NUR 221 - Ch 25 WB - Patients with Hepatic and Biliary Disorders **

The normal total bilirubin level is

0.3 to 1 mg per deciliter

The recommended daily sodium intake for patients with ascites is

2000 mg or less

The severity of pancreatitis is directly proportional to the number of indicators present. A patient with five to six signs indicative of pancreatitis would have a _____ % chance of mortality.

40%. Rationale refer to box 25-12 in the text.

A nurse is responsible for monitoring the diet of a patient with hepatic encephalopathy. The nurse knows that the 185 lb male should have a daily protein intake between

42 and 126 grams. daily protein intake should be limited to 0.5 to 1.5 grams per kilogram. There for a person who weighs 185 lb weighs 84 kg to calculate the protein intake, multiply the 84 kg by the low and high ranges. This patient would require a daily protein range from 42 to 126 grams.

The nurse reviews the laboratory values for a patient being evaluated for alcoholic cirrhosis. The nurse is aware that a diagnostic indicator present in greater than 70% of cases is which of the following?

AST/ALT ratio greater than 3. Rationale the aspartate aminotransferase alanine aminotransferase ratio is helpful in diagnosing liver damage and is present in More than 70% of cases.

An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is

Acetaminophen. Rationale although any medication can affect liver function, use of acetaminophen has been identified as the leading cause of acute liver failure. Other medications commonly associated with liver injury include anesthetic agents, medications used to treat Rheumatic and musculoskeletal disease, antidepressants, psychotropic medications, anticonvulsant, and anti tuberculin agents.

Describe the advantages of the laparoscopic procedure.

Advantages of laparoscopic procedure are that the patient does not experience the paralytic ileus that occurs with open abdominal surgery and has less post-operative abdominal pain. Early laparoscopic cholecystectomy, within 24 to 48 hours of symptoms, is the preferred intervention for treatment of acute cystitis and results in a reduced length of stay, fewer surgical complications, and faster recovery for the patient.

Management of a patient with ascites includes nutritional modifications and diuretic therapy. Which of the following interventions would a nurse expect to be part of patient care? Select all that apply.

Aldactone, and aldosterone blocking agent would be used. Daily salt intake would be restricted to 2 grams or less. The diuretic will be held if the serum sodium level decreases to less than 134 meq per liter. Rationale Lasix, a loop diuretic, combined with aldactone is the most effective regimen to control ascites. The serum sodium level should not drop below 100 34 meq per liter. A daily weight change of 1.1 lb, those without peripheral edema, or 2.2 lb, for those with peripheral edema, should be reported.

The single modality of pharmacologic therapy for chronic type B viral hepatitis is

Alpha interferon. Rationale Alpha interferon is a biologic response modifier that is highly effective for treatment of hepatitis B. The other antiviral agents are effective but not the preferred single-agent therapy.

Brenda is a 53 year old obese mother of 6. She has had chronic epigastric distress {abdominal fullness and distention} and beg pain in the right upper quadrant of her abdomen for several months.

And ultrasound detected a significant number of calculi in the gallbladder. Brenda was scheduled for surgery for a cholecystectomy.

Health teaching for a patient with ascites, who needs to follow a 2 gram sodium restricted diet, would include advice to avoid which of the following foods?

Bacon, lettuce and tomato sandwich on whole-grain bread. Rationale to follow a 2 gram sodium restricted diet sodium and processed foods like bacon and cheese should be avoided. Each meal should be restricted to 600 mg of sodium.

Exerts pressure directly to bleeding sites and esophagus and stomach

Balloon tamponade

Outline the information a nurse should provide preoperatively to explain the surgical procedure.

Before the procedure, the nurse should tell the patient that an open abdominal procedure may be necessary, and general anesthesia is administered. Laparoscopic cholecystectomy is performed through a small incision or puncture made through the abdominal wall at the umbilicus. The fiber optic scope is inserted through the small umbilical incision. Several additional punctures or small incisions are made in the abdominal wall to introduce other surgical instruments into the operative field.

Explain how cholesterol influences the formation of gallstones

Cholesterol Stones account for over 50% of gallbladder disease in the United States. Cholesterol, a normal constituent of bile, is in soluble in water. In gallstone prone patients, there is decreased bile acid synthesis and increased cholesterol synthesis in the liver, resulting in bile supersaturated with cholesterol, which precipitates out of the bile to form Stones. The cholesterol saturated bile predisposes to the formation of gallstones and acts as an irritant that produces inflammatory changes in the gallbladder.

The nurse assesses a patient who is diagnosed with decompensated cirrhosis. Which of the following are clinical indicators consistent with that diagnosis? Select all that apply.

Clubbing of the fingers, ascites, jaundice. Rationale refer to box 25-9 in the text.

Describe the medical, Surgical and nursing management of patients with esophageal varices.

Compare the various types of hepatitis and their causes, prevention, clinical manifestations, management, prognosis, and Home Health Care needs.

Absorption of the fat soluble vitamins, vitamins a, d, e, and K, as well as dietary fats may be impaired in chronic liver dysfunction because of

Decreased secretion of bile salts into the intestine

Esophageal banding choose the correct term identifying the parts involved when I look at your is slept over and esophageal varix via an endoscope and when necrosis results

Esophageal banding

Separates bleeding site from Portal system

Esophageal transaction and devascularization

Discuss medical and nursing management of patients with cancer of the liver.

Describe the post-operative nursing care of the patient undergoing liver transplantation.

Portal hypertension results from resistance to portal flow and increased portal venous inflow.

Development of portal pressure gradient of 12 or greater between the portal vein and the inferior vena cava

Discuss management of cholelithiasis.

Differentiate between acute and chronic pancreatitis.

The leading cause of liver disease and the primary indicator for liver transplantation is name the most common cause of acute liver failure

Drug-induced liver disease

A patient receiving vasopressin for the management of active bleeding due to esophageal varices should be assessed for evidence of the drugs most serious complication. Therefore the nurse should frequently check the patient's

Electrocardiogram. Vasopressin is administered during an acute esophageal bleed because of its phases constrictive properties in the splanchnic, portal, and intrahepatic vessels. This medication also causes coronary artery constriction that may dispose patients with coronary artery disease to cardiac ischemia, therefore, the nurse observes the patient for evidence of chest pain, ECG changes, and Vital sign changes.

Explain the pathophysiology of alcoholic liver disease {ALD}.

Ethanol, alcohol, is metabolized by the liver. The resultant product, acetaldehyde, is toxic to the liver, resulting in impairment of liver function and cells. Other factors contributing to the pathogenesis of ALD are oxidative stress hypoxia or oxygen depletion of cells, and mitochondrial injury. Fatty infiltration of liver cells, hepatic steatosis, is a common finding in liver biopsies of patients with ALD.

The mode of transmission of hepatitis A virus is the

Fecal oral route, uncooked food or poor food handling

The most common disorder of the biliary system is

Gallbladder disease with gallstones

The most life-threatening complication in patients with chronic liver disease is

Gastroesophageal varices

The two immediate goals for treatment for Hepatitis B are to

Hepatitis C virus

Promotes thrombosis and sclerosing of bleeding sites by injection of an agent into the esophageal varices

Injection sclerotherapy

Draft for nursing diagnosis for a patient with cirrhosis.

Nursing diagnosis include the following: activity intolerance related to fatigue, General debility, muscle wasting, and discomfort. Imbalanced nutrition, less than body requirements, related to chronic gastritis, decreased GI motility, and anorexia. Impaired skin integrity related to compromised immune illogic status, edema, and poor nutrition. Risk for injury and bleeding related to altered clotting mechanisms.

In actively bleeding patients with esophageal varices, the initial drug of therapy is usually

Pitressin. Rationale in an actively bleeding patient, medications are administered initially because other therapies take longer to initiate. Vasopressin, pitressin, maybe the initial mode of therapy, because it produces constriction of the splanchnic arterial bed and decreases portal pressure. It may be administered by IV infusion.

List the three groups of at-risk persons who should be vaccinated for Hepatitis B virus

Prevent replication of active Hepatitis B virus and reduce the effects of chronic liver inflammation

Part of preoperative patient preparation for liver transplantation is informing the patient about postoperative complications. The most severe complication is

Primary graft non function. Rationale primary graft non function is the most severe complication of liver transplant and occurs in 5 to 10% of cases.

Reduces portal pressure by be energetic blocking action

Propranolol

Clears blood and secretions before endoscopy

Room temperature saline lavage

A patient is prescribed sandostatin for the treatment of esophageal varices. The nurse knows that the purpose of this cyclic octapeptide is to reduce portal pressure by

Selected vasodilation of the portal system. Rationale sandostatin slows the flow of blood, via vasodilation, from internal organs to the portal system, thus reducing pressure. The other choices are actions of different drugs used for the treatment of esophageal varices. Refer to table 25-1 in the text.

Alcohol, which is toxic to the liver, is a common cause of hepatic disorders. As part of Health teaching, the nurse advises a group of women that the amount of daily alcohol use should be limited to the equivalent of

Two 6 oz glasses of wine. Rationale intake of 60 grams per day for men and 30 G per day for women. 10 grams of alcohol is equivalent to 1 oz of bourbon, 12 oz of beer, or 4 oz of red wine, is sufficient to cause liver injury.

The nurse should assess for an important early indicator of acute pancreatitis, which is a prolonged and elevated level of

Serum lipase. Rationale serum amylase and lipase levels are elevated within 24 hours of the onset of symptoms. Serum amylase usually returns to normal within 48 to 72 hours, but serum lipase levels May remain elevated days longer than amylase.

Reduces portal pressure by selective vasodilation of portal system

Somatostatin

A nurse assesses a patient diagnosed with hepatic encephalopathy. She observes and number of clinical signs, including asterixis and fetor hepaticus; the patient's electroencephalophalogram {EEG} is abnormal. The nurse documents that the patient is exhibiting signs of which stage of hepatic encephalopathy?

Stage 2. Rationale the signs listed in the question + disorientation, mood swings, and increased drowsiness are all indicators of stage 2 hepatic encephalopathy. Refer to table 25-2 in the text.

Ties of blood vessels at the site of bleeding.

Surgical ligation of varices

Ammonium, the major metalogic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from

The digestion of dietary and blood proteins. Crashing out circumstances that increase serum ammonia levels tend to aggravate or precipitate hepatic encephalopathy. The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. Ammonia from these sources increases as a result of GI bleeding, IE, bleeding esophageal varices, chronic GI bleeding, a high protein diet, bacterial infection, or uremia.

Describe the three goals for preventing hepatitis B.

The goals of prevention are to interrupt the chain of transmission, to protect people who are at high risk by active immunization through the use of hepatitis B vaccine, and to use passive immunization for unprotected people exposed to HBV.

Describe four major points of information that the nurse must give to the patient, prior to discharge, about managing follow-up care.

The major points that a nurse would emphasize, prior to discharge are: make an appointment with your surgeon at least 7 to 10 days after discharge. Call your surgeon If you experience any signs or symptoms of infection at or around the puncture site, redness, tenderness, swelling, heat or drainage. Call your surgeon if you develop nausea, vomiting, or abdominal pain.

List the teaching points a nurse would use to advise the patient how to resume activity post-procedure.

The teaching points would include: begin light exercise, walking, immediately. Take a shower or bath after one or two days. Wait to drive a car for 3 or 4 days. Avoid lifting objects exceeding 5 lb after surgery, usually for one week. Resume sexual activity when desired.

A nurse practitioner treating a patient who is diagnosed with Hepatitis A should provide Health Care information. Which of the following statements are correct for this disorder? Select all that apply.

There is a 70% chance that jaundice will occur. Transmission of the virus is possible with oral anal contact during sex. Typically there is a spontaneous recovery. Rationale the incubation period for Hepatitis A is 15 to 50 days, with an average of 28 days. The risk of cirrhosis occurs with hepatitis B.

Reduces portal pressure by creating a shunt within the liver between the portal and systemic venous systems

Transjugular intrahepatic portosystemic shunt

Transjugular intrahepatic portosystemic shunt TIPS. Label the figure identifying the structures involved when a scent stent is inserted via catheter to the portal vein to divert blood flow and reduce portal hypertension. (p. 171)

Transjugular intrahepatic portosystemic shunt TIPS

Hepatitis A is most commonly transmitted by

Travelers, men having sex with men, and illicit drug users

Immune serum globulin provides passive immunity against type a hepatitis in those not vaccinated if it is administered within two weeks of exposure. Passive immunity is effective for about

Two months. Rationale for those who have not been previously vaccinated, hepatitis A can be prevented by IM administration of globulin during the incubation period, if given within two weeks of exposure. This bolsters the person's antibody production and provides six to eight weeks of passive immunity.

A patient is scheduled for a paracentesis. The nurse assist the patient into the proper position. What is the correct position for this procedure?

Upright, with his feet resting on a support so that the puncture site will be readily visible. Rationale the patient should be in the upright position so that the peritoneal fluid can be close to the abdominal wall this will promote easier puncture and fluid removal.

Provides thrombosis and mucosal necrosis of bleeding sites by ligation

Variceal banding

Reduces portal pressure by constricting splanchnic arteries.

Vasopressin

Portal hypertension and increased capillary pressure abstracts venous flow.

Venus collaterals develop from high portal system pressure to systemic veins in the esophageal plexus, the hemorrhoidal plexus, and retroperitoneal veins.

Explain the etiology of viral hepatitis.

Viral hepatitis is a systemic, viral infection in which necrosis and inflammation of liver cells produce a characteristic cluster of clinical, biochemical, and cellular changes. Today 8, six types of viral hepatitis have been identified, hepatitis A, B, C, D, E, and G. These viruses infect the liver and can result in either acute or chronic liver dysfunction or disease. Initial presentation of viral hepatitis may be asymptomatic or result in fulminant liver failure or chronic liver disease.

During an assessment, a patient with chronic liver dysfunction tells the nurse that he is experiencing spontaneous episodes of bleeding and has noticed increased areas of bruising on his chest and arms. The nurse suspects a deficiency in

Vitamin K. Rationale vitamin K deficiency results in hypo protemps anemia, which is characterized by spontaneous bleeding and ecchymosis.

Describe the process for the detection of ascites.

With the patient supine, the free fluid in the abdomen will accumulate in the flanks, percussion of the abdomen will reveal timpani over the anterior abdomen and dullness over the flanks. Turning the patient to one side with repeat percussion will reveal shifting dullness oh, the uppermost area will sound tympanic while the lower area will sound dull to percussion.

Learning objectives

relate jaundice, portal hypertension, ascites, varices, nutritional deficiencies, and hepatic coma to pathophysiologic alterations of the liver.