MS2 - Quiz - Lower GI/Hepatic

Question 1

WBC

Normal range

Answer 1

5000 - 10,000/mm3

Question 2

Hemoglobin

Normal range

Answer 2

14-18 g/dL (male)

12-16 g/dL (female)

Question 3

Hematocrit

Normal range

Answer 3

42-52% (male)

37-47% (female)

Question 4

Sodium

Normal range

Answer 4

136-145 mEq/L

Question 5

Potassium

Normal range

Answer 5

3.5-5.0 mEq/L

Question 6

BUN

Normal range

Answer 6

10-20 mg/dL

Question 7

Creatinine

Normal range

Answer 7

0. 6-1.2 mg/dL (male)

0. 5-1.1 mg/dL (female)

Question 8

Peritonitis

Clinical manifestations

Answer 8

• Abdominal pain (most common symptom)
• Tenderness over involved area (universal sign)
• Rebound tenderness
• Muscular rigidity
• Spasm
• Movement causes pain
• Also may see: abdominal distention, fever, tachycardia, tachypnea, nausea, vomiting, altered bowel habits

Question 9

Peritonitis - Lab Values

Answer 9

Infection:
- Elevated WBC (norm: 5,000-10,000/mm3)

Hemoconcentration:

• Elevated Hct (norm: 42-52% (male) 37-47% (female))
• Elevated Hgb (norm: 14-18 g/dL (male) 12-16 g/dL (female))
• Elevated Na+ (norm: 136-145 mEq/L)

Question 10

Gastroenteritis

Answer 10

• Inflammation of mucosa of stomach and small intestine
• Sudden diarrhea, accompanied by N&V, abdominal cramping
• Viruses most common cause (Norovirus leading cause)
• Most cases self-limiting (elderly, chronically ill may get dehydrated - IV fluids if necessary, oral fluids with glucose & electrolytes [i.e., Pedialyte] as soon as tolerated)
• Nursing mgmt same as acute diarrhea

Question 11

Ostomy teaching

Answer 11

• Teach ostomy use/care and have patient/SO demonstrate
• Minimal oozing of blood is normal, stoma has high vascular supply
• How to monitor for complications (e.g., mechanical breakdown, chemical breakdown, rash, leaks, dehydration, infection)
• Pt should chew thoroughly, avoid foods that caused digestive upset previously, add new foods one at a time
• Encourage support groups, resuming normal life
• Don’t use alkaline soap on the skin (to prevent skin irritation)
• Water does not harm stoma, bathing and swimming can be done with or without pouching system
• Pt can resume ADLs 6-8 wks but not heavy lifting

Question 12

Hepatitis A

Answer 12

• Mild flu-like illness or acute hep w/jaundice
• Does NOT result in chronic infection
• Fecal-oral route; fecal contamination of food or drinking water
• Incubation: 15-50 days (avg 28)
• Infectivity: Most infectious during 2 wk before onset of symptoms
• Preventative: Personal and environmental hygiene, handwashing, vaccination

Question 13

Hepatitis B

Answer 13

• Sexual transmission, percutaneous or permucosal exposure to blood, perinatal transmission
• Can cause either acute or chronic disease (infection resolves in most)
• If chronic infection - may have severe liver disease
• CAN (rarely) spread through saliva or shared food, stays on dry surfaces for up to 7 days) - not urine, feces (w/out GI bleed), breast milk, tears, sweat
• Much more infectious than HIV
• Incubation: 45-180 days (avg 56-96)
• Infectivity: Before and after symptoms appear, carriers continue to be infectious for life
• Preventative: precautions against bodily fluids, Hep B vaccination

Question 14

Hepatitis C

Answer 14

• Can become acute or chronic (majority chronic)
• Asymptomatic - difficult to detect without lab testing
• Most common causes injection drug use and high risk sexual behavior, also perinatal contact
• Chronic results in progressive liver disease - 20-30% develop cirrhosis
• No vaccination available
• Most common cause of chronic liver disease and most common indication for liver transplants
• Pts at risk for HBV and HIV infections (30-40% HIV-infected have HCV)

Question 15

Hepatitis D

Answer 15

• HBV precedes HDV - chronic carriers of HBV always at risk
• Range from asymptomatic carrier to acute liver failure
• No vaccine for HDV - vaccination of HBV reduces risk of co-infection

Question 16

Hepatitis E

Answer 16

• Fecal-oral route

- Usual mode of transmission contaminated water - mostly occurs in developing countries

Question 17

Nutrition for hepatitis patient

Answer 17

• No special diet required - emphasis on well-balanced diet as tolerated (decreased bile may lead to poor fat tolerance)
• Acute viral hep - adequate calories because patient can lose weight
• Vitamin supplements, especially B-complex vitamins, vitamin K
• Severe anorexia/N&V: IV solutions of glucose or enteral nutrition
• Adequate fluid intake (2.5-3 L/day)
• Drinking carbonated beverages and avoid very hot/cold foods

Question 18

Nursing care for hepatitis patient

Answer 18

• Manage fluid and electrolyte balance - adequate calories for acute viral hepatiis
• Assess presence and degree of jaundice (light-skinned first in sclera of eyes then in skin; dark skinned first hard palate of mouth and inner canthus of eyes); urine may be dark brown or brownish red from bilirubin
• Comfort measures for pruritis (if present), headache, arthralgias (joint pain)
• Rest periods, limit environmental stimuli
• Anorexia usually not as severe in morning, plan larger meals earlier in day

Question 19

Risks for hernia

Answer 19

• Ventral/incisional: obesity, multiple surgical procedures in same area, inadequate wound healing r/t poor nutrition or infection

Question 20

S/S for hernias

Answer 20

• May be readily visible
• Discomfort as a result of tension
• If hernia strangulated - severe pain, symptoms of bowel obstruction (cramping abdominal pain, vomiting, distention)

Question 21

Treatment for hernias

Answer 21

• Laparoscopic surgery treatment of choice (herniorrphaphy - surgical repair; hernioplasty - reinforcement of weakened area with wire, fascia, mesh)
• Strangulated hernias treated immediately with resection of involved area or temp colostomy to avoid necrosis and gangrene
  Post op considerations:
• After hernia repair, pt may have trouble voiding (measure I&O, observe distended bladder)
• Scrotal edema - painful complication after inguinal repair - scrotal support, application of ice bag
• Deep breathing but not coughing (splint incision, keep mouths open when coughing or sneezing)
• Restricted from heavy lifting for 6-8 weeks

Question 22

Types of cirrhosis

Answer 22

Alcoholic cirrhosis (Laennec’s cirrhosis)

• Alcohol causes metabolic changes in the liver - fatty infiltration - normally would heal but with continued abuse hepatocytes inflammed and eventually necrosis - necrosis causes fibrosis and scarring - scarring causes nodules to form - liver shrinks
• Malnutrition commonly present

Fatty liver

• Due to diets high in fat, epidemic of obesity
• Can cause liver failure

Biliary

• Primary - chronic inflammatory condition (exact cause unknown - genetic/environmental factors)
• Primary sclerosing cholangitis - associated w/ulcerative colitis

Posthepatic/postnecrotic

• Viral hepatitis
• Liver decreases in size, nodules and fibrosis

Cardiac cirrhosis

• Longstanded right-sided heart failure
• Liver is swollen
• Can be reversed if heart failure treated effectively (some fibrosis occurs)

Question 23

Cirrhosis - risk factors

Answer 23

• Any chronic liver disease can cause cirrhosis
• Most common causes in US: chronic hep C infection, alcohol-induced liver disease
• Environmental factors, genetic predisposition
• 10-20% of those w/hep B

Question 24

Cirrhosis - complications

Answer 24

• Portal hypertension with resultant esophageal and gastric varices
• Peripheral edema and ascites
• Hepatic encephalopathy (mental status changes, including coma)
• Hepatorenal coma

Question 25

Toxic and drug induced hepatitis

Answer 25

• Drugs can cause hepatitis

- Some of same symptoms as Hepatitis, depending on degree of inflammation

Question 26

Autoimmune hepatitis

Answer 26

• Unknown cause, presence of antibodies and immunoglobins, frequently occurs with other autoimmune diseases

Question 27

Fulminant hepatitis

Answer 27

• Rapidly progressive disease with liver failure within a couple of weeks of symptoms
• Rare
• Hep B, especially B+D
• Death usually occurs

Question 28

Portal Hypertension and Esophageal & Gastric Varices - interventions

Answer 28

• Prevent bleeding and hemorrhage - avoid alcohol, aspirin, NSAIDs
• Upper endoscopy (EGD) to screen for varices
• B-blocker reduces incidence of hemorrhage, high portal pressure

Variceal bleeding:

• Stabilize patient, manage airway, IV therapy initiated (may include blood products) - combination of endoscopal therapy and drug therapy (vasopressin / nitroglycerin often combination therapy)
• Band ligation (band around base of varix) or sclerotherapy (injection of sclerosant solution) - may be used to prevent rebleeding
• Balloon tamponade if cannot be controlled via endoscopy and bleeding acute - mechanically compresses the varices (* deflate balloons for 5 min every 8-12 hrs to prevent tissue necrosis)
• Fresh frozen plasma, packed RBCs, vit K, PPIs, antibiotics to prevent infection

Shunting:

• Surgical and nonsurgical methods available
• Used more after 2nd major bleeding episode than 1st
• TIPS - nonsurgical - shunt between systemic and portal venous systems to redirect portal flow
• Surgical - usually portacaval shunt or distal splenorenal shunt

Question 29

Interventions specific to balloon tamponade from bleeding varices

Answer 29

• Gastric balloon breaks or is deflated - esophageal balloon will slip upward, obstructing airway and causing asphyxiation - cut the tube or deflate balloon - keep scissors at bedside
• Minimize regurgitation - oral and pharyngeal suctioning, pt in semi-Fowler’s
• Patient is unable to swallow saliva - encourage to expectorate, provide emesis basin and tissues
• Frequent oral and nasal care

Question 30

Ascites

Answer 30

• Abdominal distention with weight gain
• Abdominal striae with distended abdominal wall veins
• Signs of dehydration (dry mouth/skin, sunken eyeballs, muscle weakness) and decreased urine output
• Hypokalemia common

Management

• Sodium restriction
• Diuretics
• Fluid removal (paracentesis - needle puncture of abdominal cavity to remove fluid or test for infection) - reserved for patient with impaired respiration or ab pain caused by severe ascites - temporary measure b/c fluid builds back up
• Usually NOT on fluid restriction unless severe ascites develops
• TIPS when ascites does not respond to diuretics

Question 31

Interventions - Ascites/Edema

Answer 31

• Accurate I&O, daily weights
• Observe F&E imbalances - high risk for hypokalemia
• Measurements of abdominal girth and extremities
• Have patient void immediately before paracentesis to prevent bladder puncture
• After paracentesis - patient sits on side of bed or in high-Fowler’s - monitor for hypovolemia, electrolyte imbalances; check dressing for bleeding/leakage
• Dyspnea - semi-Fowlers or Fowlers; use pillows to support arms and chest
• Edematous tissues subject to breakdown - meticulous skin care, turning schedule min 2 hr, alternating-air pressure mattress, ROM exercises, coughing/deep breathing
• Elevate lower extremities; scrotal support for scrotal edema

Question 32

Hepatic encephalopathy

Answer 32

Clinical manifestations

• Changes in neurological/mental responsiveness
• Impaired consciousness
• Inappropriate behavior - range from sleep disturbances to lethargy to deep coma
• Asterixis - flapping tremors - characteristic manifestation

Goal of mgmt - reduce ammonia formation

• Lactulose - drug that traps ammonia in the gut and has laxative effect to expel (can be given orally, NG tube, enema)
• Antibiotics can be given
• Constipation should be prevented
• Treatment of precipitating causes (GI hemorrhage, constipation, hypokalemia, hypovolemia, infection, etc)
• Controlling GI bleeding, and removing blood from GI tract to decrease protein in intestine

Question 33

Hepatic encephalopathy - nursing care

Answer 33

• Assess patient’s level of responsiveness, sensory and motor abnormalities, fluid and electrolyte imbalances, acid-base imbalances, effect of treatment measures
• Neurologic status at least Q2H
• Institute measures to prevent constipation to reduce ammonia production - give drugs, laxatives and enemas as ordered, encouraged fluids if indicated
• Any GI bleeding will worsen encephalopathy
• Assess pt taking lactulose for diarrhea and excessive fluid/electrolyte losses
• Control factors known to precipitate, including anything that may cause constipation

Question 34

Major classes of medications to treat IBD

Answer 34

Aminosalicylates - first line therapy for mild-moderate CD, more effective for UC - achieve and maintain remission

• Decrease GI inflammation through direct contact with bowel mucosa
• Yellowish orange discoloration of skin and urine

Antimicrobials
- Prevent or treat secondary infection

Corticosteroids - used to achieve remission - given for SHORTEST period of time

• Decrease inflammation
• Tapered to low levels when surgery is planned

Immunosuppressants - maintain remission after corticosteroid induction therapy

• Suppress immune response
• Require regular CBC monitoring - can suppress bone marrow and lead to inflammation of pancreas or gallbladder
• Delayed onset of action

Biologic and targeted therapy

• Inhibit cytokine tumor necrosis factor (TNF); prevent migration of leukocytes from bloodstream to inflamed tissue
• Do not work for everyone; costly and may produce allergic reactions
• Most effective when given at regular intervals and must not be d/c’d unless pt can’t tolerate
• Before starting anti-TNF, pt must be tested for TB and hepatitis; cannot receive live virus immunizations

Question 35

Nursing care plan - patient with inflammatory bowel disease (IBD)

Answer 35

• Instruct pt to record color, volume, frequency and consistency of stools
• Perform actions to rest bowel (NPO, liquid diet)
• Stress-reduction techniques
• Frequent, small feedings, add bulk gradually; eliminate gas-forming and spicy foods
• Low-fiber, high-protein, high-calorie diet
• Weigh at specified intervals

Question 36

ESR (Erythrocyte Sedimentation Rate)

Normal range

Answer 36

Female: less than 20 mm/hr
Male: less than 15 mm/hr