AH4 UNIT 2 WK 8

A

During a client's neurologic assessment, the nurse finds that the client is arousable only with vigorous or painful stimulation. How does the nurse document this client's level of consciousness? A. Stuporous B. Lethargic C. Comatose D. Alert

liver transplantation

For the patient who has had a ________________, monitor the temperature frequently per hospital protocol and report elevations, increased abdominal pain, distention, and rigidity, which are indicators of peritonitis. Nursing assessment also includes monitoring for a change in neurologic status that could indicate encephalopathy from a nonfunctioning liver. Report signs of clotting problems (e.g., bloody oozing from a catheter, petechiae, ecchymosis) to the surgeon immediately because they may indicate impaired function of the transplanted liver.

encephalopathy

Frequently assess for changes in level of consciousness and orientation. Check for asterixis and fetor hepaticus. These signs suggest worsening _________. Thiamine supplements and benzodiazepines may be needed if the patient is at risk for alcohol withdrawal.

6

Hepatitis is considered to be chronic when liver inflammation lasts longer than _ months. Chronic hepatitis usually occurs as a result of hepatitis B or hepatitis C. Superimposed infection with hepatitis D virus (HDV) in patients with chronic hepatitis B may also result in chronic hepatitis.

dopamine

Hypotension, if severe, is treated with continuous IV sympathomimetic agents such as ________ or other vasoactive agent.

acetaminophen

One of the most important aspects of ongoing care for the patient with cirrhosis is health teaching about the need for the client to avoid ___________, alcohol, smoking, and illicit drugs. By avoiding these substances, the patient may: • Prevent further fibrosis of the liver from scarring • Allow the liver to heal and regenerate • Prevent gastric and esophageal irritation • Reduce the incidence of bleeding • Prevent other life-threatening complications

cirrhosis

Patients with ________ have increased nutritional requirements—high-carbohydrate, moderate-fat, and high-protein foods. However, the diet may be changed for those who have elevated serum ammonia levels with signs of encephalopathy. Patients should have a moderate amount of protein and fat foods and simple carbohydrates.

83 mL/hr

Prescription: Infuse Packed Red Blood Cells 250 mL over 3 hours, one time, now. Using an infusion pump that delivers only whole numbers what is the correct IV rate? Include units of measure for your calculation.

Viral

Prevention of ____ Hepatitis in Health Care Workers • Use Standard Precautions to prevent the transmission of disease between patients or between patients and health care staff (see Chapter 21). • Eliminate needles and other sharp instruments by substituting needleless systems. (Needlesticks are the major source of hepatitis B transmission in health care workers.) • Take the hepatitis B vaccine, which is given in a series of three injections. This vaccine also prevents hepatitis D by preventing hepatitis B. • For postexposure prevention of hepatitis A, seek medical attention immediately for immunoglobulin (Ig) administration. • Report all cases of hepatitis to the local health department. Levels of ALT and AST may possibly rise into the thousands in acute or fulminant cases of hepatitis. Alkaline phosphatase levels may be normal or elevated. Serum total bilirubin levels are elevated and are consistent with the clinical appearance of jaundice.

prolonged

Prothrombin time/international normalized ratio (PT/INR) is ________ because the liver decreases the production of prothrombin. The platelet count is low, resulting in a characteristic thrombocytopenia of cirrhosis. Anemia may be reflected by decreased red blood cell (RBC), hemoglobin, and hematocrit values. The white blood cell (WBC) count may also be decreased.

loop

Serious fluid and electrolyte imbalances, such as dehydration, hypokalemia (decreased potassium), and hyponatremia (decreased sodium), may occur with ____ diuretic therapy.

hepatic

Serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH) typically are elevated because these enzymes are released into the blood during _______ inflammation. However, as the liver deteriorates, the hepatocytes may be unable to create an inflammatory response, and the AST and ALT may be normal. ALT levels are more specific to the liver, whereas AST can be found in muscle, kidney, brain, and heart.

Viral Hepatitis

Sign and symptoms of _________ __________ • Abdominal pain • Yellowish sclera (icterus) • Arthralgia (joint pain) or myalgia (muscle pain) • Diarrhea/constipation • Light clay-colored stools • Dark yellow to brownish urine • Jaundice • Fever • Fatigue • Malaise • Anorexia • Nausea and vomiting • Dry skin • Pruritus (itching)

such as fat-soluble

Teach patients to avoid excessive vitamins and minerals that can be toxic to the liver, ______________ vitamins, excessive iron supplements, and niacin. Remind patients to check with their primary health care provider before taking any vitamin supplement. Advise the patient to avoid all over-the-counter drugs, especially NSAIDs and hepatic toxic herbs, vitamins, and minerals.

Check blood glucose and oxygen saturation

What actions will the nurse take to determine if an altered level of consciousness (LOC) in a client is a neurological emergency or if it represents one of two other conditions that may also lead to altered LOC?

A. Disability, neuro deficits, B. Circulation, central pulses, C. Airway, alertness and Breathing

What are the assessments related to the first few seconds of the trauma primary survey? Select all that apply

"We're sorry to inform you that your loved one died due to extensive injuries"

What is the best way for the emergency health care provider and nurse to inform a family that their family member has died of extensive injuries despite resuscitation efforts?

Impervious cover gown, gloves, eye protection, face mask, cap, and shoe covers are required.

What type of personal protective equipment (PPE) or attire would the nurse wear to provide care for a motor vehicle crash victim with severe chest trauma who is coughing up blood and has a crush injury to the right leg?

44 year-old with a dislocated elbow

Which client would the triage nurse categorize as urgent?

A-fib

Which dysrhythmia does the nurse expect to see when a client with an embolic stroke is placed on a cardiac monitor?

Decrease in level of consciouness (LOC)

Which is the first sign of increased intracranial pressure (ICP) that the nurse will notice in a client at risk for this condition?

Correct Answer:4. A 18 year-old with a concussion complaining of headache 7/10, projectile vomiting, VS 150/90; 102; 16; SaO2 98% on room air, temp 37.1.

Which patient should the nurse assess first?

1. ICP 5-15 2. Ensures consistent Cerebral blood flow 4. Only effective if mean arterial pressure (MAP) 70 to 150 mm Hg 5. Adjusts diameter of blood vessels

Which statements are correct regarding cerebral auto-regulation? Select all that apply.

Urine output increases above 0.5ml/kg per hour

Which vital sign change in a client with hypovolemic shock indicates to the nurse that the therapy is effective?

Pupils

_____ should be equal in size, round and regular in shape, and react to light and accommodation (PERRLA)

Hepatitis

______ is the widespread inflammation and infection of liver cells. Viral hepatitis, which can be acute or chronic, is the most common type. Less common types of hepatitis are caused by chemicals, drugs, and some herbs. The liver becomes enlarged and congested with inflammatory cells, lymphocytes, and fluid, resulting in right upper quadrant pain and discomfort

Hepatic

_______ cell damage may lead to these common complications: • Portal hypertension • Ascites and esophageal varices • Biliary obstruction • Hepatic encephalopathy

Esophageal varices

________ _________ occur when fragile, thin-walled esophageal veins become distended and tortuous from increased pressure. Varices occur most often in the distal esophagus but can be present also in the stomach and rectum.

Laennec's Cirrhosis

or alcoholic cirrhosis (caused by chronic alcoholism)

Biliary cirrhosis

(also called cholestatic; caused by chronic biliary obstruction or autoimmune disease)

postnecrotic cirrhosis

(caused by viral hepatitis [especially hepatitis C] and certain drugs or other toxins)

A,C

1. A client is receiving adefovir for management of hepatitis B. What health teaching will the nurse provide for the client about this drug? Select all that apply. A. "Avoid places with crowds and individuals who have infection." B. "Report increased bruising to your doctor because the drug can cause bleeding." C. "Get your lab work done regularly because the drug can affect your kidneys." D. "Be careful and avoid falls because the drug can cause fractures." E. "Follow up with the dietitian to ensure that you adhere to your special diet."

C

1. The nurse is preparing to conduct a focused neurologic assessment for a client who had a traumatic brain injury. Which assessment finding is the immediate concern of the nurse? A. Disorientation B. Numbness in both arms C. Decreased level of consciousness D. Report of headache

A;D;E

1. The nurse reassesses a client who was admitted 8 hours after stroke symptoms began and documents the following findings. Which assessment findings would the nurse report immediately to the primary health care provider? Select all that apply. A. Blood pressure increase to 196/100 mm Hg B. Heart rate of 88 beats/min C. Respiratory rate of 22 breaths/min D. New-onset headache reported as 8/10 pain intensity E. Increased drowsiness and dozing frequently F. Urine output of 360 mL since admission

D

2. A client was admitted to the hospital unit a few minutes ago with a new diagnosis of right hemiparesis and aphasia, which resulted from a traumatic brain injury. Which of the following interventions is a priority for the client at this time? A. Contact the physical therapist (PT) to plan care to increase the client's mobility. B. Contact the occupational therapist (OT) to assess the client's ADL ability. C. Contact the unit social worker (SW) to talk with the family about the client's discharge. D. Contact the speech-language pathologist (SLP) to schedule a swallowing study.

B

2. The nurse is caring for a client following a cerebral angiography. Which assessment finding will the nurse report immediately to the primary health care provider? A. Discomfort at the injection site B. Bleeding from the injection site C. Fatigue and weakness D. Mild headache

C

2. The nurse is caring for a patient with cirrhosis who has hepatic encephalopathy. Which assessment finding should the nurse report to the primary health care provider? A. Fatigue B. Difficulty sleeping C. Seizure D. Disorientation

2. Glasgow coma scale (GCS) 13 5. ICP 7. Temperature

22-year-old with Traumatic Brain Injury (TBI) in the ICU for 3 days. Awakes to verbal stimuli by name, oriented to name, age, and mother. PERRL @ 3mm, equal grips and strong, inconsistent following commands moves to localized pain, wrist restraints, See the monitor for patient's current VS, ICP; Pt's temp is 38.6 (101.4); Pulse ox 95% on 3 liters nasal cannula. Which are the priority cues. Select all that apply.

2. Head of bed is elevated at 45 degrees 3. Reassess GCS and neuro checks 4. Notify the physician regarding the patient's cerebral perfusion pressure (CPP) is low. 5. Patient's room is darkened and limiting patient to minimum

A 23 y/o MVA admitted last night is restless, not following commands, and fighting with staff. The patient's Vital signs: 110/40 (63); HR 108; RR 24; SpO2 99% on 4L nc; Intracranial pressure (ICP) 18, PERRL @ 5mm; moves all extremities but not to command, mannitol 25gm infusing over 30 minutes. Which actions should the nurse to take next. Select all that apply.

Correct Answer:B. Check the time on the tourniquet and report to the trauma leader

A 32 year/old is admitted post motor cycle wreck. The patient's right leg has a tourniquet 2 inches above a bleeding wound. Which assessment should the nurse do next?

10

A 43 y/o male with head trauma is sleeping, eyes closed. The nurse walks in the room and says "Good Morning" , the patient wakes up and attempts to talk. The nurse asked the patient for his name and his age, the response were words were mumbled and unclear. When the patient was asked to grip and/or move their legs, no movement. The nurse did see movement of arms and legs to painful stimulation. The patient falls back asleep when not stimulated. What is the patient's glasgow score (GCS)?

C

A client who sustained a recent cervical spinal cord injury reports having a throbbing headache and feeling flushed. The client's blood pressure is 190/110 mm Hg. What is the nurse's priority action at this time? A. Perform a bladder assessment. B. Insert an indwelling urinary catheter. C. Place the patient in a sitting position. D. Turn on a fan to cool the patient.

A

A nurse is caring for a client who has a halo fixator device with vest for a complete cervical spinal cord injury. Which assessment finding will the nurse report to the primary health care provider? A. Purulent drainage from the pin sites on the client's forehead B. Painful pressure injury under the collar C. Inability to move legs or feet D. Oxygen saturation of 95% on room air

Notify the health care provider (HCP)

A patient admitted with a diffuse axonal injury has a blood pressure of 106/52, MAP (70) and intracranial pressure (ICP) of 30. Calculate the cerebral perfusion pressure (CPP) and decide which action should the nurse take first?

Blood pressure 176/60; pulse 50; respirations 12 and irregular

A patient with a head injury has vital signs: BP 126/68; HR 110; RR 26 on admission. One hour later the vital signs are repeated again. Which vital signs indicate the patient has a life threatening risk of brain injury?

90

A systolic blood pressure below ___ mm Hg requires treatment because lack of perfusion to the spinal cord could worsen the patient's condition.

hypovolemia

An elevated BUN, decreased serum proteins, and increased hematocrit may indicate ___________.

Hepatitis C

Currently there is no vaccine for ______; however, patients may be treated with antiviral drug therapies. The desired outcome of treatment of ____-infected patients is to reduce mortality and liver-related health adverse consequences, including end-stage liver disease and liver cancer.

prothrombin

Decreased __________ production places the patient with cirrhosis at risk for bleeding. Bleeding esophageal varices are a life-threatening medical emergency. Severe blood loss may occur, resulting in shock from hypovolemia. The bleeding may present as either hematemesis (vomiting blood) or melena (black, tarry stools).

bile

In patients with cirrhosis, the production of ___ in the liver is decreased. This prevents the absorption of fat-soluble vitamins (e.g., vitamin K). Without vitamin K, clotting factors II, VII, IX, and X are not produced in sufficient quantities, and the patient is susceptible to bleeding and easy bruising.

bilirubin

Indirect _____ levels increase in patients with cirrhosis because of the inability of the failing liver to excrete bilirubin. Therefore bilirubin is present in the urine (urobilinogen) in increased amounts. Fecal urobilinogen concentration is decreased in patients with biliary tract obstruction. These patients have light- or clay-colored stools.

Elevated serum ammonia

Is elevated with advanced liver disease or portal-systemic encephalopathy (PSE)

Hepatitis D

It occurs only with HBV to cause viral replication. This usually develops into chronic disease. The incubation period is about 14 to 56 days. As with hepatitis B, the disease is transmitted primarily by parenteral routes, especially in patients who are IV drug users. Having sexual contact with someone with ____ is also a high-risk factor

Hepatitis E

Like hepatitis A, hepatitis __ is caused by fecal contamination of food and water. It is transmitted via the fecal-oral route, and the clinical course resembles that of hepatitis A. Hepatitis __ has an incubation period of 15 to 64 days. There is no evidence at this time of a chronic form of the disease. The disease tends to be self-limiting and resolves on its own

Nimotop:Vasospasms Mannitol:Cerebral osmotic diuretic Furosemide:Cerebral edema lorazepam:seizure prn Keppra:Anti-seizure

Match the medications to their indications for use in the care of patients with neurological impairment. QuestionCorrect Match

Hepatitis A

Measures for preventing hepatitis __ in adults include: • Proper handwashing, especially after handling shellfish • Avoiding contaminated food or water (including tap water in countries with high incidence) • Receiving immunoglobulin within 14 days if exposed to the virus • Receiving the ___ vaccine before traveling to areas where the disease is common (e.g., Mexico, Caribbean) • Receiving the vaccine if living or working in enclosed areas with others, such as college dormitories, correctional institutions, day-care centers, and long-term care facilities is established when hepatitis __ virus (HAV) antibodies (anti-___) are found in the blood.

2. Docusate sodium (Colace) liquid 100mg per FT 3. Enoxaparin (Lovenox) 30mg Subcutaneous 4. Give the Sodium chloride (HYPERTONIC) 3% IV bolus 300ml every 4 hours as needed for ICP greater than 20 for greater than 5 minutes. 5. amiodarone (Pacerone) liquid 200mg per FT 6. Give Labetalol 10mg IV 7. Give Magnesium Sulfate 2 grams in 50 ml sterile water IVPB over 1 hour x 2 doses 8. Give insulin Novolog 6 units subcutaneous 9. Sucraifate (Carafate) 1GM/10ml suspension per FT

The 36 year-old with MVA with multiple extremity fractures, Traumatic head injury, with a GCS of 9, and on ventilator support. The patient has a cortrak in the left nare with continuous tube feedings, ICP bolt, and oral ETT. VS: 181/88; 108, 20, SaO2 98% on FiO2 50%; temp 36.7, ICP 24 for last 8 minutes, blood glucose 240 sliding scale insulin listed below and due now, sodium 159, potassium 3.8; sodium 159, chloride 120; BUN 28, creatinine 1.2; GFR >90, INR1.2; magnesium 1.0. Which PRN and scheduled medications should be given now? Sodium chloride (HYPERTONIC) 3% IV bolus 300ml every 4 hours as needed for ICP greater than 20 for greater than 5 minutes and Hold for serum sodium greater than 160-last dose given 4 hrs ago; Labetalol (Normodyne Trandate) 10 mg IV every 4 hours prn for SBP>180, last dose given 5 hrs ago. Magnesium Electrolyte Replacement.pdf Insulin Sliding Scale protocol listed below. Novolog Insulin Sliding Scale glucose checks AC & HS 140-200 give 3 units sub-q 201-250 give 6 units sub-q 251-300 give 9 units sub-q 301-399 give 12 units sub-q Call physician if FSBS is greater than 400 or less than 60.

Paracentesis

The Patient Having a ____________ • Explain the procedure and answer patient questions. • Obtain vital signs, including weight, before the procedure. • Ask the patient to void before the procedure to prevent injury to the bladder! • Position the patient in bed with the head of the bed elevated. • Monitor vital signs per protocol or primary health care provider request during the procedure. • Measure the drainage and record accurately. • Document the characteristics of the collected fluid. • Label and send the fluid for laboratory analysis; document in the patient health record that specimens were sent. • After the catheter is removed, apply a dressing to the site; assess for leakage. • Maintain bedrest per protocol. • Take vital signs and weigh the patient after the paracentesis; document in the patient record weight both before and after paracentesis. (The patient should experience a weight loss due to fluid removal.)

hepatic portal

The ________ _______ system is the venous system that returns blood from the digestive tract and spleen to the liver (where raw nutrients in blood are processed before the blood returns to the heart).

C,D

The nurse is caring for a client diagnosed with hepatitis A. Which transmission-based precautions are required when providing care for this client? Select all that apply. A. Place client in a private room. B. Wear a mask when handling patient bedpan. C. Wear gloves when touching the client. D. Wear a gown when providing personal care to this patient. E. Wear eye goggles when providing care.

A,C

The nurse is caring for a client in end-stage liver failure. Which interventions should be implemented when observing for hepatic encephalopathy? Select all that apply. A. Assess the client's neurologic status as prescribed. B. Monitor the client's hemoglobin and hematocrit levels. C. Monitor the client's serum ammonia level. D. Monitor the client's electrolyte values daily. E. Prepare to insert an esophageal balloon tamponade tube. F. Make sure the client's fingernails are short.

A,B,C,D,E

The nurse is caring for a client who is diagnosed with cirrhosis. Which serum laboratory value(s) will the nurse expect to be abnormal? Select all that apply. A. Prothrombin time B. Serum bilirubin C. Albumin D. Aspartate aminotransferase (AST) E. Lactate dehydrogenase (LDH) F. Acid phosphatase

D

The nurse is teaching a client about what to expect immediately after a cerebral angiographic examination. Which statement by the client indicates a need for further teaching? A. "I'll have a pressure dressing on my groin for a couple of hours." B. "I'll have to keep my leg straight for a while after the procedure." C. "The nurses will check circulation in my injected leg frequently." D. "I can use heat on my groin to decrease any discomfort."

A,B,D,E

The nurse performs an initial neurologic assessment on an older client. Which assessment findings would the nurse expect to be the result of normal physiologic aging? Select all that apply. A. Decreased coordination B. Hearing loss C. Long-term memory loss D. Recent memory loss E. Decreased balance control

Spinal Shock

The patient has complete but temporary loss of motor, sensory, reflex, and autonomic function that often lasts less than 48 hours but may continue for several weeks

lactulose (or lactitol)

The primary health care provider may prescribe __________to promote the excretion of ammonia in the stool. This drug is a viscous, sticky, sweet-tasting liquid that is given either orally or by NG tube. The patient may report intestinal bloating and cramping. Hypokalemia and dehydration may result from excessive stools.

propranolol

The role of early drug therapy is to prevent bleeding and infection in patients who have varices. A nonselective beta-blocking agent such as ___________ is usually prescribed to prevent bleeding.

pneumothorax

The trauma patient with a visible wound to the chest wall, cyanosis, tachycardia, paradoxical/asymmetric chest wall movement, and tracheal deviation to the opposite side indicates which complication of trauma?

albumin

Total serum ______ levels are decreased in patients with severe or chronic liver disease as a result of decreased synthesis by the liver. Loss of osmotic "pull" proteins such as albumin promotes the movement of intravascular fluid into the interstitial tissues (ascites). Dilutional hyponatremia (low serum sodium) may occur in patients with ascites.

Hepatitis B

a double-shelled particle containing DNA composed of a core antigen (HBcAg), a surface antigen (HBsAg), and another antigen found within the core (HBeAg) that circulates in the blood May be spread through these common modes of transmission: • Unprotected sexual intercourse with an infected partner • Sharing needles, syringes, or other drug-injection equipment • Sharing razors or toothbrushes with an infected individual • Accidental needlesticks or injuries from sharp instruments primarily in health care workers (low incidence) • Blood transfusions (that have not been screened for the virus, before 1992) • Hemodialysis • Direct contact with the blood or open sores of an infected individual • Birth (spread from an infected mother to baby during birth) Symptoms usually occur within 25 to 180 days of exposure. Blood tests confirm the disease, although many individuals with hepatitis __ have no symptoms. Most adults who get hepatitis __ recover and clear the virus from their body and develop immunity. However, a small percentage of people do not develop immunity and become carriers.

Dextran

a plasma expander, may be used to increase capillary blood flow within the spinal cord and prevent or treat hypotension.

Asterixis

aka Liver Flap, a flapping tremor of the hands. When the client extends the arms & hands in front of the body, the hands rapidly flex & extend.

Hepatic encephalopathy

complex cognitive syndrome that results from liver failure and cirrhosis. Patients report sleep disturbance, mood disturbance, mental status changes, and speech problems early as this complication begins.

Hepatitis B

groups for whom immunization against ______ should be used include: • People who have sexual intercourse with more than one partner • People with sexually transmitted infection (STI) or a history of STI • Men having unprotected sex with men (MSM) • People with any chronic liver disease (such as hepatitis C or cirrhosis) • Patients with human immune deficiency virus (HIV) infection • People who are exposed to blood or body fluids in the workplace, including health care workers, firefighters, and police • People in correctional facilities (prisoners) • Patients needing immunosuppressant drugs • Family members, household members, and sexual contacts of people with HBV infection Antigens located on the surface (shell) of the virus (H__sAg) and IgM antibodies to hepatitis __ core antigen (anti-H__cAg IgM) are the most significant serologic markers. The presence of these markers establishes the diagnosis of hepatitis __. The patient is infectious as long as hepatitis __ surface antigen (H__sAg) is present in the blood.

Hepatitis A

has a mild course similar to that of a typical flulike infection and often goes unrecognized. It is spread most often by the fecal-oral route by fecal contamination either from person-to-person contact (e.g., oral-anal sexual activity) or by consuming contaminated food or water. Common sources of infection include shellfish caught in contaminated water and food contaminated by food handlers infected with HAV. The incubation period of hepatitis A is usually 15 to 50 days, with a peak of 25 to 30 days.

vaccination

hepatitis A and hepatitis B is declining as a result of CDC recommendations for _______________

neurogenic shock

hypoperfusion due to nerve paralysis (sometimes caused by spinal cord injuries) resulting in the dilation of blood vessels that increases the volume of the circulatory system beyond the point where it can be filled. NEURO=LOW LOW; low BP low HR Monitor the patient with acute spinal cord injury at least hourly for indications of ____________ ___________: • Pulse oximetry (SpO 2) <95% or symptoms of aspiration (e.g., stridor, garbled speech, or inability to clear airway) • Symptomatic bradycardia, including reduced level of consciousness and deceased urine output • Hypotension with systolic blood pressure (SBP) <90 or mean arterial pressure (MAP) <65 mm Hg Notify the Rapid Response Team or primary health care provider immediately if these symptoms occur because this problem is an emergency! Respiratory compromise from aspiration may be treated with intubation or bronchial endoscopy. Similar to interventions for any type of shock, neurogenic shock is treated symptomatically by providing fluids to the circulating blood volume, adding vasopressor IV therapy, and providing supportive care to stabilize the patient.

Portal Hypertension

increase in pressure within the portal vein greater than 5 mm Hg. Results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Blood flow backs into the spleen, causing splenomegaly (spleen enlargement). Veins in the esophagus, stomach, intestines, abdomen, and rectum become dilated. Portal hypertension can result in ascites (excessive abdominal [peritoneal] fluid), esophageal varices (distended veins), prominent abdominal veins (caput medusae), and hemorrhoids.

hepatorenal syndrome

indicates a poor prognosis for the patient with liver failure. This syndrome is manifested by: • A sudden decrease in urinary flow (<500 mL/24 hr) (oliguria) • Elevated blood urea nitrogen (BUN) and creatinine levels with abnormally decreased urine sodium excretion • Increased urine osmolarity

Decortication (decorticate posturing)

is abnormal motor movement seen in the patient with lesions that interrupt the corticospinal pathways. The patient's arms, wrists, and fingers are flexed with internal rotation and plantar flexion of the legs.

Decerebration (decerebrate posturing)

is abnormal movement with rigidity characterized by extension of the arms and legs, pronation of the arms, plantar flexion, and opisthotonos (body spasm in which the body is bowed forward). Decerebration is usually associated with dysfunction in the brainstem area.

Cirrhosis

is extensive, irreversible scarring of the liver, usually caused by a chronic reaction to hepatic inflammation and necrosis. Early signs include: • Fatigue • Significant change in weight • GI symptoms, such as anorexia and vomiting • Pain in the abdominal area and liver tenderness (both of which may be ignored by the patient) Late-Stage Cirrhosis • Jaundice and icterus (yellow coloration of the eye sclerae) • Dry skin • Pruritus (itchy skin) • Rashes • Purpuric lesions, such as petechiae (round, pinpoint, red-purple hemorrhagic lesions) or ecchymoses (large purple, blue, or yellow bruises) • Warm and bright red palms of the hands (palmar erythema) • Vascular lesions with a red center and radiating branches, known as spider angiomas (also called telangiectases, spider nevi, or vascular spiders), on the nose, cheeks, upper thorax, and shoulders • Ascites • Peripheral dependent edema of the extremities and sacrum • Vitamin deficiency (especially fat-soluble vitamins A, D, E, and K)

Ascites

is the collection of free fluid within the peritoneal cavity caused by increased hydrostatic pressure from portal hypertension. The collection of plasma protein in the peritoneal fluid reduces the amount of circulating plasma protein in the blood. When this decrease is combined with the inability of the liver to produce albumin because of impaired liver cell functioning, the serum colloid osmotic pressure is decreased in the circulatory system. The result is a fluid shift from the vascular system into the abdomen, a form of "third spacing." As a result, the patient may have hypovolemia and edema at the same time.

Hepatitis C

is the leading cause of end-stage liver disease in the world. Transmission is blood to blood. Is spread most commonly by (Chaney, 2019): • Illicit IV drug needle sharing (highest incidence) • Blood, blood products, or organ transplants received before 1992 • Baby boomers (those adults born between 1945 and 1965) • Needlestick injury with ___-contaminated blood (health care workers at high risk) • Hemodialysis • Health care workers • People who are incarcerated (prisoners) • Sharing of drug paraphernalia The disease is not transmitted by casual contact or intimate household contact. However, those infected are advised not to share razors, toothbrushes, or pierced earrings because microscopic blood may be on these items. Incubation period ranges from 2 weeks to 6 months. Unlike with hepatitis B, most people infected with hepatitis __ do not clear the virus, and a chronic infection develops.

Glascow Coma Scale (GCS)

is used in many acute care settings to establish baseline data in each of these areas: eye opening, motor response, and verbal response. The patient is assigned a numeric score for each of these areas. The lower the score, the lower the patient's neurologic function. For patients who are intubated and cannot talk, record their score with a "t" after the number for verbal response. A decrease of 2 or more points total is clinically significant and should be communicated to the primary health care provider immediately.

Atropine sulfate

is used to treat bradycardia if the pulse rate falls below 50 to 60 beats/min.

Cardiac Tamponade

may occur when small volumes (20 to 50 mL) of fluid accumulate rapidly in the pericardium and cause a sudden decrease in cardiac output (CO). If the fluid accumulates slowly, the pericardium may stretch to accommodate several hundred milliliters of fluid. Can occur with pericarditis, as well as other conditions such as ventricular wall rupture from acute MI, cancer, aortic dissection, and as a complication from invasive cardiac. Inspect for other indications, including jugular venous distention with clear lungs, muffled heart sounds, and decreased cardiac output. FINDINGS INCLUDE: • Jugular venous distention • Paradoxical pulse, also known as pulsus paradoxus. Subtract the inspiratory pressure from the expiratory pressure to determine the amount of pulsus paradoxus (>10 mm Hg is an indication of _______). • Tachycardia • Muffled heart sounds • Hypotension After the pericardiocentesis, closely monitor the patient for the recurrence of tamponade. Pericardiocentesis alone often does not resolve acute tamponade. Be prepared to provide adequate fluid volumes to increase CO and to prepare the patient for surgical intervention if tamponade recurs.

Autonomic Dysreflexia

patients with spinal cord injuries are at risk for developing ____________ _______ (T-7 or above) is a neurologic emergency and must be promptly treated to prevent a hypertensive stroke! Be sure to reduce potential causes for this complication by preventing bladder and bowel distention, managing pain and room temperature, and monitoring for early vital sign changes. If the patient experiences ____, raise the head of the bed immediately to help reduce the blood pressure as the first action. Notify the Rapid Response Team or primary health care provider immediately for drug therapy to quickly reduce blood pressure as indicated. Give nifedipine or nitrate as prescribed to lower blood pressure as needed. HIGH BP, LOW HR • Sudden, significant rise in systolic and diastolic blood pressure, accompanied by bradycardia • Profuse sweating above the level of lesion—especially in the face, neck, and shoulders; rarely occurs below the level of the lesion because of sympathetic cholinergic activity • Goose bumps above or possibly below the level of the lesion • Flushing of the skin above the level of the lesion—especially in the face, neck, and shoulders • Blurred vision • Spots in the patient's visual field • Nasal congestion • Onset of severe, throbbing headache • Flushing about the level of the lesion with pale skin below the level of the lesion • Feeling of apprehension Specific risk factors are bladder distention, urinary tract infection, epididymitis or scrotal compression, bowel distention or impaction from constipation, or irritation of hemorrhoids. Pain; circumferential constriction of the thorax, abdomen, or an extremity (e.g., tight clothing); contact with hard or sharp objects; and temperature fluctuations can also cause AD. Patients with altered sensory perception are at great risk for this complication

primary health care provider

requiring urgent communication with the __________ include a new finding of abnormal flexion or extension, particularly of the upper extremities (decerebrate or decorticate posturing); pinpoint or dilated nonreactive pupils; and sudden or subtle changes in mental status. Remember, a change in level of consciousness is the earliest sign of neurologic deterioration! Communicate early recognition of neurologic changes to the Rapid Response Team or primary health care provider for the best opportunity to prevent complications and preserve CNS function.

Spleenomegaly

results from the backup of blood into the spleen. The enlarged spleen destroys platelets, causing thrombocytopenia (low serum platelet count) and increased risk for bleeding

fetor hepaticus

sweet, slightly fecal odor to the breath, presumed to be of intestinal origin; prevalent with the extensive collateral portal circulation in chronic liver disease

Increased Intracranial Pressure (ICP)

• Decreased level of consciousness (LOC) (earliest sign) • Behavior changes: restlessness, irritability, and confusion • Headache • Nausea and vomiting (may be projectile) • Aphasia • Change in speech pattern/dysarthria • Change in sensorimotor status: • Pupillary changes: dilated and nonreactive pupils ("blown pupils") or constricted and nonreactive pupils (very late sign) • Cranial nerve dysfunction • Ataxia • Seizures (usually within first 24 hours after stroke) • Cushing triad (very late sign): • Severe hypertension • Widened pulse pressure • Bradycardia • Abnormal posturing (very late sign) (see Chapter 38): • Decerebrate • Decorticate