Carrie's Iggy Acute II Midterm Exam #1 Complete Set

Chronic Hep B can lead to

cirrhosis and liver cancer

cholestrol

comes from food and the liver also makes it

chronic viral hepatitis

(usually Hep C but can also be B)- #2 cause

Stage II

-continuing mental changes -mental confusion -disorientation to time, place, or person -asterixis (handflapping)

vitamin K

biggest clotting factor

melena

black stools

lasix

drops K (look up labs before you give)

Ascites

excessive fluid in the peritoneal cavity (excessive abdominal or peritoneal fluid) -ascites caused from increased hydrostatic pressure from portal HTN. -Decreasing plasma proteins in the circulating blood and the liver decreasing its production of albumin due to its impaired function, decreases the osmotic pressure and "third spacing" occurs causing fluid to shift from circulating system to the peritoneal cavity. -This causes hypovolemia and edema at the same time. -Massive ascites affects the kidneys causing renal vasoconstriction which results in Na+ and water retention, increasing the hydrostatic pressure and the vascular volume then more ascites.

nonalcoholic steatohepatitis (NASH)

fatty liver

hypertensive gastropathy

gastric mucousa, lining of the stomach becomes very acidic

hepatitis

inflammation of liver cells

Hypovolemia

low blood volume

other physical assessment

observe vomitus and stool for blood. Observe for presence of fetor hepaticus, or fruity or musty breath odor seen in patients with chronic liver disease or hepatic encephalopathy. Inactive hormones may cause amenorrhea in women and testicular atrophy and gynecomastia in men. Continually assess neurological status. Monitor for tremors.

esophageal varices

occurs from back up of blood from the liver into fragile esophageal veins. Bleeding can occur from these varices and cause severe blood loss. Bleeding esophageal varices is a medical emergency

imaging

plain x-rays CT MRI (massess or lesions)

hematochezia

red stools (bright red blood)

anatomy of the liver

right lobe left love gall bladder bile duct portal vein hepatic artery

chronic alcoholism (Laennec's cirrhosis)-

#1 Alcohol is toxic to the hepatocytes and causes liver inflammation (alcoholic hepatitis), liver enlargement with increased leukocytes, lymphocytes, fat and cellular degeneration. Eventually the inflammatory process decreases and the destructive phase begins. If a patient stops drinking, the fatty infiltration and inflammation is reversible. If the drinking continues, scar tissue and fibrosis will occur in the liver and can cause cellular necrosis. Long-term use of illicit drugs such as cocaine can have the same effects.

lab testing

-AST and ALT (normal less than 50s) first indicator of liver issue -LDH -PT/INR (K) -bilirubin (total, direct. and indirect) -ammonia levles -CBC (platelets, Hgb, Het) -urinalysis for bilirubin

nursing considerations: preventing or managing hemorrhage

-Esophageal varices is common with cirrhosis, can cause rapid blood loss and is an emergent situation -Commonly occurs from infection -Drug therapy: propranolol (Inderal) used to decrease hepatic venous pressure-check HR before giving this beta blocker -Endoscopic therapies: banding/ligation and sclerotherapy

Hepatitis B

-Many People are asymptomatic. Many people recover and clear the virus and then have immunity. A small percentage develop immunity and become carriers and can go on to infect others. Chronic Hep B can lead to cirrhosis. -Serological markers positive for Hep B include presence of HBsAg (antigen) & IgM antibodies to Hep B. A patient is infectious as long as HBsAg is present in the blood. If a patient has been vaccinated, they will be positive for Hepatitis B (antibodies).

self management and education

-Patient's sent home with PleurX drains need to be instructed to not remove more than 2000ml from the abdomen at one time to prevent hypovolemic shock -Small frequent meals -avoid OTC meds: NSAIDS (can cause GI bleeding) & tyenol -Teach family on signs and symptoms encephalopathy -Importance of alcohol abstinence

commplications of cirrhosis (depends on amount of damage of liver)

-Portal HTN -Causes splenomegaly & dilated veins in esophagus, stomach, intestines, & rectum -Ascites -Esophageal Varices -Hypertensive gastropathy -Coagulation defects -Jaundice -Portal-systemic encephalopathy (PSE) -Hepatorenal syndrome (HRS) -Spontaneous bacterial peritonitis (SBP)

Portal-systemic encephalopathy (PSE)

-Possibly caused from elevated ammonia levels due to liver not being able tot break down toxins -from liver failure and cirrhosis. -Early symptoms include: poor sleep, mood disturbances, mental changes, & speech problems. - Later symptoms include: altered LOC, impaired thinking processes, and neuromuscular problems. -May occur slowly or quick onset with acute liver dysfunction. (table 58-2, pg. 1194). -Elevated serum ammonia levels are common due to liver not being able to break down toxins.

functions of the liver

-Regulates the amounts of glucose, protein, and fat that enter the bloodstream. -Removes bilirubin, ammonia, and other toxins from the blood. -Processes most of the nutrients absorbed by the intestines during digestion and converts those nutrients into forms that can be used by the body. It stores some nutrients, such as vitamin A, iron, and other minerals. -Produces cholesterol and proteins, such as albumin. -Produces clotting factors. It produces bile, a compound needed to absorb vitamins A, D, E, & K -Metabolizes alcohol, drugs and hormones such as estrogen -Removes bacteria from blood

Coagulation defects

-Splenomegaly- from back up blood into spleen. -Destroys platelets causing thrombocytopenia. -Low platelets are often the first clinical sign of liver damage. - Decreased bile production occurs from liver damage, preventing absorption of Vitamin K. -This decreased production of important clotting factors and increases risk for bleeding.

cirrhosis causes

-alcoholism -chronic vital hepatitis (Hep B & C**) -bile duct disease (chronic biliary obstruction or autoimmune disease) -fatty liver (steatohepatitis) -diabetes, obesity, high cholesterol

Jaundice

-excess bilirubin deposited into skin & sclera -if present, patient will probably report itchy skin from excess bilirubin on the skin which causes irritation and pruritus.

Portal HTN

-increased pressure in portal vein - Major complication. blood flow backs up causing splenomegaly. Veins in esophagus, stomach, intestines, and rectum become dilated. and esophageal varices

cirrhosis

-it is extensice scarring of the liver caused by chronic inflammation and necrosis -multisystem disease -extensive scarring of the liver

other testing

-liver biopsy- look for s/s hypovolemic shock and bleeding -EGD -ERCP- can remove stones, place stents

Hypertensive gastropathy

-may occur with or without esophageal varices. -This is slow gastric mucosal bleeding due to friable tissues with chronic slow blood loss. -Will have + occult stools and anemia.

nursing considerations: managing fluid volume

-monitor for signs/symptoms of fuild and electrolyte imbalances -low sodium diet (<2 gm/day) -drug therapy: diuretics such as fursomide and/or spironolactone (lasix drops K) -paracentesis: draining of fluid (high risk for hypovolemic shock) given fluids or albumin -monitor daily weights -provide respiratory support

Esophageal Varices

-occurs from back up of blood from the liver into fragile esophageal veins -Esophageal veins are fragile and become distended and tortuous. -Bleeding esophageal varices are a medical emergency that may result in severe blood loss resulting in shock from hypovolemia. -This may present as hematemesis (vomiting blood) or melana (black tarry stools). - Loss of consciousness may occur prior to any obvious bleeding. - Any activity that caused increased abdominal pressure may cause variceal bleeding such as heavy lifting, vigorous physical exercise, or vomiting. - Also chest trauma or swallowing hard food can traumatize the esophagus.

Stage III

-progressive deterioation -marked mental confusion -stuporous, drowsy but arousable -abnormal electroncephalogram tracing -muscle twitching -hyperreflexia -asterixis (hand flapping)

Spontaneous bacterial peritonitis (SBP)

-seen in very advanced liver disease. -May have usual fever, chills, abd pain but also may be absent of fever with or without mild symptoms. -Diagnoses is done with paracentesis.

Stage I

-subtle manifestations that may not be recognized immediately -personality changes -behavior changes (agitation, belligerence) -emotional lability (euphoria, depression) -impaired thinking -inability to concentrate -fatigue, drowsiness -slureed or slowed speech -sleep pattern disturbances

Stage IV

-unresponsiveness, leading to death in most patients -unarousable, obtunded -usually no response to painful stimulus -no asterixis -positive babinski's sign -muscle ridgity -fetor hepaticus (characteristic liver breath- musty, sweet odor) -seizures

Hepatitis A

-virus of the enterovirus family. Survives on human hands. It is resistant to soaps but is killed by bleach and extremely high temps -spreads fecal-oral route. Symptoms similar to flu-like symptoms. Commonly transferred by consuming contaminated food or water. Incubation period is 15-50 days with a peak at 25-30 days. Usually not life threatening.

lab testing (from the notes)

1. Aspartate aminotransferase (AST) 2. Alanine aminotransferase (ALT) 3. Elevated lactate dehydrogenase (LDH) 4. Bilirubin: total, indirect, and direct depending on cause. 5. Increased Urobilinogen (tea colored) & decreased fecal urobilinogen (light or clay colored stools) 6. Elevated ammonia levels in advanced stages 7. Low levels of serum protein and albumin (low levels of albumin causes 3rd spacing- into peritoneal cavity). 8. Low platelets and possible anemia- Thrombocytopenia 9. Prolonged prothrombin (PT) or International normalized ratio (INR) due to low levels of Vit. K

possible nursing dianoses for cirrhosis

1. Excess Fluid Volume r/t 3rd spacing of fluid into peritoneal cavity 2. Risk for hemorrhage r/t portal HTN, and coagulopathies 3. Risk for hepatic encephalopathy r/t elevated ammonia levels

A 55-year-old patient with a history of alcohol abuse spanning 10 years has been diagnosed with cirrhosis. The patient will be undergoing abdominal paracentesis on the medical unit today. Which assessment finding would alert the nurse that the paracentesis has been successful? A) Decrease in post-procedure weight B) No residual obtained during procedure C) Substantial decrease in blood pressure D) Immediate sensation of a need to urinate

A. decrease in post-procedure weight

A nurse assesses a client with tachycardia. Which clinical manifestation requires immediate intervention by the nurse? a. Mid-sternal chest pain b. Increased urine output c. Mild orthostatic hypotension d. P wave touching the T wave

ANS: A Chest pain, possibly angina, indicates that tachycardia may be increasing the client's myocardial workload and oxygen demand to such an extent that normal oxygen delivery cannot keep pace. This results in myocardial hypoxia and pain. Increased urinary output and mild orthostatic hypotension are not life-threatening conditions and therefore do not require immediate intervention. The P wave touching the T wave indicates significant tachycardia and should be assessed to determine the underlying rhythm and cause; this is an important assessment but is not as critical as chest pain, which indicates cardiac cell death.

A nurse teaches a client who experiences occasional premature atrial contractions (PACs) accompanied by palpitations that resolve spontaneously without treatment. Which statement should the nurse include in this client's teaching? a. "Minimize or abstain from caffeine." b. "Lie on your side until the attack subsides." c. "Use your oxygen when you experience PACs." d. "Take amiodarone (Cordarone) daily to prevent PACs."

ANS: A PACs usually have no hemodynamic consequences. For a client experiencing infrequent PACs, the nurse should explore possible lifestyle causes, such as excessive caffeine intake and stress. Lying on the side will not prevent or resolve PACs. Oxygen is not necessary. Although medications may be needed to control symptomatic dysrhythmias, for infrequent PACs, the client first should try lifestyle changes to control them.

A nurse prepares to discharge a client with cardiac dysrhythmia who is prescribed home health care services. Which priority information should be communicated to the home health nurse upon discharge? a. Medication reconciliation b. Immunization history c. Religious beliefs d. Nutrition preferences

ANS: A The home health nurse needs to know current medications the client is taking to ensure assessment, evaluation, and further education related to these medications. The other information will not assist the nurse to develop a plan of care for the client.

A nurse supervises an unlicensed assistive personnel (UAP) applying electrocardiographic monitoring. Which statement should the nurse provide to the UAP related to this procedure? a. "Clean the skin and clip hairs if needed." b. "Add gel to the electrodes prior to applying them." c. "Place the electrodes on the posterior chest." d. "Turn off oxygen prior to monitoring the client."

ANS: A To ensure the best signal transmission, the skin should be clean and hairs clipped. Electrodes should be placed on the anterior chest, and no additional gel is needed. Oxygen has no impact on electrocardiographic monitoring.

A nurse cares for a client who is on a cardiac monitor. The monitor displayed the rhythm shown below: Which action should the nurse take first? a. Assess airway, breathing, and level of consciousness. b. Administer an amiodarone bolus followed by a drip. c. Cardiovert the client with a biphasic defibrillator. d. Begin cardiopulmonary resuscitation (CPR).

ANS: A Ventricular tachycardia occurs with repetitive firing of an irritable ventricular ectopic focus, usually at a rate of 140 to 180 beats/min or more. Ventricular tachycardia is a lethal dysrhythmia. The nurse should first assess if the client is alert and breathing. Then the nurse should call a Code Blue and begin CPR. If this client is pulseless, the treatment of choice is defibrillation. Amiodarone is the antidysrhythmic of choice, but it is not the first action.

A nurse is teaching a client with premature ectopic beats. Which education should the nurse include in this client's teaching? (Select all that apply.) a. Smoking cessation b. Stress reduction and management c. Avoiding vagal stimulation d. Adverse effects of medications e. Foods high in potassium

ANS: A, B, D A client who has premature beats or ectopic rhythms should be taught to stop smoking, manage stress, take medications as prescribed, and report adverse effects of medications. Clients with premature beats are not at risk for vasovagal attacks or potassium imbalances.

A nurse teaches a client with a new permanent pacemaker. Which instructions should the nurse include in this client's teaching? (Select all that apply.) a. "Until your incision is healed, do not submerge your pacemaker. Only take showers." b. "Report any pulse rates lower than your pacemaker settings." c. "If you feel weak, apply pressure over your generator." d. "Have your pacemaker turned off before having magnetic resonance imaging (MRI)." e. "Do not lift your left arm above the level of your shoulder for 8 weeks."

ANS: A, B, E The client should not submerge in water until the site has healed; after the incision is healed, the client may take showers or baths without concern for the pacemaker. The client should be instructed to report changes in heart rate or rhythm, such as rates lower than the pacemaker setting or greater than 100 beats/min. The client should be advised of restrictions on physical activity for 8 weeks to allow the pacemaker to settle in place. The client should never apply pressure over the generator and should avoid tight clothing. The client should never have MRI because, whether turned on or off, the pacemaker contains metal. The client should be advised to inform all health care providers that he or she has a pacemaker.

A nurse cares for a client with congestive heart failure who has a regular cardiac rhythm of 128 beats/min. For which physiologic alterations should the nurse assess? (Select all that apply.) a. Decrease in cardiac output b. Increase in cardiac output c. Decrease in blood pressure d. Increase in blood pressure e. Decrease in urine output f. Increase in urine output

ANS: A, D, E Elevated heart rates in a healthy client initially cause blood pressure and cardiac output to increase. However, in a client who has congestive heart failure or a client with long-term tachycardia, ventricular filling time, cardiac output, and blood pressure eventually decrease. As cardiac output and blood pressure decrease, urine output will fall

A nurse is assessing clients on a medical-surgical unit. Which client should the nurse identify as being at greatest risk for atrial fibrillation? a. A 45-year-old who takes an aspirin daily b. A 50-year-old who is post coronary artery bypass graft surgery c. A 78-year-old who had a carotid endarterectomy d. An 80-year-old with chronic obstructive pulmonary disease

ANS: B Atrial fibrillation occurs commonly in clients with cardiac disease and is a common occurrence after coronary artery bypass graft surgery. The other conditions do not place these clients at higher risk for atrial fibrillation.

A nurse evaluates prescriptions for a client with chronic atrial fibrillation. Which medication should the nurse expect to find on this client's medication administration record to prevent a common complication of this condition? a. Sotalol (Betapace) b. Warfarin (Coumadin) c. Atropine (Sal-Tropine) d. Lidocaine (Xylocaine)

ANS: B Atrial fibrillation puts clients at risk for developing emboli. Clients at risk for emboli are treated with anticoagulants, such as heparin, enoxaparin, or warfarin. Sotalol, atropine, and lidocaine are not appropriate for this complication.

A nurse cares for a client who has a heart rate averaging 56 beats/min with no adverse symptoms. Which activity modification should the nurse suggest to avoid further slowing of the heart rate? a. "Make certain that your bath water is warm." b. "Avoid straining while having a bowel movement." c. "Limit your intake of caffeinated drinks to one a day." d. "Avoid strenuous exercise such as running."

ANS: B Bearing down strenuously during a bowel movement is one type of Valsalva maneuver, which stimulates the vagus nerve and results in slowing of the heart rate. Such a response is not desirable in a person who has bradycardia. The other instructions are not appropriate for this condition.

A nurse assesses a client with atrial fibrillation. Which manifestation should alert the nurse to the possibility of a serious complication from this condition? a. Sinus tachycardia b. Speech alterations c. Fatigue d. Dyspnea with activity

ANS: B Clients with atrial fibrillation are at risk for embolic stroke. Evidence of embolic events includes changes in mentation, speech, sensory function, and motor function. Clients with atrial fibrillation often have a rapid ventricular response as a result. Fatigue is a nonspecific complaint. Clients with atrial fibrillation often have dyspnea as a result of the decreased cardiac output caused by the rhythm disturbance.

A nurse assists with the cardioversion of a client experiencing acute atrial fibrillation. Which action should the nurse take prior to the initiation of cardioversion? a. Administer intravenous adenosine. b. Turn off oxygen therapy. c. Ensure a tongue blade is available. d. Position the client on the left side.

ANS: B For safety during cardioversion, the nurse should turn off any oxygen therapy to prevent fire. The other interventions are not appropriate for a cardioversion. The client should be placed in a supine position.

After assessing a client who is receiving an amiodarone intravenous infusion for unstable ventricular tachycardia, the nurse documents the findings and compares these with the previous assessment findings: Vital Signs Nursing Assessment Time: 0800 Temperature: 98° F Heart rate: 68 beats/min Blood pressure: 135/60 mm Hg Respiratory rate: 14 breaths/min Oxygen saturation: 96% Oxygen therapy: 2 L nasal cannula Time: 1000 Temperature: 98.2° F Heart rate: 50 beats/min Blood pressure: 132/57 mm Hg Respiratory rate: 16 breaths/min Oxygen saturation: 95% Oxygen therapy: 2 L nasal cannula Time: 0800 Client alert and oriented. Cardiac rhythm: normal sinus rhythm. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Time: 1000 Client alert and oriented. Cardiac rhythm: sinus bradycardia. Skin: warm, dry, and appropriate for race. Respirations equal and unlabored. Client denies shortness of breath and chest pain. Client voids 420 mL of clear yellow urine. Based on the assessments, which action should the nurse take? a. Stop the infusion and flush the IV. b. Slow the amiodarone infusion rate. c. Administer IV normal saline. d. Ask the client to cough and deep breathe.

ANS: B IV administration of amiodarone may cause bradycardia and atrioventricular (AV) block. The correct action for the nurse to take at this time is to slow the infusion, because the client is asymptomatic and no evidence reveals AV block that might require pacing. Abruptly ceasing the medication could allow fatal dysrhythmias to occur. The administration of IV fluids and encouragement of coughing and deep breathing exercises are not indicated, and will not increase the client's heart rate.

A nurse cares for a client with an intravenous temporary pacemaker for bradycardia. The nurse observes the presence of a pacing spike but no QRS complex on the client's electrocardiogram. Which action should the nurse take next? a. Administer intravenous diltiazem (Cardizem). b. Assess vital signs and level of consciousness. c. Administer sublingual nitroglycerin. d. Assess capillary refill and temperature.

ANS: B In temporary pacing, the wires are threaded onto the epicardial surface of the heart and exit through the chest wall. The pacemaker spike should be followed immediately by a QRS complex. Pacing spikes seen without subsequent QRS complexes imply loss of capture. If there is no capture, then there is no ventricular depolarization and contraction. The nurse should assess for cardiac output via vital signs and level of consciousness. The other interventions would not determine if the client is tolerating the loss of capture.

After teaching a client who has an implantable cardioverter-defibrillator (ICD), a nurse assesses the client's understanding. Which statement by the client indicates a correct understanding of the teaching? a. "I should wear a snug-fitting shirt over the ICD." b. "I will avoid sources of strong electromagnetic fields." c. "I should participate in a strenuous exercise program." d. "Now I can discontinue my antidysrhythmic medication."

ANS: B The client being discharged with an ICD is instructed to avoid strong sources of electromagnetic fields. Clients should avoid tight clothing, which could cause irritation over the ICD generator. The client should be encouraged to exercise but should not engage in strenuous activities that cause the heart rate to meet or exceed the ICD cutoff point because the ICD can discharge inappropriately. The client should continue all prescribed medications.

The nurse is caring for a client on the medical-surgical unit who suddenly becomes unresponsive and has no pulse. The cardiac monitor shows the rhythm below: After calling for assistance and a defibrillator, which action should the nurse take next? a. Perform a pericardial thump. b. Initiate cardiopulmonary resuscitation (CPR). c. Start an 18-gauge intravenous line. d. Ask the client's family about code status.

ANS: B The client's rhythm is ventricular fibrillation. This is a lethal rhythm that is best treated with immediate defibrillation. While the nurse is waiting for the defibrillator to arrive, the nurse should start CPR. A pericardial thump is not a treatment for ventricular fibrillation. If the client does not already have an IV, other members of the team can insert one after defibrillation. The client's code status should already be known by the nurse prior to this event.

A telemetry nurse assesses a client with third-degree heart block who has wide QRS complexes and a heart rate of 35 beats/min on the cardiac monitor. Which assessment should the nurse complete next? a. Pulmonary auscultation b. Pulse strength and amplitude c. Level of consciousness d. Mobility and gait stability

ANS: C A heart rate of 40 beats/min or less with widened QRS complexes could have hemodynamic consequences. The client is at risk for inadequate cerebral perfusion. The nurse should assess for level of consciousness, light-headedness, confusion, syncope, and seizure activity. Although the other assessments should be completed, the client's level of consciousness is the priority.

A nurse administers prescribed adenosine (Adenocard) to a client. Which response should the nurse assess for as the expected therapeutic response? a. Decreased intraocular pressure b. Increased heart rate c. Short period of asystole d. Hypertensive crisis

ANS: C Clients usually respond to adenosine with a short period of asystole, bradycardia, hypotension, dyspnea, and chest pain. Adenosine has no conclusive impact on intraocular pressure.

A nurse cares for a client with atrial fibrillation who reports fatigue when completing activities of daily living. What interventions should the nurse implement to address this client's concerns? a. Administer oxygen therapy at 2 liters per nasal cannula. b. Provide the client with a sleeping pill to stimulate rest. c. Schedule periods of exercise and rest during the day. d. Ask unlicensed assistive personnel to help bathe the client.

ANS: C Clients who have atrial fibrillation are at risk for decreased cardiac output and fatigue when completing activities of daily living. The nurse should schedule periods of exercise and rest during the day to decrease fatigue. The other interventions will not assist the client with self-care activities.

The nurse asks a client who has experienced ventricular dysrhythmias about substance abuse. The client asks, "Why do you want to know if I use cocaine?" How should the nurse respond? a. "Substance abuse puts clients at risk for many health issues." b. "The hospital requires that I ask you about cocaine use." c. "Clients who use cocaine are at risk for fatal dysrhythmias." d. "We can provide services for cessation of substance abuse."

ANS: C Clients who use cocaine or illicit inhalants are particularly at risk for potentially fatal dysrhythmias. The other responses do not adequately address the client's question.

A nurse performs an admission assessment on a 75-year-old client with multiple chronic diseases. The client's blood pressure is 135/75 mm Hg and oxygen saturation is 94% on 2 liters per nasal cannula. The nurse assesses the client's rhythm on the cardiac monitor and observes the reading shown below: Which action should the nurse take first? a. Begin external temporary pacing. b. Assess peripheral pulse strength. c. Ask the client what medications he or she takes. d. Administer 1 mg of atropine.

ANS: C This client is stable and therefore does not require any intervention except to determine the cause of the bradycardia. Bradycardia is often caused by medications. Clients who have multiple chronic diseases are often on multiple medications that can interact with each other. The nurse should assess the client's current medications first.

A nurse assesses a client's electrocardiograph tracing and observes that not all QRS complexes are preceded by a P wave. How should the nurse interpret this observation? a. The client has hyperkalemia causing irregular QRS complexes. b. Ventricular tachycardia is overriding the normal atrial rhythm. c. The client's chest leads are not making sufficient contact with the skin. d. Ventricular and atrial depolarizations are initiated from different sites.

ANS: D Normal rhythm shows one P wave preceding each QRS complex, indicating that all depolarization is initiated at the sinoatrial node. QRS complexes without a P wave indicate a different source of initiation of depolarization. This finding on an electrocardiograph tracing is not an indication of hyperkalemia, ventricular tachycardia, or disconnection of leads.

A nurse assesses a client's electrocardiogram (ECG) and observes the reading shown below: How should the nurse document this client's ECG strip? a. Ventricular tachycardia b. Ventricular fibrillation c. Sinus rhythm with premature atrial contractions (PACs) d. Sinus rhythm with premature ventricular contractions (PVCs)

ANS: D Sinus rhythm with PVCs has an underlying regular sinus rhythm with ventricular depolarization that sometimes precede atrial depolarization. Ventricular tachycardia and ventricular fibrillation rhythms would not have sinus beats present. Premature atrial contractions are atrial contractions initiated from another region of the atria before the sinus node initiates atrial depolarization.

A nurse prepares to defibrillate a client who is in ventricular fibrillation. Which priority intervention should the nurse perform prior to defibrillating this client? a. Make sure the defibrillator is set to the synchronous mode. b. Administer 1 mg of intravenous epinephrine. c. Test the equipment by delivering a smaller shock at 100 joules. d. Ensure that everyone is clear of contact with the client and the bed.

ANS: D To avoid injury, the rescuer commands that all personnel clear contact with the client or the bed and ensures their compliance before delivery of the shock. A precordial thump can be delivered when no defibrillator is available. Defibrillation is done in asynchronous mode. Equipment should not be tested before a client is defibrillated because this is an emergency procedure; equipment should be checked on a routine basis. Epinephrine should be administered after defibrillation.

hepatitis pathophysiology

After exposure to the causative agent, the liver becomes enlarged and full of fluid, inflammatory cells, and lymphocytes causing RUQ pain. As the disease progresses, the liver becomes inflamed and necrotic. Portal pressure increases. Edema of the liver's bile channels causes obstructive jaundice.

history

Ask about exposure to alcohol, drugs and chemical toxins. Ask about sexual history. Ask about family history of alcoholism or liver disease. Hx of tattoos? Hx of alcoholism or drug addiction? Make sure to ask in a nonjudgmental manner and provide privacy when asking questions. Ask about jaundice or acute viral hepatitis, biliary tract disorders (cholecystitis), viral infections, surgery, blood transfusions, autoimmune problems, obesity, Hx of elevated liver enzymes, or liver injury.

What is the priority nursing intervention in the management of a patient with decompensated cirrhosis? A) Limiting protein intake B) Managing nausea and vomiting C) Monitoring fluid intake and output D) Elevating the head of bed >30 degrees

B. managing nausea and vomiting

cirrhosis progression

Chronic inflammation will cause destruction of hepatocytes (liver cells). As cirrhosis progresses, fibrotic connective tissue damages the liver, nodules develop that block bile ducts and normal blood flow. Eventually the liver will shrink in size and decrease in function. My take weeks or years. Many patients may be asymptomatic until cirrhosis is severe and liver enzymes are elevated (AST/SGOT, ALT/SGPT).

psychosocial assessment

Monitor for subtle or obvious personality, cognitive or behavioral changes, such as agitation, depression, emotional lability, sleep changes. If patient is alcohol dependent, monitor for s/s of withdrawal as these can be a medical emergency.

Nutrition therapy:

Needs low Na+ diet of usually < 2 gm/day. No table salt. Teach patient to read food labels and alternative spices to add flavor. Instruct them, low sodium diet is an acquired taste that may take a little time. Vitamin supplements may also be added due to the liver being unable to store vitamins. Such vitamins may include Thiamine (esp. for alcohol withdrawal), folate & multivitamin. These may be given IV or orally.

Stages if Hepatic Encephalopathy

Stage 1 Stage II Stage III Stage IV

Px assessment

Symptoms may be vague. Assess for fatigue and changes in weight. GI symptoms such as anorexia or vomiting, abd pain or tenderness. Many times, liver problems are found on routine labs, pre-surgical labs or found on health insurance screenings. The compensated cirrhosis patient may be asymptomatic. The labs affected may be either thrombocytopenia and/or elevated AST/ ALT. Advanced stage symptoms cause patient to seek treatment such as GI bleeding, jaundice, ascites, & spontaneous bruising. Assess for jaundice, dry skin, rashes, petechiae, ecchymosis, palmar erythema, spider angiomas on the nose, cheeks, upper thorax & shoulders, Ascites, peripheral edema and edema of the sacrum, Vitamin K deficiency.

decompensated cirrhosis

The liver is damaged with obvious manifestations of liver failure

Hepatitis B is transfered through?

Transfered through blood: -Unprotected sex -Sharing needles -Accidental needle sticks -Blood transfusions -Hemodialysis -Close person-to person contact with open sores or lesions -Symptoms occur within 25-180 days

other diagnositic testing

Ultrasound is usually the first diagnostic test for a patient suspected of liver disease. Looks for splenomegaly, hepatomegaly and ascites. US can also look for biliary stones or obstruction. Liver biopsy may be required. These patients are high risk for bleeding. If liver biopsy is not an option, a nuclear scan of the liver can be done to detect cirrhosis or other diffuse disease. Arteriography may be done to look for portal vein thrombosis. Esophagogastroduodenoscopy (EGD) to assess esophageal varices, stomach irritation, and ulcerations, or duodenal ulceration and bleeding. Endoscopic retrograde cholangiopancreatography (ERCP)- views the biliary tract and may remove stones, sphincterotomies, biopsies, and stent placements.

hepatitis causes

Viral hepatitis is the most common type and may be either acute or chronic. There are 5 major hepatitis viruses: ABCDE. Non- A-E hepatitis viruses may be caused from Epstein-Barr, herpes simplex, varicella-zoster, and cytomegalovirus. Also may caused from exposure to hepatotoxins (Industrial, alcohol, & drugs).

portal vein

a lot of liver problems stem from here

Drug Therapy:

a. Diuretics such as Furosemide (Lasix) or spironolactone (Aldactone)- to reduce fluids accumulation & prevent heart and lung complications. Monitor daily weights & I&O's. Monitor for electrolyte imbalances such as hypokalemia and hyponatremia with Lasix use. Mainly hypokalemia. Aldactone is potassium sparing. Many times the two are used together to maintain K+ balance.

Factors that could lead to PSE in patients with cirrhosis include:

a. High-protein diet b. Infection c. Hypovolemia d. Hypokalemia e. Constipation f. GI bleeding g. Drugs (hypnotics, opiods, analgesics, sedatives, diuretics, illicit drugs)

physical assessment

abd assessment (clinical manifestation of caput medusae), daily weights. Assess respiratory, neurological and psychosocial systems. -measure girth, respiratory status, dypenia, not being able to lay flat, take daily weights, fruity breath( ammonia build up), atrophy of the testicals (can't get rid of estrogen)

bile duct disease

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

Interventions for managing fluid volume:

goal is to control ascites through nutrition, drug therapy, paracentesis, & respiratory support. Fluid and electrolyte balance is important.

portal HTN

increased pressure in portal vein. Causes splenpmegaly and dilated veins in esophagous, stomach, intestines, and rectum -back flow of blood will back up and cause spelomegaly; platelets will start to destroy (thrombocytopenia)

Hepatorenal syndrome (HRS)

indicates poor prognosis. Often the cause of death for these patient's -Often the cause of death for these patients. -Manifested by urinary output < 500cc/24 hour) & elevated BUN & creatinine with abnormally decreased Na+. Increased urine osmolality. May occur from complication of other liver problems.

Bilirubin

is a by-product of the breakdown of hemoglobin from red blood cells

massive ascites

kidneys will notice there's not enough blood volume and it will retain sodium and water (holding fluid) more and more fluid

abdominal assessment

look for ascites. May have dilated veins from umbilicus. Orthopnea and dyspnea may occur from increased pressure and interfere with lung expansion. May have difficulty walking erect and may have balance problems. Minimal ascites is harder to detect. Assess for hepato and splenomegaly. Measure abdominal girth to evaluate progression of disease. Taking daily weights is the most reliable indicator of fluid retention.

Hepatitis A-E symptoms

symptoms of all types of viral hepatitis are similar and can include one or more of the following: -loss of appetite -Vomiting -Fever -Fatigue -RUQ pain -Dark urine & light stool -Arthralgias & myalgias -Jaundice

compensated cirrhosis

the liver has sustained damage but is still able to perform its essential functions -usually no damage or symptoms (inflammation) -found typically by accident when assessing for other issues; during tests