Liver and Gallbladder

Which individual has the greatest risk for developing hepatitis A? A) Health care worker B) Intravenous drug user C) Client receiving hemodialysis D) Person who consumes raw oysters

D Undercooked or raw shellfish from contaminated waters and food handled by those who have not washed their hands thoroughly are at risk for hepatitis A. Intravenous drug users, those undergoing hemodialysis, and health care workers are more at risk for hepatitis B or C, which is spread by blood or body fluids.

method of transmission for Hep C

blood

who does Hep A most often affect?

places with poor sanitation, most often in children

adverse effects of interferon alfa

causes severe depression and alters blood glucose levels

surgical management for cholecystitis

cholecystectomy (laparoscopic or traditional)

symptoms of Hep D

(same as Hep B) anorexia, N/V, fever, fatigue, RUQ pain, jaundice

some people can become chronic carriers of what type of hepatitis?

B

The nurse suspects that which client is at highest risk for developing gallstones? A) Obese male with a history of chronic obstructive pulmonary disease B) Obese female on hormone replacement therapy C) Thin male with a history of coronary artery bypass grafting D) Thin female who has recently given birth

B Both obesity and altered hormone levels increase a woman's risk for developing gallstones. Men are at lower risk than women for developing gallstones. Although pregnancy increases the risk for a woman to develop gallstones, this woman's thin frame lessens that risk.

A client with viral hepatitis has clay-colored stools and dark urine. These findings are typically characteristic of which complication of hepatitis? A) Cirrhosis of the liver B) Hepatic carcinoma C) Intrahepatic obstruction D) Obstructive jaundice

C Clients with hepatitis may develop intrahepatic obstruction, which will cause clay-colored stools and dark urine when the bile ducts are blocked. These findings may occur with hepatic obstruction in cirrhosis or carcinoma, but do not necessarily indicate that these have occurred. Obstructive jaundice is another sign of intrahepatic obstruction.

What teaching does the home health nurse give the family of a client with hepatitis C to prevent the spread of the infection? A) The client must not consume alcohol. B) Avoid sharing the bathroom with the client. C) Members of the household must not share toothbrushes. D) Drink only bottled water and avoid ice.

C Toothbrushes, razors, towels, and items that may spread blood and body fluids should not be shared. The client should not consume alcohol, but abstention will not prevent spread of the virus. The client may share a bathroom if he or she is continent. To prevent hepatitis A when traveling to foreign countries, bottled water should be consumed and ice made from tap water should be avoided.

A client who was previously treated for hepatitis B virus (HBV) is tested for the presence of the hepatitis B surface antigen (HBsAg) in the blood. The test is positive. What does this result indicate? A) Permanent immunity to HBV B) Recurrence of infection C) Long-term liver damage D) Client is infectious

D As long as the HBsAg is present, the client is infectious and may be in a carrier state. It does not indicate permanent immunity, recurrence of infection, or long-term liver damage.

The nurse is counseling an asymptomatic client who is worried about possible hepatitis C exposure several years ago. What does the nurse tell this client about the risk of this disease? A) "Unless you have signs of liver disease, you are no longer infected." B) "You have probably cleared the virus since you have not had symptoms." C) "You may be a carrier, but will never have serious symptoms of the disease." D) "You may have serious long-term damage even without symptoms."

D Clients exposed to hepatitis C may develop chronic infection even without symptoms until the damage occurs over decades of infection. A client is likely to be asymptomatic for months or years before the virus is detected. A carrier may or may not have serious symptoms of the disease. Individuals with HCV do not clear the virus like those with HBV.

nursing diagnoses for hepatitis

acute pain activity intolerance imbalanced nutrition risk for deficient fluid volume

what will speed up the progression of Hep C?

alcohol consumption

complications of chronic cholecystitis

pancreatitis (because the pancreas cannot drain adequately) cholangitis (inflammation of the bile ducts; RUQ pain and intermittent fever) jaundice (liver cannot drain bile so bilirubin builds up in bloodstream)

Which statement about hepatitis A is accurate? A) It is transmitted by the fecal-oral route. B) It is resistant to the action of chlorine (bleach). C) It is more common in affluent countries. D) It is more severe in children and young adults.

A Hepatitis A virus is spread via the fecal-oral route either by consumption of contaminated water and food, or by person-to-person contact in those who engage in oral-anal sexual activity. The virus is destroyed by chlorine (bleach). It is more common in nonaffluent countries where sanitation is inadequate or lacking. The course of the infection is more severe in those who are older than 40 years.

The nurse is preparing a client for a laparoscopic cholecystectomy. After reinforcing the surgeon's preoperative teaching, what does the nurse instruct the client about next? A) Discuss postoperative pain medications, deep-breathing, and leg exercises. B) Give information about home health agencies to provide postoperative nursing care. C) Show the client the T-tube drain and give instructions about how to care for it. D) Teach the client and family about the need to maintain a no-fat diet after surgery.

A A laparoscopic cholecystectomy is a minimally invasive procedure. The client should receive routine instructions for postoperative care including pain management, deep-breathing, and leg exercies. Home nursing is not required since most clients resume normal activity within a week. A T-tube drain is not used with this procedure. A normal diet is usually indicated, but some clients may need to avoid a high-fat diet.

The nurse is assessing diagnostic test results for a client with hepatitis. Which elevated test result does the nurse correlate to the presence of jaundice? A) Bilirubin B) Blood urea nitrogen (BUN) C) Aspartate aminotransferase (AST) D) Alanine aminotransferase (ALT)

A Elevation of the bilirubin level correlates to yellow stain of the skin and sclera secondary to biliary obstruction and inflammation. BUN is a measure of renal function. AST and ALT are enzymes released in response to liver inflammation, but do not correlate to jaundice.

Which is an important institutional measure that a hospital may take to prevent the transmission of hepatitis B (HBV) to health care workers? A) Develop a hospital-wide needleless system for delivery of medications. B) Provide immunoglobulin injections within 14 days of exposure to the virus. C) Provide information about HBV transmission to at-risk employees. D) Reinforce Standard Precautions procedures among all hospital employees.

A Needlesticks are the leading cause of HBV exposure among health care workers, so eliminating needles would make a huge impact on preventing transmission of the disease. Providing immunoglobulin injections, providing HBV information, and reinforcing Standard Precautions may all be done as well, but are not as important as the implementation of needleless systems.

which forms of hepatitis have available immune globulins?

A, B, C, D

types of hepatitis with available vaccines

A, B, D

When teaching a client with viral hepatitis, which instructions does the nurse include in the plan of care? Select all that apply. A) Do not consume any alcohol. B) Consume a high-protein diet. C) Do not drive a car for 1-2 weeks. D) Monitor blood pressure and pulse daily. E) Avoid medications containing acetaminophen. F) Avoid carbonated beverages.

A, E The client with hepatitis should avoid all alcohol as well as hepatotoxic medications such as acetaminophen unless instructed otherwise by the provider. The diet should be high in carbohydrates with moderate fat and moderate protein content. The client may drive if he or she feels well. As hepatitis does not directly affect the cardiovascular system, there is no need to monitor vital signs. While carbonated beverages may contribute to a sense of fullness, it is not required that they be absolutely excluded.

A client who has undergone a laparoscopic cholecystectomy reports mild postoperative abdominal bloating and discomfort. Which nursing action is correct? A) Administer an opioid analgesic medication. B) Encourage the client to ambulate in the hall. C) Notify the provider of possible peritonitis. D) Withhold oral fluids until these symptoms have passed.

B Early ambulation can help promote absorption of the carbon dioxide used to insufflate the abdomen. Signs of continued CO2 retention are abdominal bloating and discomfort. Opioid analgesics are not recommended for mild pain. The client would have severe discomfort and a rigid abdomen if peritonitis were present. The client does not require oral fluid restriction.

The community health nurse is exploring the cause of an outbreak of hepatitis A. Which individual does the nurse suspect may be the source? A) Individual who recently got a tattoo B) Clients who were infected after eating at the same restaurant C) Spouse of an intravenous drug abuser who developed hepatitis D) Client who had a blood transfusion during cardiac surgery in 1985

B Hepatitis A is spread by the fecal-oral route either by person-to-person contact, or by consuming contaminated food or water; failure to clean the hands after using the toilet and then preparing food is an example of how hepatitis can be spread by this route. Tattoos, injection drug use, and blood transfusions can spread hepatitis B or C through blood or body fluids.

The nurse is teaching a spouse and client with hepatitis C about preventing the spread of infection. Which instruction does the nurse include in the teaching plan? A) "Drink only bottled water." B) "Do not share toothbrushes." C) "Donate blood only once yearly." D) "You should use a separate bathroom."

B Household members should not share any personal items with the client infected with hepatitis C such as a toothbrush, razor, drinking glasses, drug paraphernalia, or any item where blood or body fluids could be encountered by others. Bottled water is not necessary as the client is not at risk for contamination from tap water. The client with hepatitis C may become a carrier, so blood should not be donated. There is no need to use a separate bathroom if the client is continent of urine and stool and if the bathroom can be regularly disinfected.

Female clients with which factors are considered to be at high risk for developing cholelithiasis? Select all that apply. A) Low body mass index B) Pregnancy C) Over age 40 years D) Anemia

B In pregnancy, hormone levels (progesterone and estrogen) are altered, which delays muscular contraction of the gallbladder and decreases the rate of bile emptying. Similarly, hormonal changes in the "fertile" age (20-60 years) and hormonal replacement therapy make women more susceptible to develop cholelithiasis. Obese women are at a high risk of developing cholelithiasis due to impaired fat metabolism and increased cholesterol. Anemia is not associated with the development of gallstones.

A client scheduled for a cholecystectomy because of gallstones causing cholecystitis reports a pain level of 4 on a 0-to-10 pain scale. Which analgesic medication does the nurse anticipate will be prescribed for the client? A) Hydromorphone (Dilaudid) B) Ketorolac (Toradol) C) Meperidine (Demerol) D) Morphine

B Ketorolac may be used for mild to moderate pain. Acute biliary pain requires opioid analgesia, such as morphine or hydromorphone. In the past, meperidine was the drug of choice for acute biliary pain because it was thought to cause fewer spasms of the sphincter of Oddi, which blocks bile flow. However, this drug breaks down into a toxic metabolite and can cause seizures, especially in order adults. All opioids may cause some degree of sphincter spasm.

When providing community education, the nurse emphasizes that which group should receive immunization for hepatitis B? A) Clients who work with shellfish B) Men who prefer sex with men C) Clients traveling to a third-world country D) Clients with elevations of aspartate aminotransferase (AST) and alanine aminotransferase (ALT)

B Men who prefer sex with men are at increased risk for hepatitis B, which is spread by the exchange of blood and body fluids during sexual activity. Consuming raw or undercooked shellfish may cause hepatitis A, not hepatitis B. Travel to third-world countries exposes the traveler to contaminated water and risk for hepatitis A; hepatitis B is not of concern, unless the client is exposed to blood and body fluids during travel. Clients who have liver disease should receive the vaccine, but men who have sex with men are at higher risk for contracting hepatitis B.

Which is a risk factor for the development of hepatitis C? A) Consuming shellfish B) Employment in the health care field C) Traveling internationally D) Chronic alcohol consumption

B Risk factors for hepatitis C include illicit drug use by IV or intranasal route, unsanitary tattoo equipment, and current or former employment in the health care field (because health care workers can easily be exposed to blood and body fluids). Hepatitis A can be contracted by consuming contaminated shellfish. Hepatitis E can be contracted by individuals who travel to countries with poor sanitation. Chronic alcohol consumption is a risk factor for cirrhosis, not hepatitis.

The nurse is teaching a client with hepatitis about proper diet. Which meal selection demonstrates that the client has a correct understanding of the teaching? A) Whole-wheat pasta, vegetable oil, and garlic B) Baked chicken breast with spinach and lemon C) Roast duck with orange sauce, and broccoli with cheese D) Fried fish with baked potato, sour cream, and green beans

B The diet of a client with hepatitis should be high in carbohydrates and calories with moderate amounts of fat and protein. Dietary items such as vegetable oil, duck, fried fish, and sour cream are considered high in fat.

When providing dietary teaching to a client with hepatitis, what practice does the nurse recommend? A) Having a larger meal early in the morning B) Consuming increased carbohydrates and moderate protein C) Restricting fluids to 1500 mL per day D) Limiting alcoholic beverages to once weekly

B To repair the liver, the client should have a high-carbohydrate and moderate-protein diet; fats may cause dyspepsia. The client with hepatitis feels full easily and should have four to six small meals daily. Fluids are restricted with ascites caused by cirrhosis; not all clients with hepatitis progress to cirrhosis. Complete abstention from alcohol is necessary until the liver enzymes return to normal.

The nurse is teaching a client with gallbladder disease about diet modification. Which meal does the nurse suggest to the client? A) Steak and French fries B) Fried chicken and mashed potatoes C) Turkey sandwich on wheat bread D) Sausage and scrambled eggs

C Turkey is an appropriate low-fat selection for this client. Steak, French fries, fried chicken, and sausage are too fatty, and eggs are too high in cholesterol for a client with gallbladder disease.

When assessing a client with hepatitis B, the nurse anticipates which assessment findings? Select all that apply. A) Recent influenza infection B) Brown stool C) Tea-colored urine D) Right upper quadrant tenderness E) Itching

C, D, E The urine may be brown, tea-, or cola-colored in clients with hepatitis. Inflammation of the liver may cause right upper quadrant pain. Deposits of bilirubin on the skin, secondary to high bilirubin levels, and jaundice irritate the skin and cause itching. Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored.

A client reports fever, yellowing of the skin and eyes, clay-colored stools, and dark urine to the nurse. What do these symptoms indicate? A) Peritonitis B) Malnutrition C) Vitamin deficiency D) Chronic cholecystitis

D Fever, yellowing of the skin and eyes, clay-colored stools, and dark urine are symptoms of chronic cholecystitis. These symptoms occur when repeated episodes of cystic duct obstruction cause chronic inflammation. Peritonitis is an infection of the peritoneal cavity in which the client presents with a hard, distended abdomen. Clients with malnutrition are underweight for their height and have low albumin. Clients with a vitamin deficiency do not display these symptoms; symptoms are always dependent upon the vitamin in which the client is deficient.

client diagnosed with hepatitis A asks the nurse how this disease may have been contracted. Which answer by the nurse is correct? A) "If you received a blood transfusion, you may have been exposed." B) "The virus is airborne, so you may have contracted it from an infected person." C) "You may have been exposed if you had unprotected sexual intercourse." D) "You may have consumed foods contaminated with the virus."

D Hepatitis A is transmitted through the fecal-oral route and may be contracted by consuming contaminated foods; it is not a blood-borne or airborne virus. Hepatitis B, C, and D can be transmitted by blood transfusions received before 1992. Unprotected sex is a risk factor for hepatitis B and C (although the rate of sexual transmission with hepatitis C is very low in a monogamous relationship, but increases with multiple sex partners). There is no hepatitis virus that is airborne.

A client with acute cholecystitis is admitted to the medical-surgical unit. Which nursing activity associated with the client's care will be best for the nurse to delegate to unlicensed assistive personnel (UAP)? A) Assessing dietary risk factors for cholecystitis. B) Checking for bowel sounds and distention. C) Determining precipitating factors for abdominal pain. D) Obtaining the admission weight, height, and vital signs.

D Obtaining height, weight, and vital signs is included in the education for unlicensed assistive personnel (UAP) and usually is included in the job description for these staff members. Assessment, checking bowel sounds, and determining precipitating factors for abdominal pain require broader education and are within the scope of practice of licensed nursing staff.

Which precaution is most appropriate for the nurse to implement with a client with hepatitis A? A) Enteric precautions B) Droplet precautions C) Protective isolation D) Standard Precautions

D Standard Precautions are used with all clients to prevent the spread of blood and body fluids, including the client with hepatitis A. Standard Precautions prevent the spread of hepatitis A infection, which is spread by the fecal-oral route. Enteric precautions would be needed for clients with gastrointestinal infection if Standard Precautions were not used. Droplet precautions prevent the inhalation of respiratory droplets that spread infection, such as with meningitis. Protective isolation involves strict handwashing and limiting visitors and plants to protect the immunocompromised client.

A health care worker believes that he or she may have been exposed to hepatitis A. Which intervention is the highest priority to prevent the health care worked from developing the disease? A) Requesting vaccination for hepatitis A B) Using a needleless system in daily work C) Getting the three-part hepatitis B vaccine D) Requesting an injection of immunoglobulin

D The administration of immunoglobulin, antibodies to hepatitis A, may prevent development of the disease. The vaccine for hepatitis A will take several weeks to stimulate the development of antibodies; passive immunity in the form of immunoglobulin is needed. Implementing a needleless system and getting the three-part vaccine may prevent the development of hepatitis B, not hepatitis A.

5 lab assessments done to diagnose hepatitis

alanine aminotransferase, aspartate transaminase, alkaline phosphate, bilirubin, hepatitis antibodies

symptoms of Hep B

anorexia, N/V, fever, fatigue, RUQ pain, jaundice, dark urine, light stool, joint pain

drug therapy for cholecystitis

anticholinergics to decrease spasms in the ducts morphine is avoided because it causes spasms toradol (NSAID) is most commonly used

drug therapy for hepatitis

avoid medications as much as possible because most drugs are metabolized in the liver talk to HCP before taking OTC drugs can give anti emetics, antivirals

nursing care and education for hepatitis B

avoid sharing needles, use condoms, cover cuts with bandage, vaccination

why does hepatitis cause pruritus and jaundice?

bilirubin builds up in the bloodstream because the damaged hepatocytes cannot excrete is the body tries to compensate by excreting it through the skin

why does hepatitis cause dark colored urine?

bilirubin builds up in the bloodstream because the damaged hepatocytes cannot excrete it the body tries to compensate by excreting it in the urine

why does hepatitis cause light colored stool?

bilirubin must be conjugated by hepatocytes in order to be excreted in the stool if hepatocytes are damaged by hepatitis, bilirubin is not conjugated and not excreted in the stool

method of transmission for Hep D

blood

method of transmission for Hep B

blood, unprotected sex sharing needles (patients that received a transfusion before 1992)

cholelithiasis

calculous cholecystitis cholesterol stones or bile stones obstruct the flow of bile from the gallbladder gallbladder becomes inflamed infection and potential ischemia of the gallbladder because the bile is reabsorbed

harvoni

combination drug for hepatitis C that contains sovaldi

method of transmission for Hep A

fecal-oral most commonly through consumption of contaminated food or water (four F's: food, fingers, feces, flood)

method of transmission for Hep E

fecal-oral possibly undercooked meat of infected animals

four Fs of cholecystitis/lithiasis

female, fat, fertile, and forty highest risk for acute cholecystitis

symptoms of cholecystitis

flatulence, dyspepsia, eructation (burping), anorexia, N/V, abdominal pain, dark urine, light stools, fever, tachycardia, dehydration "DAD FELT FAN I"

ribavirin

given in combination with interferon alfa to treat Hep C

sovaldi

given in conjunction with ribavirin and interferon alfa for hepatitis C

leading cause of liver transplantation in the U.S.

hepatitis C

what is the most common type of hepatitis?

hepatitis C

when is recovery for Hep A or B a problem?

if the patient has a pre-existing liver condition otherwise, it is non-life threatening

interferon alfa

immune booster given for hepatitis C must be given with ribavirin (antiviral) because interferon does not actually fight the virus

cholecystitis

inflammation of the gallbladder acute is more common can be calculous or a calculous

how to destroy Hep A

it is resistant to a lot of detergents and cleaners but it can be destroyed by bleach and extremely high temperatures

why can Hep D not survive without Hep B?

it needs helper cells that are produced in Hep B to survive

bilirubin

lab assessment done for the diagnosis of hepatitis byproduct of RBC breakdown (comes from heme) travels to the liver and is conjugated by hepatocytes in hepatitis, hepatocytes are damaged, so bilirubin is not conjugated

aspartate transaminase (AST)

lab assessment done for the diagnosis of hepatitis found in the liver and heart (not as specific as ALT)

alanine aminotransferase (ALT)

lab assessment done for the diagnosis of hepatitis predominantly found in the liver when the liver is damaged, it releases ALT into the bloodstream

alkaline phosphatase (ALP)

lab assessment done for the diagnosis of hepatitis will be elevated if you have a biliary duct problem

chronic carriers of hep B

may not have symptoms but can pass it on to people higher risk for cirrhosis and cancer of the liver

acalculous cholecystitis

most often related to problems with drainage of the gallbladder decreased blood flow or kinking of the duct

symptoms of Hep C

mostly asymptomatic but it causes progressive destruction of the liver and scarring of the liver cells that can lead to cirrhosis

nonsurgical management of cholecystitis

nutrition therapy (low fat diet), extracorporeal shock wave lithotripsy (breaks up stones to be removed), percutaneous transhepatic biliary catheter insertion (drain)

nursing care associated with a traditional cholecystectomy

opioids via patient controlled analgesia T-tube placed in the common bile duct to maintain patency of the inflamed duct drainage bag below the level of abdomen (bloody at first and then greenish brown bile color; no foul odor) antiemetics given NPO

nonsurgical management for hepatitis

physical rest (decreases demand thus increasing blood flow to liver), psychological rest (decrease stress), diet therapy (high in carbs and calories, moderate in fats and proteins)

what is another side effect related to jaundice?

pruritis

blumberg's sign

rebound tenderness associated with cholecystitis

nursing care associated with a laparoscopic cholecystectomy

recovery is quick provide pain management (opioids) postop, start with fluids and advance to solids as tolerated normal activity in 1-3 weeks

chronic cholecystitis

repeated episodes of cystic duct obstruction resulting in chronic inflammation usually due to gallstones most likely to develop gangrene

nursing care and education for hepatitis A

sanitation, purified water, vaccination prior to traveling

biliary colic

severe abdominal pain associated with cholecystitis occurs when a stone is moving through or is lodged in the biliary tract sweaty, pale, tachycardia

symptoms of Hep A

similar to typical viral syndrome (people think they have a stomach bug)

symptoms of Hep E

similar to typical viral syndrome (people think they have a stomach bug)

"the vowels go through the bowels"

symptoms of Hep A and E both have to do with bowel issues like vomiting and diarrhea

murphy's sign

test for cholecystitis take your fingers and hook them under the right side of their rib cage and ask the patient to take a deep breath and if their gallbladder is enlarged, they will experience pain

what is a serious complication of cholelithiasis?

the gallbladder can rupture causing peritonitis

hepatitis

widespread inflammation of liver cells the body is exposed to some causative agent, which causes the liver to become enlarged and congested with inflammatory cells, lymphocytes, and fluid, causing the liver to take on a distorted shape the distorted shape increases pressure in the liver, which interferes with blood flow to the liver edema is in the bile channels so bile is unable to drain

when is immune globulin given?

with recent exposure to hepatitis within 2-7 days of contact