distress (ie ulcers, diarrhea, upset stomach, etc).
109
Melena=
black, tarry stools.
110
What are the earliest manifestations of hypovolemia?
Restlessness & tachycardia
111
Performed to eliminate the acid-secreting stimulus to gastric cells
Vagotomy
112
Performed to reduce the acid-secreting portions of the stomach
Antrectomy
113
Some complications of gastric surgeries:
*Pernicious anemia
–Why? Removed gastric cells (bc of antrum removed)=no intrinsic factor (which helps with absorption of B12) = B12 used for maturation of RBC's... May need B12 injections
*Dumping syndrome
–Undigested food enters jejunum without duodenal digestion
–s/s: vertigo, tachycardia, syncope, diarrhea and cramping, sweating, pallor, palpitations, nausea
–Rarely vomit
-Management: slow gastric motility
–Avoid drinking 1 hour before or 2 hours after meals
–Diet – high protein, high fat, low CHO, dry
–Lie down after meals--opposite of GERD
–Antispasmodics to slow gastric emptying
114
With Dumping Syndrome, avoid drinking ___ hour(s) before meals and ___ hour(s) after.
1;2
115
What position should you be in after meals with Dumping Syndrome?
Lie down. (opposite of GERD).
116
What kind of diet should you be on with dumping syndrome?
High protein, high fat, low CHO, dry.
117
Signs and symptoms of Dumping Syndrome:
vertigo, tachycardia, syncope, diarrhea and cramping, sweating, pallor, palpitations, nausea
118
Name some functions of the liver:
```
o Carbohydrate metabolism
o Fat metabolism
o Protein metabolism
o Detoxification
o Bile production & excretion
o Storage of glycogen, vitamins, fatty acids, albumin
o Ingestion of bacteria, RBCs
o Clotting
```
119
Associated manifestations with jaundice:
- Clay colored stools (bile pigments)
- Tea-colored urine (bile pigments)
- Pruritis (accumulation of bile salts in skin)
- Anorexia & Fatigue (bc of alteration in metabolism)
- Taste and smell deficiency
120
What is the main route for Hepatitis A & E?
Fecal-Oral route.
121
Hep A is transmitted by __ &___
fecal-oral & sexual/body fluid
122
Who's at risk for Hep A & E?
* Hepatitis A & E (E is rare in US- times of epidemics with very poor sanitation, young children at risk)
* Enteric viruses
* *Fecal-oral route**: predominant way
- Tainted produce
- Poor sanitation of food service
- Travelers at high risk
- Day-care workers
- Meat-processing work
- Hep A also be transmitted by blood & sexual activity
123
You must have Hepatitis __ first before you can get Hepatitis ___; they coexist.
B; D
124
Risk factors for Hepatitis B,C,&D:
```
o Multiple sexual partners
o IV/intranasal drug use
o Needle-stick injuries
o Tattoos/piercings
o Sharing razors/toothbrushes
```
125
Main transmission of Hepatitis B, C, & D?
Blood/body fluids.
126
oWhich of the following measures would be most effective in preventing transmission of the hepatitis C virus to health care personnel?
Select all that apply
A. administer Hepatitis C vaccine to all health care personnel
B. use standard precautions when caring for all clients
C. wear gloves when emptying bedpans
D. wear mask and gown when providing direct care
B&C; A=there is no vaccine; D=depends on what you're doing.
127
Administration of immune globulin is helpful prophylaxis and for after-exposure of _____. It should be given within ___ of exposure.
Hep A; 1-2 weeks.
128
Hepatitis A vaccine can be given to those with a high-risk of exposure. Who would that be?
Children. Travellers. Day-care. Sanitation workers. Meat-processors. Farmers. Those exposed to tainted water/food
129
The Hep A vaccine is given in __ doses, ___ months apart. It cannot be given to those under the age of ___.
2; 6-12 months; 1
130
After getting the Hep A vaccine, it takes ___ days to become immune.
30
131
How should the Hep B vaccine be given?
In deltoid; get first dose, then 2nd dose one month later, then 3rd dose six months later
132
What do you give to someone who was exposed to Hep B?
A combo of Hep B vaccine & immune globulin. Possibly get some interferon.
133
What is the most common Hepatitis and also the one that doesn't have a vaccine?
Hep C
134
What is the treatment post-exposure for Hep C?
Interferon can be given for 12-24 weeks, 3x/week; Ribavirin may also be given to have a synergistic effect and only given once a week (but contraindicated in pregnancy).
135
It may take ___ for s/s to appear with Hep C.
15-20 years.
136
Hepatitis __ &__ are two of the more chronic ones.
B&C
137
Hepatitis ___ is more rare in the U.S., as it if found in Asia, India, Mexico, & Africa via contaminated food/water.
E
138
Hepatitis that co-exists with other forms of Hepatitis and HIV=
Hep G
139
Clinical Manifestations of Hepatitis:
* GI
- Malaise, Fatigue, Anorexia, N/V/D or constipation; things don't taste/smell good.
- RUQ pain/ Glisson’s capsule (liver is encased by this; has lots of nerve endings; enlargement pressures nerves)
* Other
- Common viral symptoms, decrease in senses
- Hepatomegaly, Splenomegaly, elevated liver enzymes (AST, ALT, LDH)
* Jaundice-areas to assess? sclera first then skin
* Anemia: liver has role in clotting
* Bleeding
* Dark urine/clay colored stools: urobilinogen excreted thru them
140
Asterixis =
aka "Liver Flap": tremor of the hand when extended
141
With hepatic encephalopathy/severe liver problems, ____ accumulates in the bloodstream and is a CNS depressant.
Ammonia.
142
What are some signs of severe liver dysfunction?
* Acute Liver Failure- Cirrhosis
- Scarring, fibrosis, altered flow of blood/bile
* Hepatic encephalopathy
- Ammonia to urea breakdown is messed up- altered metabolism: Ammonia accumulates in bloodstream
* Ammonia is a CNS depressant!
- Decreased LOC (elevated ammonia level): very confused; can go into coma if ammonia gets too high.
* Asterixis: late sign. -“Liver Flap”: hands tremor/"flap"
* Deterioration of handwriting: bc of ammonia buildup in brain; late sign.
143
What labs are going to be high with liver dysfunction?
AST, ALT, Alk phosphatase, LDH, bilirubin, & PT (increased risk for bleeding!)
144
What labs will be decreased with liver dysfunction?
Vitamin K, Albumin (which affects oncotic pressure leading to third-spacing/ascites), RBC/Hgb/Hct (anemia)
145
HIGH PT levels = ____ clotting.
decreased.
146
Nutrition for people with Hepatitis:
low fat, high carb, high cals, normal protein for less severe/low protein for those with severe liver impairment
147
What's the max amount of Tylenol in 24 hours?
4 g (4000 mg)
148
Can give ___ if the PT is elevated.
Vitamin K (helps with clotting).
149
What is a normal PT level?
12-15
150
What are some hepatotoxic meds?
- Estrogen (raises bilirubin)
- Tylenol
- ASA
- Sedatives
- Phenothiazines (ie: Thorazine & Compazine)--sedatives.
151
What is a treatment med for Hepatitis?
Epivir.
152
Name some other forms of Hepatitis (other than A-E, G):
* Toxic – in response to chemicals or meds
- Causes liver necrosis
- May also develop renal failure
* Autoimmune-young women
* Alcoholic – in response to alcohol intake
- Symptoms occur after heavy drinking
- Poor prognosis if continue drinking
- Folic acid & thiamine supplements
- Nutrition is a main priority
153
Most common type of cirrhosis?
Laennec's (alcoholic) cirrhosis
154
Clinical Manifestations of Cirrhosis:
```
•Early
–Initial progression of disease is slow
–Changes due to altered CHO metabolism: fatigue, anorexia, nausea, low-grade fever, etc.
–Hepatomegaly: causes tenderness in RUQ
–Elevated liver enzymes
•AST, ALT, LDH
–RUQ heaviness
•Lumpy/ nodular
```
```
Later S/S- MANY!!
*Jaundice
*Peripheral edema
-oncotic pressure decreased
*Spider angiomas: star-shaped, broken capillaries
*Ascites
*Hypoalbuminemia
*Enlarged spleen
•Anemia, leukopenia, thrombocytopenia
–Decreased clotting: elevated PT/INR
*Altered LOC
-Rising ammonia level-Liver can’t break down into urea- Hepatic Encephalopathy
*Portal Hypertension: medical emergency
```
155
Post-procedure care for Liver Biopsy:
–Positioning: things to decrease risk of bleeding= lay them on right side (pressure on liver to stop bleeding); may be on right side for 2-3 hours post-op; may have shoulder pain which can make it hard to breathe.
–Activity: No, bc of risk for bleeding; probably on bed rest for several hours.
–Pain control
–What is highest priority? Bleeding.
156
Portal hypertension can lead to the development of _______ & the enlargement of the _____.
Esophageal Varices; Spleen
157
Vasopressin is a potent ___ which can stop bleeding; it may be contraindicated in those with ____
vasoconstrictor; bad hearts bc it may cause myocardial ischemia
158
What meds may be used for prevention of bleeding of esophageal varices?
Beta-Blockers
159
What device may be used to apply pressure to ruptured varices? How do you care for it?
p1156
*Balloon Tamponade (Sengstaken-Blakemore or Minnesota Tube)
*Monitor airway
*May be 1-1 patient in ER or CCU
•Label lumens: which lumen to which balloon (gastric or esophageal)
•Suction and lavage ready
•Scissors at the BS
–Potential for gastric balloon rupture which will migrate up into airway (scissors would be used immediately to cut it)
•Semifowlers position
•Intermittent release of pressure
–5 min q 8-12 hours
160
How often do you release pressure in the Sengstaken-Blakemore Tube used with esophageal varices?
5 mins q8-12 hours.
161
What do you need to check before a patient gets a TIPS? (transjugular intrahepatic portosystemic shunt)
PT/INR must be near normal level.
162
What are some meds for Hepatic Encephalopathy?
•Decrease GI bacterial production of ammonia
–Neomycin (however nephrotoxic): decreases bacterial count in the gut but is nephrotoxic
–Lactulose- syrupy, gross liquid; traps ammonia-eliminates through gut; Should get diarrhea and WANT diarrhea--good sign.
*Avoid sedatives and opiates.
163
What is the major reason for performing a paracentesis for ascites?
The fluid can push against the lungs and cause respiratory problems
164
When someone has Ascites, do you give the albumin or diuretics first?
The alubumin so that it is pulled back into the intravascular space and can then be elminated with the diuretics.
165
What kind of diet for a person with Ascites?
Low protein/fat, High carbs/cals
166
Things that lead to Pancreatitis:
```
–Bile reflux from duodenum
–Gallstones cause blockage
–ETOH intake (most common cause in US)
–High lipids, hypercalcemia
§Obesity -highest risk!
–Ductal trauma (ERCP)
–CA-pancreatic tumor
–Some meds
§Anticonvulsants, estrogen, sulfonamides
```
167
What is the biggest risk for severe Pancreatitis?
Obesity
168
What is the most common cause of Panreatitis in the US?
Alcohol
169
What is a procedure that is used to diagnose Pancreatitis and/or remove an obstruction in the pancreatic ducts?
ERCP (Endoscopic Retrograde Cholangiopancreatography): -Scope inserted into mouth, throat will be numbed, conscious sedation
- Get down to duodenum and go thru a sphincter into the pancreas
- can get rid of obstruction
- can make papillotomy to encourage flow of bile
170
Clinical Manifestations of Pancreatitis:
*Varies from mild to very severe dz (necrotizing/hemorrhagic pancreatitis)
*Severe abdominal pain- LUQ and may radiate (throughout abdomen)
–Edema/local peritonitis!
–Mid-epigastric after big meal or ETOH (activation of enzymes), but can radiate
–Can cause Paralytic ileus-caused by inflammation of peritoneum (peritonitis)--decreased bowel sounds, n/v, distended abdomen; May need NG tube for decompression.
*N/V – no relief from pain
*dehydration
*Fever
*Tachycardia
*Stool gray, greasy, foul-smelling
–Deposits of fat: Steatorrhea
*Possible jaundice
–Obstruction of bile
*Severe pancreatitis
-Massive Fluid shifts=Third-spacing.
§Loss of plasma proteins in retroperitoneal space
–Vasodilation- inflammatory response
–Hemorrhage (results from necrosis of blood vessels)
§Turner’s sign (flank bruising), Cullen’s sign (peri-umbilical area blue)=blood in retroperitoneal space
–Severe hypotension: from fluid volume deficit
–Hypovolemia (fluid shifts to third space)
–Decreased LOC, restless, agitated
*Could also have damage to islet cells: BS increase.
171
Bruising of the flanks that indicates retroperitoneal hemorrhage; may indicate necrotizing pancreatitis, etc
Turner's Sign
172
Pancreatitis can lead to ____ complications.
Respiratory
173
What is a risk of doing an ERCP for pancreatitis?
May exacerbate the pancreatitis.
174
What is the most specific lab indicator for Pancreatitis?
Lipase.
175
What do the labs look like for Pancreatitis?
* Amylase – elevated for 24-72 hours; elevated for other probs as well
* Lipase –most specific indicator !
* LFTs elevated: especially if obstruction
* Elevated WBC: inflammation
* Increased Blood glucose level
* Low Ca indicates severe disease: calcium trapped in feces; low serum calcium
* Low HCT, Low Albumin
* Low PO2- Why? Volume depletion and breathing shallow
176
What is the best test for test for diagnosing Pancreatitis?
CT/MRI
177
What would be the most comfortable position for a patient with Pancreatitis?
On left side in fetal position; Or if they are having trouble breathing, they may need to sit upright with trunk flexed.
178
What are two signs that can mean the Pancreatitis is getting better?
Pain decreasing & they are able to tolerate clamping of the NG tube.
179
Why does a person with Pancreatitis need to be NPO and have an NGT?
to decrease enzymes to prevent gastrin from entering the duodenum
180
Why does a person with Pancreatitis have the chance of developing ARF (Acute Renal Failure)?
Bc they are hypovolemic and anyone who is hypovolemic has that possibility bc of decreased perfusion to the kidneys.
181
What type of fluids could a patient with Pancreatitis receive?
FFP, LR, Albumin, NS
182
What "sign" is used to assess gallbladder pain?
Murphey's Sign: It is elicited by firmly placing a hand at the costal margin in the right upper abdominal quadrant and asking the patient to breathe deeply. If the gallbladder is inflamed, the patient will experience pain and catch their breath as the gallbladder descends and contacts the palpating hand.
183
Biliary colic occurs in which quadrant?
RUQ (where gallbladder is)
184
A cholelithiasis "attack" is often triggered by ____
a high fat meal.
185
Bile is necessary for the digestion of ____
fat.
186
What is the diagnostic test of choice for Cholelithiasis?
Ultrasound of gall bladder
187
What are the labs like with Cholelithiasis?
Often normal; if the Common Bile Duct is obstructed then LFT's and amylase may be abnormal.
188
What is the usual treatment of Cholelithiasis?
Gallbladder removal--Cholecystectomy.
189
What type of tube will be used post-op Open Cholecystectomy?
T-tube: sutured into the common bile duct; allows drainage of bile (will be tea-colored).
Care: –Bile flows from hepatic duct into t-tube bag
–300-500 ml in first 24 hours
-As edema decreases, bile decreases in bag.
–Down to <200 after 3-4 days
–Bag on bed, NOT below – rationale? Don't want gravity making more bile come out; want body to push it out like it normally would (as pressure builds up)
–After drainage decreases, begin clamping: evaluate tolerance after that==n/v?
–Can re-open if N/V occur
