Test 4 Nutrition-Elimination Flashcards
Cleft Lip and Cleft Palate
Failure of maxillary and median nasal processes to fuse during embryonic development
Remember: psycho-social implications for these children and families
Early first trimester development.
Cleft lip and cleft palate assessment
various degrees.
Cleft lip concerns
scarring
teeth issues
cleft palate concerns
sucking - feeding
speech
cleft lip and palate issues
increased severity of scarring, teeth issues, sucking - feeding, speech.
Cleft lip/palate treatment
- surgical repair between 3 and 6 months
- multidisciplinary team - involving many specialists including plastic surgeons, nurses, ENT specialists, orthodontists, audiologists, and speech therapists
- reconstruction begins in infancy and can continue through adulthood
- homecare by the family prior to surgery.
Cleft lip/palate pre-op nursing care
TWO main goals
- prevention of aspiration
2. maintain nutrition
Cleft lip/palate
Pre-op nursing care
- may breast feed if has small cleft lip
- if bottle fed, use compressible bottle, longer nipple, larger hoe in nipple, any other special device for feeding this infant
- feed slowly in upright position and burp frequently
- keep bulb syringe and suction equipment at bedside
- position on side after feeding
Cleft lip/palate
feeding problems
lack proper seal around nipple to create necessary suction
excessive air intake
cleft lip/palate
use of special feeding techniques
feeder with compressible sides
syringes with tubing
Cleft lip/palate
Prevent trauma to suture line
- Logan’s bow to protect site (kind of brace that protects mouth/nose post-surgery)
- do not allow to suck
- maintain upper arm restraints
- position supine
- no hard objects in mouth - straws, pacifiers,spoons
- do not take temperature orally
Cleft lip/palate
Reduce pain
mild analgesics and sedatives
parents to provide, holding, rocking, and parental voices
Cleft lip/palate
prevent infection
-cleanse suture line as ordered
rinse with water after each feeding
use cotton swab, use rolling motion vertically down suture line
- apply anti-infective ointment as ordered
- call doctor for any swelling or redness, bleeding, drainage, fever
Make early referrals to appropriate team members
daily weights, dietitian, speech therapy, audiologists
Cleft lip/palate
assess for complications
otitis media (cleft lip/palate increased risk)
hearing loss
speech difficulties
altered dentition
Esophageal atresia
Malformation from failure of esophagus to develop as a continuous tube.
Esophageal atresia
variations
esophagus not connected to anything
esophagus connected to trachea
trachea connected to stomach, esophagus connected to nothing
esophagus connected to trachea and stomach
Esophageal atresia
clinical manifestations
- excessive amounts of salivation/mucus, frothy bubbles in the mouth and sometimes nose,
- three C’s - coughing choking and syanosis when fed, overflow may be aspirated
- food may be expelled through the nose immediately following the feeding
- rattling respirations and frequent respiratory problems such as aspiration pneumonia
- gastric distention, if fistula
- history of polyhydramnios during pregnancy can suggest a high gastrointestinal obstruction.
Esophageal atresia
diagnosis and management
early diagnosis
- ultrasound - radiopague catheter inserted in the esophagus to illuminate defect on x-ray
surgical repair
-thoracotomy and anastomosis
Esophageal atresia
pre-op nursing care
- maintain airway
- keep NPO administer iv fluids
- place in warmer give humidified o2
- elevate hob 30 degrees
- suction PRN
- give prophylactic antibiotics
Esophageal atresia
post op nursing care
maintain airway maintain thermoregulation maintain nutrition prevent trauma (can't see suture line) monitor for potential complications...dehydration, internal bleeding, aspiration monitor weight, growth and developmental achievements
Gastroesophageal Reflux Disease (GERD)
Backward flowing of gastric contents into esophagus
GERD causes
incompetence of lower esophageal sphincter
transient lower esophageal relaxation
increased intragastric pressure
GERD risk factors
obesity, pregnancy, hiatal hernia, chewing tobacco, smoking, caffeine, chocolate, drugs
GERD pathogenesis
Reflux of stomach contents
Gastric acid
esophageal mucosal injury
GERD assessment: infant
- regurgitation almost immediately after each feeding when the infant is laid down
- excessive crying, irritability
- failure to thrive
- life threatening risk/complications:
- aspiration pneumonia
- apnea
GERD assessment: child
- Heartburn
- Abdominal pain
- cough, recurrent pneumonia
- dysphagia
GERD: clinical manifestations adult
heartburn after eating abdominal pain chestpain chronic cough asthma complications -strictures -> dysphagia -Barrett's esophagus (change in the normal cell structure of the esophagus)
GERD Diagnosis
Esophageal endoscopy
pH monitoring
GERD Nursing diagnosis
pain
ineffective management of therapeutic regimen
inadequate nutrition
knowledge deficit
GERD Pediatric client
management and nursing care
small frequent feedings, of predigested formula or thicken the formula
frequent burping
positioning-keep upright for 30 minutes after feedings
avoid excessive movement
GERD pediatric client management and nursing care
if history of apnea, brady, r/t GERD - needs continuous cardiac and apnea monitoring, arrange for CPR teaching for caregivers
if infant does not respond to non-invasive therapy, then a nissen fundoplication may be done to increase competence of the cardiac sphincter.
GERD fundoplicatino post op nursing care
assess for pain, abdominal distention, and return of bowel sounds
teach parents about gastrostomy tube feedings
GERD planning and implementation
dietary management
limit or eliminate citrus juices, fatty and spicy foods, coffee, caffeine, alcohol, chocolate and peppermint
eat smaller meals
stay upright for 2 hr after meals
refrain from eating for 3 hr before bedtime
elevate HOB on 6-8 inch blocks
weight reduction
avoid restrictive clothing
GERD
Medications
Antacids(maalox, mylanta, gaviscon, gelusil, riopan, amphojel
Histamine 2-receptor blockers (cimetidine, famotidine, rantidine, nazatidine)
proton pump inhibitors (lansoprazole, omeprazole, pantoprazole, rabeprazole)
prokinetic agent (metoclopramide)
Gastritis
inflammation of the stomach lining, results from irritation of the gastric mucosa
gastritis
Acute
benign self-limiting related to ASA, ETOH, caffeine, or foods with bacteria
stress ulcer - major stressor
Chronic gastritis
progressive and irreversible changes in gastric mucosa
gradually leads to atrophy of gastric tissues
chronic gastritis
type A
autoimmune
chronic gastritis
type B
chronic infection (Helicobacter pylori)
Gastritis assessment
acute
anorexia, n/v
hematemesis
malaise
gi bleeding
gastritis assessment
chronic
may be asymptomatic
anorexia, n/v
belching
heartburn after eating
Gastritis
nursing diagnosis
deficient fluid volume
imbalanced nutrition: < body requirements
Gastritis
planning and implementation
NPO status will help mucosa to heal then start back slowly with clear liquids, toast, bland fluids, slowly return to regular diet
administer anti-emetics, antacids, H2 antagonists, antibiotics
weigh daily
monitor and maintain fluid and electrolyte balances, intake and output
control nausea and vomiting
gastritis planning and implementation
medications
histamine 2-receptor blockers antacids PPI vitamin b12 antibiotics -biaxin, amoxicillin, flagyl, tetracylcine with bismuth(may not be appropriate if pt is on anti-coagulant therapy) or PPI
Pyloric Stenosis
Narrowing of the pyloric sphincter
delayed emptying of the stomach
symptoms develop 3-5 weeks after birth…NOT congential
associate with infant receiving erythromycin, mother receiving erythromycin late in pregnancy, or mother taking erythromycin and baby breastfeeding.
pyloric stenosis
assessment
hypertrophied pylorus distended abdomen projectile vomiting constant hunger fussiness visible peristaltic waves
pyloric stenosis
treatment and nursing care
treatment - surgery (pyloromyotomy)
pyloric stenosis
postoperative care
STRICT I&O Feeding Position with head elevated assess surgical site to prevent infection patient teaching
Hirschprung’s disease
congenital disorder of nerve cells in lower colon
no innervation.
occurs 5x more in males than females. usually associated with other conditions, esp Down’s syndrome
hirschprung’s disease
assessment
failure to pass meconium ribbon like stools vomiting reluctance to feed abdominal distention foul odor of breath
hirschprung’s disease
diagnosis
history and physical
barium enema (xray)
rectal biopsy
hirschprung’s disease
management
surgical intervention (series of surgeries
colostomy
resection
hirschprung’s disease
nursing care
pre-op
cleanse bowel
patient/parent teaching
hirschprung’s disease
nursing care
post-op
npo vital signs (rectal temperature is absolutely FORBIDDEN) gi assessment patient/parent teaching colostomy care skin care nutrition
Intussuception
most commonly seen in infants 3-12 months
bowel “telescopes” within itself.
don’t know why happens, but usually seen after a rotovirus infection.
Volvulus
twisting of the bowel that leads to a bowel obstruction
Intussuception
assessment
pain vomiting stools- resemble currant jelly, bloody mucus sausage shape abdominal mass dehydration serious complications - shock and sepsis
volvulus
assessment
pain
bilious vomiting
abdominal distention
tachycardia
therapeutic intervention
Intussuception
hydrostatic reduction inject barium or air to try to fix the telescoping
surgery
therapeutic intervention
volvulus
surgery
nursing care
Intussuception/volvulus
following the hydrostatic reduction
clear liquids and diet is advanced gradually
observe for passage of barium and eventually passage of stool
if reduction is not successful -> surgery
post op nursing care
Intussuception/volvulus
stabalize the child
npo and start iv fluids
ng tube to decompress the bowel
pain medications
provide information to the parents
surgery usually completely fixes these issues.
Lactose Intolerance
manifestations
diarrhea that is frothy, but not fatty abdominal distention cramping abd pain excessive flatus
Lactose Intolerance
removal of lactose from the diet
eliminate- milk, formulas that contain dairy products, ice cream, yogurt, hard cheeses
breastfeeding moms- eliminate lactose from their diet.
medications
lactase preparations - lactaid, dairy ease, lac-dose
obtain calcium from other sources
Celiac Disease
Clinical Manifestations
Failure to grow wasting of extremities large abdomen intestinal distention malnutrition complications hypocalcemia osteomalacia osteoporosis depression
Celiac Disease
Treatment and Nursing Care
Dietary Regulations
Gluten Free Diet NO Wheat Rye Barley Oats
Appendicitis
Assessment
Intensifying pain w/rebound tenderness RLQ or periumbilical area pain McBurney's point worse with mvt, coughing, sneezing anorexia, nausea, vomiting constipation or diarrhea rebound tenderness low-grade temperature elevated WBC
Appendicitis
Diagnosis
WBC w/differential
Abdominal Ultrasound
Appendicitis
pre-op
NPO IV Comfort measures - semifowlers or R side lying Antibiotics thermal therapy - ice, not heating pads elimination patient education **narcotic pain medications are used minimally so as not mask the signs of appendicitis.
Appendicitis
post-op nursing interventions
surgery - appendectomy NPO antibiotics analgesia patient teaching rupture -> drainage tube (penrose), antibiotics, NG tube, check for peritonitis
Peritonitis assessment
GI secretions and enteric bacteria enters peritoneal cavity from GI tract rupture
"acute abdomen" increased fever and chills, tachycardia, tachypnea abrupt onset of diffuse severe abdominal pain entire abdomen tender and board-like extreme guarding paralytic ileus distention anorexia, n/v
Irritable Bowel Syndrome (IBS)
Functional disorder of the bowel
chronic and recurrent intestinal symptoms
IBS
Etiology
Unclear
Anxiety and depression???
IBS
Pathogenesis
visceral hypersensitivity or "brain-gut axis" dysregulation abnormal GI motility and secretion intestinal infection overgrowth of intestinal flora food allergy or intolerance psychosocial
IBS
Clinical Manifestations
At least 2 or more than 3 months, w/onset occurring at least 6 months before recurrent abdominal pain or discomfort:
abdominal pain or discomfort improved by defecation
onset associated with a change in frequency of stool
onset associated with a change in form (appearance) of stool
IBS
Clinical Manifestations
diagnosis
based on signs and symptoms
rule out other etiologies
Inflammatory Bowel Disease (IBD)
Term used to describe two similar but different forms of inflammation of the intestines Crohn's disease (no cure) Ulcerative Colitis (can be cured)
IBD
Crohn’s disease and Ulcerative Colitis
Similarities
unclear etiology
failure of immune regulation
genetic predisposition
environmental trigger
Crohn’s Disease
Recurrent granulomatous lesions primarily involving the small and large intestines
autoimmune disease
exaggerated immune response against bacteria in the normal intestinal flora
Crohn’s Disease
pathogenesis
inflammation begins in the intestinal submucosa
extension to the mucosa and serosa
activated neutrophils and macrophages promote inflammation and tissue injury
sharply demarcated “skip” lesions
Crohn’s Disease
Clinical manifestations
exacerbations and remissions **INTERMITTENT diarrhea, possible bloody abdominal tenderness weight loss malaise complications: fistulas malabsorption (anemia)
Ulcerative Colitis
chronic inflammatory disease that causes ulceration of the colonic mucosa
rectum and sigmoid colon
Ulcerative Colitis
etiology
unknown
familial tendency
autoimmune
activated macrophages, anticolon antibodies, and cytotoxic t-cells.
Ulcerative Colitis
pathogesis
inflammation of the crypts of lieberkuhn
intestinal secretory glands
inflammation of the crypts result in:
pinpoint mucosal hemorrhages ->suppuration->crypt abscess->ulceration and necrosis
Ulcerative Colitis
Clinical manifestations
remission and exacerbation abdominal pain* diarrhea* rectal bleeding* anorexia weakness fatigue *cardinal signs
Ulcerative Colitis
diagnosis
sigmoid or colonoscopy
Ulcerative Colitis
complications
increased incidence of colon cancer
fissures
perirectal abcess
differences between crohn’s and Ulcerative Colitis
Slide 74
Inflammatory bowel disease(IBD)
diagnosis
colonoscopy or sigmoidoscopy barium enema cbc w/ differential ESR (erythrocite sedimentation rate) electrolytes serum albumin
IBD medication
Aminosalicylates
sulfasalazine
mesalamine
olsalazine
IBD medication
corticosteroids
methylprednisolone
prednisolone
prednisone
IBD medication
immunosuppressives
azathioprine
cyclosporine
ibd medication
antidiarrheal agents
loperamide
diphenoxylate
IBD dietary management
NPO w/ TPN progressing diet
bland, low fat, low residue
increased calories, carbohydrates, proteins, vitamins
free of milk products, caffeine, and gas-producting or raw fruits and vegetables
Total Parenteral Nutrition (TPN)
Given to patients intravenously (IV) when nutritionally deficient for several days in absence of normal GI functioning
High dextrose concentration (>10%)
Central line required of dextrose >15%
contents guided by AM labs (Na+, K+, Mg+, Cl, Protein, albumin, etc) to meet specific caloric and protein needs of the client
may also add vit K, insulin, heparin, pepcid, Vit C, B12, thiamine, lipids, folic acid.
IBD surgical management
Total colectomy segmental resection with reanastomosis ostomy ileostomy colostomy
Types of Ostomies
Ileostomy
Cecostomy (output going to be very liquidy)
ascending colostomy
transverse colostomy
descending colostomy
sigmoid colostomy (output fairly formed…may require irrigation, can be regular elimination…don’t necessarily need bag or appliance)
IBD
Nursing diagnosis
diarrhea disturbed body image imbalanced nutrition: less than body requirements fluid volume deficit electrolyte imbalance pain altered sexuality paterns ineffective individual coping knowledge deficit social isolation
IBD: Diarrhea
Therapeutic Nursing Interventions
Monitor appearance, frequency and amount of bowel movements
monitor presence of blood in stools - occult and frank blood
assess vital signs and weight
assess skin turgor, weakness, lethargy
monitor labs: cbc, lytes, albumin
administer prescribed anti-inflammatory and anti-diarrheal medications
IBD: Diarrhea
Therapeutic Nursing Interventions
Maintain fluid intake provide good skin care assess perineal area for irritated skin, provide measures to protect perianal area nutritional consult post-op ostomy care
IBD: Ostomy Care
Assess the stoma - is it healthy?
assess peristomal skin
apply protective barriers to the peristomal skin
apply ostomy pouch over stoma
note characteristics of stool, record on I&O
refer to enterostomal nurse therapist
Intestinal Obstruction
Interference with normal peristaltic movement of intestinal contents due to neurological or mechanical impairment
most often occurs in small bowel
may be partial or complete
Intestinal Obstruction
Causes
Mechanical (intussusception/volvulus/scar tissue)
or Functional
Intestinal Obstruction
Assessment
Paralytic Ileus
hypoactive or absent bowel sounds
Intestinal Obstruction
Assessment
Mechanical obstruction
very hyperactive bowel sounds at first then absent
Intestinal Obstruction
Assessment
General
Abdominal distention, cramping, mild to moderate abdominal pain, vomiting, constipation
Intestinal Obstruction
Diagnostic Tests
Abdominal XRays
Barium Enema
Colonoscopy
Intestinal Obstruction
Diagnostic Tests: Labs
WBC H/H Serum creatinine blood urea nitrogen electrolytes abg's
Intestinal obstruction
Therapeutic nursing interventions
restrict oral intake/NPO Decompression of GI tract - NG tube Fluid/electrolyte replacement measure abdominal girth q4 to 8 hrs assess bowel sounds q4 to 8 hrs surgical intervention
Colorectal cancer
3rd most common cancer diagnosis in the US
Adenocarcinoma (glandular epithelium) of the large intestine
begin as adenomatous polyps
Colorectal Cancer Location
Rectum
Sigmoid
Cecum
Ascending Colon
Colorectal cancer Risk factors
age older than 50 years polyps of the colon and/or rectum family history of colon cancer inflammatory bowel disease exposure to radiation diet: high animal fat and kilocalorie intake
colorectal cancer
clinical manifestations
General
change in bowel habits rectal bleeding pain anemia weight loss
colorectal cancer
clinical manifestations
Cecum & ascending colon
guiac positive stools
anemia
colorectal cancer
clinical manifestations
rectum or sigmoid tumors
diarrhea and cramping bloody mucous stools distention anemia obstruction narrow, ribbon like stools
Colorectal cancer
metastasis
direct infiltration of the bladder
lymphatic spread
liver via the portal vein
Diverticular disease
Diverticulosis
mall outpouchings of the intestinal mucosa
most common in sigmoid colon
diverticular disease
diverticulitis
inflammation of one more diverticula
perforated diverticulum can progress to peritonitis
Diverticulosis Pathogenesis
roughage diet
small hard fecal material
increased pressure to propel fecal material through the colon
increased intralumenal pressure
herniation through weak areas where blood vessels enter
diverticulosis clinical manifestations
generally asymptomatic
may have : mild flatulence, diarrhea alternating with constipation
Diverticulitis
Inflammation of diverticula
generally undigested food or bacteria lodges in a diverticulum obstructing the opening into the bowel.
Diverticulitis
clinical manifestations
LLQ pain and tenderness n/v low-grade fever elevated WBC complications: minor bleeding, abscess formation (rupture of an abscess with perforation of the bowel wall would cause peritonitis)
Diverticular disease
diagnosis
CT Barium enema sigmoidoscopy/colonoscopy WBC H&H Hemoccult
diverticular disease
nursing diagnosis
impaired tissue integrity: GI
Pain
Anxiety
Deficient knowledge
Diverticular disease
dietary management
Diverticulosis
High fiber, high residue
diverticular disease
dietary management
diverticulitis
NPO…need to rest the gut. Advance as tolerated.
Low fiber, low residue until symptoms subside. Then go back on diverticulOsis diet.
avoid foods with small seeds/nuts
Disorders of the Gallbladder
cholelithiasis
gallstones (acute or chronic)
Diverticular disease
Medication
Broad-spectrum antibiotics mild-flagyl, cipro, septra severe-mefoxin, zosyn, timentin pain medications talwin, demerol, morphine surgical intervention colon resection temporary colostomy
disorders of the gallbladder
cholangitis
Duct inflammation
Cholelithiasis
cholesterol, calcium salts, or mixed
cholelithiasis
etiology
bile composition abnormalities
bile stasis
inflammation
cholelithiasis
risk factors
pregnancy
oral contraceptives
obesity surgeries
Cholelithiasis
assessment
sudden, severe and steady RUQ pain - radiates to right scapula or shoulder
occurs after high fat meal
lasts up to 6 hours
n/v/heatburn/flatuelnce
jaundice (Check whites of eyes…possibly palms/soles)
clay colored stools
Cholecystitis
assessment
all previous symptoms present plus
Fever
increased WBC
abdominal guarding
Cholelithiasis/Cholecystitis
Abdominal x-rays
ultrasonography
nuclear med scan
Surgical Management
laparoscopic cholecystectomy
Open cholecystectomy
ERCP with endoscopic sphincterotomy (remove gallstones, enlarge sphincter).
Cholelithiasis/Cholecystitis
Nursing Diagnosis
Pain
Imbalanced nutrition-less than body requirements
Risk for Infection
Cholelithiasis/Cholecystitis
Goal: Control Pain
Discuss relationship between fat intake and pain. Teach about low fat diet.
Withhold oral food and fluids during episodes of acute pain. Insert NG tube and connect to low suction.
Administer demerol, morphine, ketorolac (toradol) or other analgesic.
Place in fowler’s position.
Cholelithiasis/Cholecystitis
Goal: Maintain adequate nutrition
Assess nutritional status
Evaluate laboratory results, including serum bilirubin, albumin, glucose, and cholesterol levels.
Refer to a dietician for diet counseling to promote healthy weight loss and reduce pain episodes.
Administer vitamin supplements as ordered.
Cholelithiasis/cholecystitis
monitor vital signs q4
assess abdomen q4
assist with c/db or use IS q1-2 hrs. splint abdominal incision during coughing.
Place in fowler’s position and encourage ambulation as allowed.
administer antibiotics as ordered
maintain T-tube placement. report drainage >1000mL.
Hepatitis
Inflammation of the liver
Hepatitis
Etiologies
drugs
toxins
microorganisms
autoimmune
Prodromal or preicterus manifestations
RUQ pain
-malaise, fatigability, low grade fever, athralgia, n/v
Anorexia and/or weight loss
Fatique
Elevated AST&ALT
**Infection highly transmissible during this phase.
Liver Enzymes
Aspartate aminotranserase (AST) Alanine asinotransferase (ALT) Alkaline Phosphatase(ALP)
Aspartate aminotransferase (AST) Normal Levels
5-35 units/mL
Alanine aminotransferase (ALT) Normal Levels
5-35 units/mL
Alkaline phosphatase (ALP) Normal Levels
30-120 IU/L
Icteric Phase
2nd phase. longer period of time.
begins with onset of Jaundice.
Jaundice (except HCV) concurrent with a rise in serum bilirubin
Hepatic symptoms (dark urine, hepatosplenomegaly, severe pruritus, possibly tender lymphadenophathy)
Elevated direct and indirect bilirubin
Normal to moderately increased ALP (liver enzyme)
Serum Bilirubin
Conjugated Normal levels
direct bilirubin 0.1-0.3 mg/dl
Serum Bilirubin
Unconjugated normal levels
Indirect bilirubin
0.2-0.7 mg/dl
Serum Bilirubin
Direct + Indirect = Total normal levels
Total Bilirubin
0.3-1.0mg/dl
Convalescent or recovery
Increase sense of well-being
Return of appetite
Resolution of jaundice
Clinical Recovery: 9 weeks HEP-A. 16 weeks uncomplicated HEP-B
Hepatitis Diagnosis
Hepatitis antigens/antibodies present
increased alt, alp, ast
increased bilirubin
liver biopsy
Hepatitis Nursing diagnosis
Risk for infection (transmission)
fatigue
imbalanced nutrition: less than body requirements
Hepatitis therapeutic nursing interventions
Risk for infection (transmission) use universal precautions contact isolation (HAV, HEV) plan room assignments private bathroom hep A/ hep B vaccines
Hepatitis
client and family teaching
do not share bathroom unless strict personal hygiene maintaine
no sharing of: bed linens, washcloths, towels, drinking and eating utensils, razors, nail clippers, toothbrushes, needles, body piercings.
avoid sexual activity/safe sex
avoid ETOH, OTC drugs, esp eacetaminophen/sedatives
do not donate blood, organs, tissue
small, frequent meals - Increase CHO, decrease fat, nutritional supplements.
Cirrhosis
Replacement of normal cells with fibrous tissue (scar tissue)
Cirrhosis
Macronodular
Hepatitis
Cirrhosis
Micronodular
alcoholism
Liver Dysfunction
Hepatocellular dysfunction
portal hypertension
ascites
hepatic encephalopathy
Hepatocellular dysfunction
failure to inactive ADH and aldosterone
retention of sodium and water….loss of K+
decreased synthesis of proteins (hypoalbuminemia)
decreased production of urea from NH3 (increased serum ammonia NH3)
decreased detoxification of potentially harmful substances (drug interactions and toxicities)
Cirrhosis
Assessment
Anorexia and weight loss dyspepsia n/v change in bowel habits/flatulence dull abdominal pain fatigue jaundice petechiae or ecchymosis peripheral edema ascites dilated abdominal veins hepatomegaly
Ascites
Accumulation of fluid in the peritoneal space increased hydrostatic pressure sodium and water retention decreased colloid osmotic pressure increased abdominal girth Fluid wave seen tenderness SOB
Cirrhosis
Diagnosis
liver biopsy - definitive diagnosis liver function - ast, alt, ldh elevated bilirubin (total, indirect) elevated protein, albumin - decreased PT/PTT (intrinsic measure) - elevated platelets - decreased CBC, H/H, WBS's (anemia and leukopenia) Serum ammonia - elevated creatinine- renal failure often develops
Cirrhosis - excess fluid volume
therapeutic nursing interventions
diet: decrease Na+, decrease protein, increase CHO, decrease fat
fluid restriction with presence of ascites
weigh daily - same time, same type clothes
measure abdominal girth - to assess ascites
diuretics - remove excess fluid
Cirrhosis - ineffective protection
therapeutic nursing interventions
Institute bleeding precautions - spontaneous bleeding an issue
monitor signs of bleeding (vs, gums, nasal membranes, conjunctiva, stool for occult blood, emesis, neuro changes, abdomen.
LABS: CBC platelets, PT/PTT
avoid invasive procedures/devices
apply pressure to puncture sites for 10 minutes
blood transfusions and vit K
beta-blockers - decrease portal hypertension
lactulose/neomycin - decrease ammonia
Cholelithiasis
(gallstones)
Acute or chronic
Cholangitis
duct inflammation
Cholesterol, calcium salts, or mixed Etiology: -Bile composition abnormalities -Bile stasis -Inflammation Risk factors: Pregnancy, Oral Contraceptives Obesity surgeries
cholelithiasis
Sudden, severe & steady RUQ pain – radiates to right scapula or shoulder Occurs after high fat meal Lasts up to 6 hours Nausea/vomiting/heartburn/flatulence Jaundice Clay colored stools
cholelithiasis assessment
inflammation and scar tissue destroy common bile ducts
cholangitis
stones in the common bile duct itself
choledocholithiasis
*key symptoms differentiating cholelithiasis from?
Fever
↑ WBC
Abdominal guarding
cholecystitis
Cholelithiasis / Cholecystitis patient teaching and management
- Discuss relationship between fat intake and pain. Teach about low fat diet.
- Withhold oral food and fluids during episodes of acute pain. Insert NG tube and connect to low suction.
- Administer Demerol, morphine, ketorolac (Toradol) or other analgesic.
- Place in Fowler’s position.
risk factors associated with cholelithiasis/cholecystitis
- female, fat, fourties, still fertile
- seeing a blurring of that, and starting to see gallbladder problems in kids
labs to monitor in cholelithiasis/cholecystitis
serum bilirubin, albumin, glucose, and cholesterol levels
T-tube
- report drainage greater than 1,000
- sits in common bile duct to keep it open post op and drain off excess bile
- often pts go home with it in place for up to 6 weeks
- inflammation of the liver
- etiologies: drugs, toxins, microorganisms, autoimmune
hepatitis
- RUQ pain: malaise, fatigability, low grade fever, arthralgia, N/V
- Anorexia and/or weight loss
- Fatigue
- Elevated AST & ALT
- *Infection highly transmissible during this phase
-prodromal or preicterus manifestations
Aspartate aminotransferase (AST) *normal values
Normal 5-35 units/ml
Alanine aminotransferase (ALT) *normal values
Normal 5-35 units/ml
Alkaline phosphatase (ALP) *normal values
Normal 30-120 IU/L
-Jaundice (except HCV) concurrent with a rise in serum bilirubin
-Hepatic symptoms: Dark urine, Hepatosplenomegaly, Severe pruritus
Possibly tender lymphadenopathy
-Elevated direct & indirect bilirubin
-Normal to moderately elevated ALP (liver enzyme)
icteric phase
Direct bilirubin: conjugated
*normal values
0.1-0.3 mg/dl
Indirect bilirubin: unconjugated
*normal values
0.2-0.7 mg/dl
Total bilirubin: Direct + Indirect = Total
0.3-1.0 mg/dl
clinical recovery of Hep-A, Hep-B
Clinical Recovery:
9 weeks HEP-A
16 weeks uncomplicated HEP-B
risk for infection nursing interventions for hepatitis
- Use universal precautions
- Contact isolation (HAV, HEV)
- Plan room assignments
- Private bathroom
- Hepatitis A / Hepatitis B vaccines
- Do not share bathroom unless strict personal hygiene maintained
- No sharing of: bed linens, washcloths, towels, drinking & eating utensils, razors, nail clippers, toothbrushes, needles, body piercings
- Avoid sexual activity / Safe sex
- Avoid ETOH, & OTC, esp acetaminophen, sedatives
- Do not donate blood, organs, tissue
- Small, frequent meals - ↑ CHO, ↓ fat, nutritional supplements
- family teaching for?
hepatitis
Replacement of normal cells with fibrous tissue
cirrhosis
Macronodular Cirrhosis
Hepatitis
Micronodular CIrrhosis
alcoholism
Liver dysfunction causes
- Hepatocellular dysfunction
- Portal hypertension
- Ascites
- Hepatic encephalopathy
- Failure to inactivate ADH & Aldosterone
- Retention of sodium & water
- Loss of K+
- Retention of sodium & water
- ↓ synthesis of proteins: hypoalbuminemia
- ↓ production of urea from NH3: ↑ serum ammonia (NH3)
- ↓ detoxification of potentially harmful substances: Drug interactions and toxicities
Hepatocellular dysfunction
- Anorexia & weight loss
- Dyspepsia
- Nausea/vomiting
- Change in bowel habits / flatulence
- Dull abdominal pain
- Fatigue
- Jaundice
- Petechiae or ecchymosis
- Peripheral edema
- Ascites
- Dilated abdominal veins
- Hepatomegaly
Cirrhosis assessment
Accumulation of fluid in the peritoneal space: increased hydrostatic pressure, ↓colloid osmotic pressure, Sodium & water retention, increased abdominal girth, + fluid wave, tenderness, SOB
Ascites
- Liver biopsy – definitive diagnosis
- Liver function – AST, ALT, LDH elevated
- Bilirubin (total, indirect) elevated
- Protein, Albumin- decreased
- PT/PTT (intrinsic measure)- elevated
- Platelets- decreased
- CBC, H/H, WBC’s (anemia & leukopenia)
- Serum Ammonia- elevated
- Creatinine- renal failure often develops
Cirrhosis diagnostics
Cirrhosis excess fluid volume nursing interventions
- Diet: ↓ Na+, ↓ protein, ↑ CHO, ↓ fat
- Fluid restriction with presence of ascites
- Weigh daily – same time, same type clothes
- Measure abdominal girth – to assess ascites
- Diuretics – remove excess fluid
Why would you see a cirrhosis patient on Beta-Blockers
Lactulose / Neomycin
Beta blockers: decrease portal hypertension
Lactulose / Neomycin: decrease ammonia
