MS II Exam 3 -Cirrho,Pancre, HepA-C, Trach, RA, SLE, &HIV

Tracheostomy

(1) bypass an upper airway obstruction. (2) facilitate removal of secretions. (3) permit long-term mechanical ventilation.

Goals of collaborative care for acute pancreatitis

(1) relief of pain; (2) prevention or alleviation of shock; (3) reduction of pancreatic secretions; (4) correction of fluid and electrolyte imbalances; (5) prevention or treatment of infections; and (6) removal of the precipitating cause, if possible

Sequence the steps for tracheostomy care

1 Assemble needed equipment on bedside table next to patient. 2 Wash hands. Put on goggles and clean gloves. 3 Remove soiled dressing and clean gloves. 4 Pour sterile H2O or normal saline in basins, and put on sterile gloves. 5 Unlock and remove inner cannula, if present. 6 Clean nondisposable inner cannula (replace if disposable). Clean at least every 8 hours 7 Cleanse around stoma and tracheostomy face plate. 8 Apply new dressing. Change tracheostomy ties if soiled. a two-person tech

Tracheostomy Sequence the steps for suctioning

1 Provide preoxygenation. 2 Gently insert catheter, without suction, to the point where the patient coughs, resistance is met, or 0.5 to 1.0 cm beyond the length of the artificial airway. 3Withdraw the catheter 0.5 to 1.0 cm before applying suction. 4 Apply suction intermittently while withdrawing catheter in a rotating manner. 5Limit suction time to 10 seconds. 6 Oxygenate for at least 30 seconds with 5 to 6 breaths. 7 Rinse catheter with sterile water and repeat procedure until airway is clear. 8 Return oxygen concentration to prior setting.

Acute PancreatitisEtiology

1. Gallbladder disease:women, --"*fair, fat, forty, fertile and female." 2. Chronic alcohol intake:men 3. Smoking 4. Hypertriglyceridemia

In order to prevent soft tissue injury, you are careful to maintain tracheostomy cuff pressure at less than or equal to XX mm Hg or XXcm H2O.

20 mm Hg or 25cm H2O.

The health care provider suspects A.S. may have a viral infection and wants to rule out hepatitis as the source. Which diagnostic studies would you expect to be ordered in a diagnostic workup of someone suspected of having hepatitis? There are 14 correct answers.

Anti-HAV-IgM Anti-HBc-IgG Anti-HBc-IgM Anti-HBe Anti-HBs Anti-HCV Anti-HDV Aspartate aminotransferase (AST) HBeAg HBsAg ϒ-Glutamyl transpeptidase (GGT) HDV Ag Serum bilirubin Alanine aminotransferase (ALT) Ambulatory and home care

Puritis: Nursing Implementation

Assess for jaundice, Measures to relieve pruritus, Cholestyramine or hydroxyzine, Baking soda or Alpha Keri baths, Lotions, soft or old linen, Temperature control, Short nails; rub with knuckles, Monitor color of urine and stools.

Hepatitis: Nursing Diagnoses Risk for impaired liver function related to viral infection

Avoidance of alcohol. Teach preventive measures to reduce transmission of virus. Explain signs of complications to monitor for and report. Instruct on necessary follow-up visits with health care provider.

Collaborative Care: Bleeding Esophageal and gastric varices Balloon Tamponade

Balloon tamponade: Mechanical compression of varices Sengstaken-Blakemore tube, Minnesota tube, Linton-Nachlas tube

Nursing Implementation: Balloon tamponade

Balloon tamponade: Monitor for complications (***i.e., aspiration pneumonia), Scissors at bedside, Semi-Fowler's position, Oral/nasal care.

Hepatitis: chronic phase

Begins as jaundice is disappearing, Lasts weeks to months, Major complaints, Malaise, Easy fatigability Hepatomegaly persists, Splenomegaly subsides.

Chronic PancreatitisCollaborative Care

Bile salts, Monitor glucose levels, Insulin or oral hypoglycemic agents, Acid-neutralizing and acid-inhibiting drugs, Antidepressants, Analgesics for pain relief -morphine or fentanyl transdermal patch [Duragesic]. Diet: Bland, low-fat, Small, frequent meals, No smoking, No alcohol or caffeine, Pancreatic enzyme with meals/snack, Observe for steatorrhea.

Hepatitis: appropriate to teach A.S. to prevent the spread of hepatitis B.

Administration of hepatitis B vaccine to close contacts of patient who are HBsAg negative and antibody negative Avoid sharing toothbrushes and razors, Good hand washing, Use condoms for sexual intercourse.

Respiratory assessment

Airway patency , Work of breathing , Breath sounds, Secretions: amount color consistency, Cough: able to clear secretions, Trach site for bleeding, infectioe

Nursing ManagementNursing Implementation

Ambulatory and home care, Supportive measures, Proper diet, Rest, Avoidance of hepatotoxic OTC drugs, Abstinence from alcohol, Nonjudgmental patient centered care. Maintenance of food/fluid intake to meet needs, Maintenance of skin integrity, Normalization of fluid balance, Treatment for substance abuse.

Hepatitis A virus

An RNA virus that is primarily transmitted by the fecal-oral route, mainly by ingestion of contaminated food or liquid. Crowded conditions, improper handling of food, poor hygiene, and poor sanitation increase the risk for this type of hepatitis. Ranges from mild to acute liver failure, Not chronic, Incidence decreased with vaccination, RNA virus transmitted via fecal-oral route, Contaminated food or drinking water.

Acute Pancreatitis

An acute inflammatory process of the pancreas, Varies from mild edema to severe necrosis, Most common in middle-aged persons and African Americans

Acute PancreatitisPathophysiology

Caused by autodigestion of pancreas,, Injury to pancreatic cells Activation of pancreatic enzymes, Activation of trypsinogen to trypsin within the pancreas leads to bleeding

Complications

Compensated cirrhosis, Decompensated cirrhosis, Portal hypertension, Esophageal and gastric varices, Peripheral edema and ascites, Hepatic encephalopathy, Hepatorenal syndrome

Clinical manifestations of encephalopathy

Confusion, Disorientation, Impaired consciousness and/or inappropriate behavior, Sleep disturbances to lethargy to coma, Asterixis: flapping tremor, Fetor hepaticus :musty sweet breath

Chronic Pancreatitis

Continuous, prolonged inflammatory, and fibrosing process of the pancreas: Etiology: gallstones, tumor, pseudocysts, Acute pancreatitis, Idiopathic, Heavy alcohol use, Autoimmune conditions, Genetic mutations due to cystic fibrosis, Blocked pancreatic duct or common bile duct, Familial pancreatitis.

Cuff Deflation

Deflate only if patient not at risk for aspiration. Allows talking and makes swallowing easier. Have patient cough and/or suction before and after deflation. Deflate during exhalation. Assess patient.

Chronic PancreatitisDiagnostic Studies

ERCP, CT, MRI, MRCP, abdominal and/or endoscopic, ultrasonography, Stool samples for fat content, ↓ Fat-soluble vitamin and cobalamin levels, Glucose intolerance/diabetes, Secretin stimulation test.

Hepatitis: Nursing Diagnoses Activity intolerance related to fatigue and weakness

Encourage frequent rest periods. Encourage patient to choose activities that gradually build endurance. Limit environmental stimuli (e.g., light and noise) to help promote rest.

Clinical Manifestations: Endocrine Disorders

Endocrine disorders: Secondary to decreased metabolism of hormones Gynecomastia, loss of axillary and pubic hair, testicular atrophy, impotence and loss of libido (men). Amenorrhea or vaginal bleeding, Hyperaldosteronism in both sexes

Pancreas: Endocrine definition and examples

Endocrine secreting enzymes into blood. examples: B Cells, insulin : Lower blood sugar, A Cells, glucagon : raisess blood sugar, D Cells, somatostatin : regulates pancreatic enzymes

Complications:Esophageal varices

Esophageal varices: Complex of fragile tortuous veins at lower end of esophagus, Bleed easily; bleeding can be life-threatening Gastric varices, Upper portion of stomach

Excocrine definition and examples

Excocrine secreting enzymes int o ducts. examples: Trypsinogen, Chymotrysin : protein digestion, Amylase: starch to disaccharides, Lipase: fat digestion

Cirrhosis: Early Symptoms

Fatigue, Many patients have no symptoms until late

Acute PancreatitisComplications;Pseudocyst

Fluid, enzyme, debris, and exudates surrounded by wall, Abdominal pain, palpable mass, nausea/vomiting, anorexia. Detected with imaging, Resolves spontaneously or may perforate and cause peritonitis, Surgical or endoscopic drainage.

Acute PancreatitisClinical Manifestations

Flushing, Cyanosis, Dyspnea, Nausea/vomiting, Low-grade fever, Leukocytosis, Hypotension, tachycardia Jaundice, Abdominal tenderness with guarding, Decreased or absent bowel sounds, Crackles, Abdominal skin discoloration, Grey Turner's spots or sign, Intravascular damage from circulating trypsin may cause areas of cyanosis or greenish to yellow-brown discoloration of the abdominal wall. Other areas of ecchymoses are the flanks -Grey Turner's spots or sign, a bluish flank discoloration. Cullen's sign, periumbilical area- Cullen's sign, a bluish periumbilical discoloration. Shock.

Clinical Manifestations: Jaundice

Functional derangement of liver cells, Compression of bile ducts by overgrowth of connective tissue, Decreased ability of liver cells to conjugate and excrete bilirubin, Severity varies

Serologic Events in HBV Infection

HBsAG (surface antigen) HBcAG (core antigen) HBeAg (e antigen) Hepatitis B surface antibody (anti-HBs) in the blood = immunity from the HBV vaccine or from past HBV infection.

Tracheostomy Potential Complications

Hemorrhage, Pneumothorax, Subcutaneous emphysema, Dislodged tube, Airway obstructions, Infection, Aspiration, Tracheal damage

What specific treatment measures would you expect the health care provider to order for D.L.'s encephalopathy?

Hepatic encephalopathy, Reduce ammonia formation, Lactulose (Cephulac), which traps ammonia in gut, Rifaximin (Xifaxan) antibiotic, Prevent constipation, Treatment of precipitating cause, Control GI bleeding, Remove blood from GI tract

Hepatitis

Hepatitis

Acute PancreatitisDiagnostic Studies

Laboratory tests: *Serum amylase level, *Serum lipase level, Liver enzyme levels, Triglyceride levels, Glucose level, Bilirubin level, Serum calcium level.

Diagnostic Studies

Liver enzyme tests, Total protein, albumin levels, Serum bilirubin, globulin levels, Cholesterol levels, Prothrombin time, Liver ultrasonography, Liver biopsy, Analysis of ascitic fluid, ***Ammonia levels

Hepatitis:Objective data: functional health patterns

Low-grade fever, Jaundice, Rash, Hepatomegaly, Splenomegaly, Abnormal laboratory values.

What nursing measures would you prioritize in caring for D.L. in relation to her encephalopathy? Hepatic encephalopathy

Maintain safe environment, Assess, Level of responsiveness, Neuro Assessment q 2 hours, Sensory and motor abnormalities, Fluid/electrolyte imbalances, Acid-base balance, Effects of treatment measures, Prevent constipation, Encourage fluids.

Pancreatitis

Pancreatits

Paracentesis: Nursing Implementation

Patient voids immediately before, High Fowler's position or sitting on side of bed, Monitor for fluid and electrolyte imbalances, Monitor dressing for bleeding/leakage

Acute PancreatitisNursing Implementation Ambulatory and home care. Dietary teaching. Patient/family teaching.

Physical therapy, Assessment of narcotic addiction, Counseling regarding abstinence from alcohol and smoking. Dietary teaching: Low-fat, high-carbohydrate, No crash diets. Patient/family teaching: Signs of infection, diabetes mellitus, steatorrhea, Medications/diet.

Acute Pancreatitis Systemic Complications

Pleural effusion, Atelectasis, Pneumonia, ARDS, Hypotension, Hypocalcemia: tetany.

Acute PancreatitisNursing Implementation;Post procedure care

Post procedure care: Observation for signs of infection, TCDB:turning, coughing, and deep breathing , semi-Fowler's position, Wound care, Observation for paralytic ileus, renal failure, mental changes, Monitor serum glucose, Post-op wound care.

Collaborative Care: Esophageal and gastric varices

Prevent bleeding/hemorrhage, Avoid alcohol, aspirin, and irritating foods, Screen for presence with endoscopy, Nonselective β-blocker: propranolol (Inderal) (decreases portal hypertension)

Hepatitis: After 1 week, A.S.'s bilirubin continues to rise and jaundice appears. For which associated symptoms would you monitor A.S.?

Pruritus, Dark tea-colored urine. Pruritus sometimes accompanies jaundice. The pruritus occurs as a result of the accumulation of bile salts beneath the skin. The urine becomes tea-colored as the liver becomes unable to take up bilirubin from the blood for excretion in the bile.

Chronic PancreatitisPotential Complications

Pseudocyst formation, Bile duct or duodenal obstruction, Pancreatic ascites, Pleural effusion, Splenic vein thrombosis, Pseudoaneurysm, Pancreatic cancer.

Nursing Implementation

Relief of dyspnea, Semi- or high Fowler's position, Skin care, Special mattress, Turning schedule, at least every 2 hours, ROM exercises, Coughing/deep breathing exercises, Elevate lower extremities/scrotum,

Complications: Hepatorenal syndrome, Cause

Renal failure with azotemia, oliguria, and intractable ascites. No structural abnormality of kidneys, Portal hypertension ,→ vasodilation ,→ renal vasoconstriction. Treat with liver transplantation.

Conservative Care

Rest, Administration of B-complex vitamins, Avoidance of alcohol, aspirin, acetaminophen, and NSAIDs

Tracheostomy: Potential for Dislodgement

Retention sutures , Free ends taped to skin and leave accessible in case tube is dislodged, Most dangerous first 5-7 days, Precautions to prevent: Replacement tube at bedside, Do not change ties for 24 hours. Physician performs first tube change.

Hypoxia: SxS

SOB, cyanosis, restless, anxiety, desaturation

Long term Management of Varices: Shunts

Shunting procedures, Used more after second major bleeding episode, Nonsurgical: transjugular intrahepatic portosystemic shunt (TIPS) Surgical: portacaval and distal splenorenal shunt.

Clinical Manifestations: Skin Lesions

Skin lesions: Due to increase in circulating estrogen caused by inability of liver to metabolize steroid hormones. Spider angiomas (teleangiectasia or spider nevi), Palmar erythema

What specific treatment measures might be used to treat D.L.'s ascites?

Sodium restriction, Albumin, Diuretics, Tolvaptan (Samsca) for Paracentesis , Transjugular intrahepatic portosystemic shunt,(TIPS) Accurate I/O recording, Daily weight measurement, Extremities measurement, Abdominal girth measurement, Monitor peripheral, scrotal and general edema

Alcohol Withdrawal Syndrome (AWS)

Stopping alcohol and two or more of the following symptoms: Diaphoresis, Tachycardia, Tremor, Insomnia, Nausea/vomiting, Hallucinations: Visual, Tactile, Auditory, Agitation, Tonic clonic seizures , Onset 6 - 48 hours after the last alcoholic drink.

Collaborative Care: Bleeding Varices

Supportive measures for acute bleed, Fresh frozen plasma, Packed RBCs, Vitamin K, Proton pump inhibitors, Lactulose (Cephulac) and rifaximin (Xifaxan) Antibiotics.

Chronic PancreatitisCollaborative Care:Surgery:

Surgery: Indicated when biliary disease is present or if obstruction or pseudocyst develops, Diverts bile flow or relieves ductal obstruction, Choledochojejunostomy, Roux-en-Y pancreatojejunostomy, Pancreatic drainage, ERCP with spincterotomy and/or stent placement.

Acute PancreatitisCollaborative Care:Surgical therapy:

Surgical therapy : For gallstones, ERCP, Cholecystectomy, Uncertain diagnosis, Not responding to conservative therapy, Drainage of necrotic fluid collections,

Hepatitis B virus

This DNA virus is transmitted perinatally; percutaneously (IV drug use, accidental needle-stick punctures); or by mucosal exposure to blood, blood products, or other body fluids. The virus can live on a dry surface for at least 7 days. Acute or chronic disease, Incidence decreased with HBV vaccine

Hepatitis C virus

This RNA virus is transmitted perinatally; percutaneously (IV drug use, accidental needle-stick punctures); or by mucosal exposure to blood, blood products, or other body fluids. Acute: asymptomatic, Chronic: liver damage

Clinical Manifestations:Hematologic disorders

Thrombocytopenia, Leukopenia, Anemia, Coagulation disorders

Tracheostomy

Tracheostomy`

Hepatitis: acute phase.

abdominal discomfort /Right upper quadrant, discomfort, anorexia, arthralgias headache, jaundice, low-grade fever, malaise, nausea, pruritus, skin rashes, vomiting, weight loss, Distaste for cigarettes. Acute phase: Physical examination findings, Hepatomegaly, Lymphadenopathy, Splenomegaly, Icteric (jaundice) or If icteric, patient can also have dark urine, Light or clay-colored stools, Pruritus

A tracheostomy tube with an inflated cuff is used if the patient is

at risk of aspiration or needs mechanical ventilation.

Cirrhosis: Etiology

chronic hepatitis C and alcohol-induced liver disease

Complications:Peripheral edema

↓ Colloidal oncotic pressure from impaired liver synthesis of albumin, ↑ Portacaval pressure from portal hypertension, Peripheral edema occurs as ankle and presacral edema.

Acute PancreatitisS S

Abdominal pain predominant: Left upper quadrant or midepigastrium, Radiates to the back, Sudden onset, Deep, piercing, continuous or steady, Aggravated by eating, Starts when recumbent, Not relieved with vomiting

Acute PancreatitisDiagnostic Studies

Abdominal ultrasonography, X-ray, Contrast-enhanced CT scan, *Endoscopic retrograde cholangiopancreatography (ERCP, Endoscopic ultrasonography (EUS), Magnetic resonance cholangiopancreatography (MRCP), Angiography, Chest x-ray.

Complications:Ascites

Accumulation of serous fluid in peritoneal or abdominal cavity, Abdominal distention with weight gain

Hepatitis: Collaborative Care: Drug Therapy

Acute hepatitis A: no specific medicines Acute hepatitis B: only if severe Acute hepatitis C Pegylated interferon to reduce progression to chronic infection Solvida Support therapy Antiemetics

Acute PancreatitisNursing Implementation

Acute intervention: Monitoring vital signs: Assess respiratory function, Monitor IV fluids. Monitor for infection: Monitor fluid and electrolyte balance: Chloride, sodium, and potassium. Hypocalcemia: Tetany, Calcium gluconate to treat. Hypomagnesemia. Rest the Pancreas: NPO, NG tube to suction, Decrease gastric acid: H2 antagonists, PPI, Antacids. Monitor for paralytic illeus, Peritonitis, Mouth Care, Nose Care. Manage pain: Opioids--morphine, Antispasmodics----dicyclomine. Oxygenation: Respiratory Assessment, Supplemental O2, Positioning, Encourage ICS, TCDB, Monitor ABGs. PC: Atelectasis, Pneumonia.

Acute PancreatitisNursing Diagnoses:

Acute pain, Deficient fluid volume, Imbalanced nutrition: less than body requirements, Ineffective self-health management, Risk for infection.

Hepatitis: Nursing Diagnoses Imbalanced nutrition: less than body requirements related to anorexia and nausea

Adequate caloric intake with patient preferences for food choice. Teach the use of nondrug techniques to manage nausea (e.g., guided imagery, relaxation). Vitamin supplementation. Adequate fluid intake (2500 to 3000 mL/day). Carbonated beverages to counteract anorexia. Avoidance of very hot or very cold folds if anorexic. Frequent oral care.

Acute PancreatitisEtiology : Less common causes

Drugs, Metabolic disorders, Vascular diseases, Surgery and endoscopic procedures, Idiopathic causes, Trauma -postsurgical, abdominal, Viral infections, Penetrating duodenal ulcer, Cysts, Abscesses, Cystic fibrosis, Kaposi sarcoma

Nursing Implementation: Bleeding Varices

Bleeding varices: Close observation for signs of bleeding, Balloon tamponade care, Explanation of procedure, Check for patency Position of balloon verified by x-ray

Chronic PancreatitisPathophysiology:Two major types

Chronic obstructive pancreatitis: Gallstones cause inflammation of sphincter of Oddi, Chronic nonobstructive pancreatitis: Inflammation and sclerosis in head of pancreas and around duct.

Cirrhosis

Chronic progressive disease of the liver

Delirium Tremors

Cognitive dysfunction, Delirium, Low grade fever, Diaphoresis, Agitation, Hallucinations, Oncet 72 -96 hours after last drink, Can last up to 7 days

Acute PancreatitisComplications:Pancreatic abscess

Collection of pus, Results from extensive necrosis, May perforate, Upper abdominal pain, mass, high fever, leukocytosis, Surgical drainage.

Nutritional Therapy

Diet for patient without complications, High in calories (3000 cal/day), ↑ Carbohydrate, Moderate to low fat, Protein restriction rarely justified, Protein supplements for protein-calorie, malnutrition, Low-sodium diet for patient with ascites and edema.

Clinical Manifestations:Peripheral neuropathy

Dietary deficiencies of thiamine, folic acid, and cobalamin :vitamin B12, Sensory symptoms predominate

Hepatitis: A.S. does have a significant other and admits to having recent sexual intercourse with him. She uses birth control for contraception. You would expect her significant other to receive what type of postexposure prophylaxis?

Hepatitis B immune globulin Hepatitis B immune globulin (HBIG) is recommended for postexposure prophylaxis in cases of needlestick, mucous membrane contact, or sexual exposure. HBIG contains antibodies to hepatitis B and confers temporary passive immunity. Preferably, it should be given within 24 hours of exposure. The vaccine series should also be started.

Hepatitis: Recovery

Homologous immunity to HAV or HBV, Patient can be reinfected with other types of viral hepatitis, as well as different strains of HCV. Most patients recover completely with no complications

Complications of Suctioning

Hypoxemia, Atelectasis or lung collapse, Mucosal trauma/bleeding, Bronchospam Dysrhytmias Pulmonary Infection, Sepsis, Cardiac arrest.

Hepatitis: Subjective data: functional health patterns

IV drug and alcohol abuse, Distaste for cigarettes (in smokers), High-risk sexual behaviors, Weight loss, anorexia, nausea/vomiting, RUQ abdominal discomfort, Urine and stool color, Fatigue/arthralgias/myalgia, Exposure to high-risk groups,

Prevent Fluid and Electrolyte imbalance Prevent Shock

IV fluids NS or LR at 125 ml/hour, I&O, Hemodynamic monitoring, CVP or PA, Peripheral circulation, UOP, Consider vasoactive drugs, Plasma expanders: albumin, Blood products, Electrolyte balance: Chloride, sodium, and potassium. Hypocalcemia: Tetany, Calcium gluconate to treat. Hypomagnesemia.

Emergency Care: Esophageal and gastric varices

If bleeding occurs, stabilize patient, manage airway, provide IV therapy and PRBC. Endoscopy to visualize bleeders, Drug therapy, Octreotide (Sandostatin) or Vasopressin (VP, terlipressin) Endoscopic therapy: to control bleeding, Band ligation, Sclerotherapy, Balloon Tamponade.

Serologic Events in HAV Infection

IgM : Positive in the blood, When the Stool turns negative IgG : past infection , Life long immunity

Tracheostomy :Accidental Dislodgement

Immediately replace tube. Spread opening by grasping retention sutures or with hemostat. Insert obturator into replacement tube, lubricate with saline, and insert at 45-degree angle. Remove obturator once tube inserted.

Complications:Portal hypertension

Increased portal venous pressure, Splenomegaly, Large collateral veins, Ascites, Gastric and esophageal varices

Cirrhosis: Later manifestations

Jaundice, peripheral edema, ascites, Skin, hematologic, endocrine, neurologic disorders

Acute PancreatitisPathophysiology

Mild pancreatitis: Edematous or interstitial., Severe pancreatitis: Necrotizing Endocrine and exocrine dysfunction, Necrosis, organ failure, sepsis, Rate of mortality: 25%.

Cuff Inflation

Minimal occlusion volume (MOV). Slowly inject air until no leak heard. Minimal leak technique (MLT). Inflate cuff with minimum amount of air to form seal. Then withdraw 0.1 mL of air. Do not use if risk for aspiration. Monitor cuff pressure every 8 hours.

Tests for hypocalcemia

Monitoring for Tetany: A. Chvostek's sign is contraction of facial muscles in response to a light tap over the facial nerve in front of the ear. B. Trousseau's sign is a carpal spasm induced by. C. inflating a blood pressure cuff above the systolic pressure for a few minutes.

Hepatitis: While teaching A.S. about the normal progression of the disease, what would you include?

Most patients recover completely from acute hepatitis B without complications. The acute phase of hepatitis usually lasts 1 to 4 months. Severe itching may accompany jaundice during the acute phase. The chronic phase of hepatitis can last an average of 2 to 4 months. Patients typically have malaise, easy fatigability, and some degree of hepatomegaly during the chronic phase.

Complications: Hepatic Encephalopathy

Neurotoxic effects of ammonia, Liver unable to convert ammonia to urea for excretion, Ammonia crosses blood-brain barrier

Acute PancreatitisCollaborative Care:Nutritional therapy:

Nutritional therapy: NPO status initially, Enteral versus parenteral nutrition, Monitor triglycerides if IV lipids given, Small, frequent feedings when able, High-carbohydrate, No alcohol, Supplemental fat-soluble vitamins.