MS3 - Quiz 3

The nurse is educating a patient with cirrhosis about lifestyle changes. Which of the following statements by the patient indicates the need for ADDITIONAL education ?

- A full night's sleep is important - I should eat more carbohydrates - I should watch buy weight closely - I will take acetaminophen (Tylenol) if I get a fever -------------- - Tylenol for fever ** Acetaminophen can cause liver damage especially in patients with cirrhosis ** The patient with cirrhosis should get adequate sleep, monitor their weight and eat an increased amount of carbohydrates.

A patient is admitted to the hospital with a diagnosis of acute hepatitis B. The nurse would expect a rise in which of the following serum labs?

- ALT - AST - Bilirubin - Creatinine - Neutrophils - Platelets ------------------ ALT, AST, Bilirubin, Creatinine ** The liver is responsible for modifying bilirubin to allow for excretion. With hepatitis, bilirubin cannot be excreted and instead builds up in the body. ** Hyperbilirubinemia causes Jaundice ** ALT/AST are enzymes normally found circulating in the bloodstream and are associated with the liver, although not exclusively. If these enzyme levels are elevated, it can indicate inflammation or chronic damage to the liver. ALT and AST can be up to 10 times the upper limits of normal during an acute hepatitis B infection. ** Creatinine is increased with kidney damage/failure ** Platelet count will decrease with hepatitis because platelets are made by the liver, and production is decreased with a hepatitis infection.

Esophageal Varices

- Decreased H&H - Anemia - CBC

Fulminating hepatitis

- EXTREMELY SEVERE and potentially fatal form of viral hepatitis. - Client develops manifestations and w/in hours or days develops severe liver failure. - No medication --> SUPPORTIVE CARE

Hepatitis E

- Fecal - Oral - Ingestion of: - Food - Water - Contaminated with fecal waste.

A pt. is receiving an infusion of TPN with 20% dextrose through a central line @ 75ml/hr. The nurse responds to the clients IV pump alarm, which indicates that the bag is empty. The new bag is not expected to arrive from the pharmacy for an hour. What is the most appropriate nursing action?

- Hang NS and increase TPN to 150mL/hr - Hang 10%dextrose in water and resume @ 75ml/hr - Hang dextran in saline until the new bag arrives @ 75ml/hr - Hang LR @ 75 ml/hr ---------------------- ** TPN is administered via CVC to meet nutrient needs. Nurse should hang 10% dextrose in water at the SAME INFUSION RATE until new bag arrives. ** NS --> Hypoglycemia

Pancreatitis S/Sx

- LUQ and radiates to the back - Sudden onset of: - Severe - Deep - Piercing - Continuous/Steady - Aggravated by eating - NOT relieved by vomiting - Pain accompanied by: - Flushing - CYANOSIS - DYSPNEA - Other Manifestations: - N/V - Low grade fever - Leukocytosis - HYPOtension - Tachycardia - Jaundice

Patients on diuretics

- Monitor: - Na, K, CL, and bicarb - Monitor renal function

Daily Weights

Allow for early intervention of fluid retention.

A nurse is caring for a hospitalized pt. with acute pancreatitis. After tx. begins, the nurse anticipates that which serum laboratory value will return to normal within 72 hours?

- Aldolase - Lipase - Amylase - Lactic dehydrogenase ----------------------------- - Amylase, pancreatitis is the most common reason for elevated amylase. Serum amylase begins to increase about 3-6 hr following onset of acute pancreatitis. The amylase level peaks in 20 to 30 hr and returns to normal in 2-3 days.

Hepatitis A (S/Sx)

- Anorexia - Weakness - Fatigue - Nausea - Vomiting Other Symptoms: - RUQ pain - Clay colored bowel - Dark/Brown urine - Low grade fever - Jaundice

Furosemide (Lasix)

- Causes extensive uresis even when severe kidney failure is present - Tx. Edema caused by liver disease - Route: Oral, IV, IM * Monitor: - Dehydration, hyponatremia, hypocloremia - Hypotension - Ototoxicity --> Tinnitus - Hypokalemia <3.5mEq/L * Potatoes, dried fruits, nuts, Spinach, citrus fruits. * NSAID's reduce blood flow to kidneys which reduce the diuretic effect --> Watch for decrease in output.

The nurse is assessing a patient diagnosed with acute pancreatitis. Which of the following assessment findings is consistent with this diagnosis ?

- Elevated temperature - Hypertension - Nausea / Vomiting - RLQ pain - Upper epigastric pain and back pain - Weight gain ------------------ - Elevated temperature, N/V, Upper gastric pain and back pain ** Common symptoms of acute pancreatitis include upper epigastric pain that bores through the body the the back, nausea, vomiting, weight LOSS, and and elevated temperature. ** Hypertension is NOT associated with pancreatitis, although blood pressure may become elevated in response to PAIN ** RLQ pain is associated with APPENDICITIS not pancreatitis.

Cirrhosis Lab Findings

- INCREASED: - Enzyme levels - AST - ALT - Bilirubin (Urine) = Tea color - Prothrombin time >13.5 sec - INR > 3.0 - GGT - Globulin levels - ADH = Edema - DECREASED: - Albumin levels < 3.5 g/dL - Hypoglycemia - H&H = Anemia - Bilirubin (Stool) = White/Clay color

Liver Failure

- Irreversible damage to liver cells

A pt. with a history of cirrhosis has a new prescription for lactulose 30ml four times a day. What does the nurse explain to the client about this medication ?

- It will decrease intestinal absorption of ammonia - It will facilitate diuresis of excess fluid - It will promote renal excretion of bilirubin - It will reduce portal pressure contributing to esophageal varices. --------------------- Decrease ammonia absorption

Hepatitis E (Medications)

- NO MEDICATION --> Supportive Care

Pancreatitis (Proton Pump Inhibitor)

- Omeprazole ** Decrease Gastric Acid Secretion - MONITOR for: - HYPOmagnesemia - Take BEFORE taking pacrelipase

Cullens sign

- Pt's with pancreatitis

Pancreatitis (Histamine Receptor antagonist)

- Ranitidine ** Decreases acid secretion - Take 1 hour before OR 1 hour after antacid. - Take BEFORE taking pancrelipase

Hepatic encephalopathy

- Sleep disturbance (early) to lethargy and coma - AMS pt. not oriented to time place or person - HE is presence of asterixis (flapping of hands) and it is assessed by having the pt. extend the arms and dorsiflex the wrist - Fetor Hepaticus musty, sweet odor of the breath) from accumulated digestive byproducts. - Elevated Ammonia levels

Pancreatitis (Acute) Assessment Findings

- Sudden onset SEVERE pain radiates through the body - Epigastric(Abdominal pain) --> radiates to the back --> left flank --> left shoulder - Pain WORSENS when LYING DOWN - Pain relieved SOMEWHAT by: - Fetal position or sitting upright - Nausea and Vomiting = Weight Loss - Fever ** Remember Flu like Symptoms

Hepatitis B, D (Medications)

- YEAST ALLERGY ACUTE: - No medications --> Supportive Care CHRONIC: - Antiviral Medications

Esophageal Varices

Dilated submucosal Veins in the esophagus. A consequence of Portal Hypertension caused by Cirrhosis - Treatment: - Banding, Ligation, Sclerotherapy --> Endoscopy - Complications: - Excessive bleeding - Infection

Liver Cancer

- Chronic Hepatitis places patient at R/F Cancer.

Hepatitis D

- Co-Infection (Hep B) - Sex - Substance Abuse -

Liver Failure Common Lab Abnormalities

- Low Albumin - Elevated INR - Elevated LFT's - Low serum K = Increase in HE ** Report to MD - Elevated serum ammonia CONFIRMS HE dx.

A nurse is caring for a pt. who is dx. with fulminant hepatic failure. Which of the following procedures should the nurse expect the pt. to be prepared for ?

- Portacaval anastomosis - Right liver lobectomy - Liver Transplant - Transjugular intrahepatic portosystemic shunt ---------------------------------- - Liver Transplant ** Caused by viral hepatitis, is characterized by the dvlp. of hepatic encephalopathy within weeks of the onset to disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemoperfusion and corticosteroids. Consequently liver transplantation has become the treatment of choice for these pt.'s

Grey Turners sign

- Pt's with pancreatitis

Asterixis

- Seen in Liver Failure

Ascites

Ascites is a result of : - Increased VENOUS hydrostatic pressure (portal hypertension secondary to liver fibrosis) - Decreased PLASMA oncotic pressure (the impaired liver does not synthesize adequate albumin). - Increase in aldosterone (the RAAS system is activated because of the low circulating volume, plus the impaired liver does not metabolize aldosterone normally) causes sodium and water retention, which contributes to the ascites.

Bilirubin

Decreased in Stool Increased in Urine --> Tea (Dark colored) Increased in Serum --> Jaundice in skin = Pruritus

Trousseau's sign

HypoCalcemia

Chvostek's Sign

Hypocalcemia

Hepatitis C (Medications)

- Combination therapy - Ribavirin - Peginterferon alfa-2a

A nurse is assessing a patient with cirrhosis. The nurse should know that which of the following would indicate LATE stage liver deterioration ?

- Confusion - Flapping tremor of hands - Lower urine output - Muscle weakness - Weight Loss --------------------- Confusion, Flapping tremor of the hands ** Hepatic deterioration the later stages of cirrhosis, cause encephalopathy due to the increased levels of ammonia in the blood. This results in a diminished level of consciousness, confusion, flapping of the hands (asterixis), sweet odor to breath. ** Weight loss and muscle weakness occur long BEFORE the LATER stages of cirrhosis. ** Low urine output would be due to kidney deterioration NOT liver

A nurse is caring for a patient with hepatic encephalopathy. When advising him on menu options, the nurse tells the patient to avoid:

- Cranberries - Salad -Steak - White bread ------------- Steak ** Hepatic encephalopathy occurs when liver failure causes the accumulation toxins such as ammonia causing confusion, AMS and coma ** The patient is unable to convert ammonia to urea, therefore patient should avoid foods high in protein.

A pt. diagnosed with chronic hepatitis is admitted to the medical unit with ascites. Which of the following mechanisms will the healthcare provider identify as contributing to the development of ascites in this pt. ?

- Decreased venous hydrostatic pressure * Decreased serum albumin - Decreased production of vitamin K * Increased serum aldosterone * Increased liver fibrosis ----------------- ** Ascites is a complication of portal hypertension and is a result of INCREASED resistance to portal flow ** Decreased plasma because the liver does not synthesize adequate albumin ** Increases aldosterone in the RAAS system because of low circulating volume. = water retention and ascites.

The nurse is caring for an alert client with jaundice, scleral icterus, and a bilirubin level of 12.3mg/dL. Which instruction would be most important to include when delegating the clients morning hygiene tasks to unlicensed assistive personnel ?

- Do not leave the client alone in the shower - Use cool water - Use hot water in the shower - Wash client with antibacterial soap ---------------------- Use cool water in the shower ** Jaundice is associated with elevated bilirubin levels and yellowing go the sclera. It often causes INTENSE ITCHING (Pruritus) that can be EXACERBATED by the use of HOT WATER and STRONG SOAPS. Therefore, use --> Cool water and mild soap.

A patient with hepatitis asks the nurse how he contracted the disease. The nurse responds, knowing that hepatitis B is transmitted via:

- Blood - Contaminated Food - Feces - Skin --------------- Blood , Sexual fluids, and Saliva

Hepatitis C

- Blood - Organ transplants - Blood products - Unsanitary tattoo equipment - Sex ** EIA--> ENZYME ImmunoAssay - Detects Hep C infection (New Dx.)

Hepatitis B

- Blood - Unprotected Sex - Born to infected mother - Contact with infected blood - Injectable substances (Substance Abuse) ** Via Blood --> Standard Precaution

The nurse is caring for a patient in the advanced stages of cirrhosis. While making menu selections, the nurse should suggest increasing:

- Carbohydrates - Fat - Fiber - Protein ----------------------- - Carbohydrates ** The liver normally provides energy to the body through various metabolic functions. In cirrhosis, the patient's need for carbohydrates increases in order to provide sufficient energy for cellular metabolism. ** Protein and Fat intake should be limited ** Fiber intake is important to aid in bowel movement (not a nutrient)

Hepatitis Complications:

- Chronic hepatitis - Fulminating hepatitis - Liver cancer - Liver failure

Which assessment finding would indicate that a patients ascites is improving ?

- Abdominal girth decreases - Abdominal skin becomes shinier - Pt. reports easier breathing - The amount of ankle edema is now 1+ pitting and 12 hours ago was reported as 3+ pitting - The pulse rate increases over time - Urine output increases ------------------ - Abd. girth decreases - Pt. reports easier breathing - Ankle edema has decreased - Urine output increases ** Increased urine output indicated that the ascitic fluid is being absorbed into the circulation and then excreted ** Ascites, increases abdominal girth and can also inhibit the movement of the diaphragm, resulting in difficulty breathing. As it resolves, breathing eases ** Abdominal skin should become LESS shiny ** Lower fluid volume should cause rate to SLOW not increase

A patient is admitted after complaints consistent with hepatitis A. The patient's blood tests confirm this diagnosis. The nurse should expect to observe which symptoms ?

- Abdominal pain radiating to the left shoulder - Anorexia - Constipation - Fatigue - Nausea/Vomiting --------------- Anorexia, Fatigue, N/V ** Abd. pain radiating to shoulder or back = Pancreatitis ** Hep A is highly contagious and contracted from contaminated food, water, or close contact with an infected person. It is most common in undeveloped countries. Causes liver damage BUT most people recover completely. Mild cases often require no treatment.

Which of the following nursing interventions would the nurse implement when caring for a pt. newly diagnosed with acute viral hepatitis ? SATA

- Administer antiemetic medications as needed - Encourage a good breakfast and small frequent meals - Promote rest periods alternating with periods of activity - Provide a diet high in protein and low in fat - Teach the pt. to abstain from alcohol. -------------------------------- ** All except : high protein and low fat. are correct ** ACUTE viral hepatitis is treated with supportive measures, including rest (alt.activity and rest), avoiding ETOH, and hepatotoxic medications and adequate nutrition.

A nurse is caring for a client with cirrhosis of the liver. Which blood test values would the nurse typically anticipate to be elevated when reviewing the pt.'s morning lab results ? SATA

- Albumin - Ammonia - Bilirubin - Prothrombin time - Sodium ----------------------- ** Chronic progressive destruction characteristic of cirrhosis causes bilirubin, ammonia, and coagulation studies to become ELEVATED ** Sodium is DILUTED due to large amounts of water in body ** Albumin is LOW liver is unable to synthesize albumin hence why it is low.

The nurse is caring for a client with End Stage Liver Failure from Hepatitis C who is being seen in the clinic for worsening ascites. The client is treated in the infusion center with IV albumin, furosemide, and oral spironolactone. The following day the nurse checks the clients labs. Which of the following lab findings is most important for the nurse to communicate to the healthcare provider ?

- Albumin 2.5g/dl - INR 1.4 - Potassium 3.0mEq/L - Sodium 131 mEq/L ------------------------------- ** Pt. with Cirrhosis is @ R/F HE (Hepatic Encephalopathy) - Hypokalemia - High protein intake - Gastrointestinal bleeding - Constipation - Hypovolemia - Infection Can precipitate hepatic encephalopathy. ** Furosemide can cause jpokalemia and precipitate hepatic encephalopathy and must be corrected immediately to prevent HE and dangerous arrhythmias ** Low Albumin is COMMON in liver failure due to decreased protein synthesis ** Elevated prothrombin time and INR are COMMON with liver disease or Cirrhosis ** NA level is low and likely from dilution hyponatremia from excess water retention (think of it as an illusion)

The nurse is assessing a patient with advanced cirrhosis. The nurse should be alert for which sign of hepatic deterioration ?

- Altered LOC - Anorexia - Confusion - Weight Gain - Weight loss -------------------- - Altered LOC, Confusion, Weight Gain ** Encephalopathy causes CNS toxicity, leading to altered LOC, confusion and coma ** Weight gain may also be seen due to third spacing, associated with lower albumin levels secondary to liver damage ** Weight loss and anorexia occur EARLY in the disease process.

A client diagnosed with cirrhosis is experiencing pruritus. Which action will the nurse take to promote comfort and minimize pruritus ?

- Apply cool, wet cloths to skin - Encourage hot showers - Gently apply calamine lotion - Promote use of cotton gloves - Request the pt. cut nails short --------------------------------- - Apply cool, wet cloths, gently apply calamine lotion, promote use of cotton gloves, request that the pt. cut nails short. ** Wear long sleeved shirts to avoid injury to the skin from scratching, baking soda baths, calamine lotion to cool and sooth irritated skin. ** Hot Showers intensify itching and cause vasodilation of the skin. Shower with tepid water. **

The nurse is caring for a client with liver cirrhosis who was admitted for cellulitis of the leg. Which assessments would the nurse perform to determine if the clients condition has progressed to hepatic encephalopathy ?

- Ask if the client knows what day it is - Ask the client to extend the arms - Assess for telangiectasia (spider nevi) - Determine if the conductive is jaundiced - Note amylase and lipase serum levels -------------------------------- - Ask pt. if he knows what day it is, ask the pt. to extend arms ** Precipitating factors of HE include: hypokalemia, constipation, GI hemorrhage, and infection. Results due to ammonia accumulation. ** Clinical manifestations of HE range from: - Sleep disturbance (early) to lethargy and coma - AMS pt. not oriented to time place or person - HE is presence of asterixis (flapping of hands) and it is assessed by having the pt. extend the arms and dorsiflex the wrist - Fetor Hepaticus musty, sweet odor of the breath) from accumulated digestive byproducts. ** Amylase and lipase are PANCREATIC ENZYMES ** Jaundice occurs when bilirubin is 2-3 times the normal value and can occur in hepatitis and tends to worsen in cirrhosis due to increasing functional derangement. It is NOT related specifically to encephalopathy.

A nurse is caring for a client who has portal hypertension. The pt. had vomiting of blood missed with food after a meal. Which of the following actions should the nurse take FIRST (ABC) or (ADPIE)?

- Assess vital signs

A patient diagnosed with hepatitis and cirrhosis has developed ascites. When assessing the patient, the healthcare provider notes an increased temperature and a decreased level of consciousness. What assessment should the healthcare provider perform next

- Auscultate the patient's lung sounds - Palpate the abdomen for tenderness - Obtain a urine sample for lab. analysis - Measure the pt.s abdominal girth ---------------------- - Obtain urine sample ** The increased intestinal permeability can cause bacteria to cross the intestinal lumen and cause bacterial peritonitis. Clinical manifestations of bacterial peritonitis include fever, altered mental status, and abdominal pain and tenderness.

The nurse is caring for a pt. with RUQ pain and jaundice. The pt.'s ALT and AST levels are 7 times the normal values. What questions would be most helpful regarding the etiology for these findings ? SATA.

- Do you have black tarry stool ? - Do you use intravenous illicit drugs ? - How much alcohol do you typically drink ? - Were you recently immunized for pneumonia ? - What OTC drugs do you take ? ----------------------------- - 2,3,5 are correct ** Besides viral ETOH consumption, OTC (acetaminophen), and certain herbal and dietary supplements. Illicit drugs increase R/F Hep B and C ** Black tarry stool is expected from a GI Bleed and seen in gastric or esophageal varices ** Immunizations DO NOT cause liver damage

Hepatitis (Disease Prevention)

- Educate on transmission and exposure - Vaccinations - Isolation Precautions - Safe Injection Practices: - Aseptic technique for prep and admin. of parenteral meds. - Single/Sterile needle use - Single Dose Vials - Needleless / Safety Caps - PPE: - Gown - Gloves - Goggles - Hand hygiene - Traveling: - Purified water - Avoid sharing eating utensils - Avoid sharing bed linens

The nurse is preparing a care plan for a patient with ascites related to cirrhosis. Which of the following nursing diagnoses should take priority ?

- Excess fluid volume - Ineffective breathing pattern - Nutritional deficiency - Risk of poisoning ------------------ Ineffective breathing pattern ** Due to accumulation of fluid in the abdomen, pressure is placed on the diaphragm and can interfere with breathing. This can lead to pneumonia or atelectasis

Liver biopsy (procedure)

- Fasting begins at midnight - Administer medications - Supine position - Right side EXPOSED - Relaxation technique - EXHALE and hold for 10 SECONDS (needle insertion) - After insertion --> RESUME BREATHING - Apply pressure to insertion site - POST-OP - RIGHT Side lying position (hours) - V/S monitored - Assess for Abdominal pain - Assess for bleeding (puncture site) - Pneumothorax (manifestations) - dyspnea, cyanosis, restlessness

A patient with chronic hepatitis is admitted to the hospital due to his declining status. The nurse assess the patient and will most likely note which of the following?

- Fatigue - High serum albumin - Increased axillary hair - Increased bleeding tendencies - Muscle wasting - Peripheral edema ----------------------- Fatigue, Increased bleeding, muscle wasting, peripheral edema

Hepatitis A

- Fecal - Oral - Ingestion of: - Contaminated Food - Contaminated Water - Contaminated SHELLFISH - Close/Personal Contact with an infected individual ** IgG --> Indicated permanent immunity

A patient with pancreatitis is at R/F developing a paralytic ileus. Which of the following assessment data indicates complication ?

- Firm mass at the right costal margin - Inability to pass flatus - Intense pain - Nausea ------------------------ Inability to pass flatus ** Paralytic ileus is the most common form of nontechnical obstruction and often presents with the inability to pass flatus. ** Nausea may be present with an obstruction, but in this case it is most likely to pancreatitis. ** Pain from an ileus is usually dull and generalized ** A firm mass at the right costalmargin is indicative of cirrhosis.

A patient with hepatitis is admitted to the hospital. The physician believes he contracted the disease from contaminated food.Which of the following is MOST LIKELY the diagnosis ?

- Hep A - B - C - D

Hepatitis (Nutrition)

- High-Carbohydrate AND High- Calorie - LOW Fat AND LOW Protein - Small Frequent meals - Promotes healing and nutrition - Due to presence of anorexia

A nurse is caring for a pt. who has hepatic encephalopathy that is being treated with lactulose. The pt. is experiencing excessive stools. Which of the following should the nurse recognize as an adverse effect of this medication ?

- Hypokalemia ** Lactulose stimulated production of stools and rids the body of excess ammonia. these excessive stools can result in hypokalemia and dehydration. ** lactulose will reduce confusion NOT cause it

Pancreatitis (Antibiotics)

- Imipenem ** Acute necrotizing pancreatitis - Monitor for infection - WBC - Monitor for Seizures

A client with ascites due to cirrhosis has increasing SOB and Abd. pain. The HCP requests that the nurse prepare the pt. for a paracentesis. Which nursing actions would the nurse implement prior to the procedure ?

- Immediately place on NPO - Obtain informed consent - Place the pt. in high Fowler's position - Request that the client empty the bladder - Take baseline V/S and weight ---------------- Place pt. in high fowlers, request pt. to empty bladder, take baseline V/S ** Nurses EXPLAIN the procedure and DO NOT OBTAIN consent that is ONLY obtained by an HCP, the nurse may WITNESS informed consent and that it is given voluntarily, the signature is authentic, and the pt. appears competent to consent. ** Instruct pt. to void to prevent puncturing the bladder ** Assess the pt.'s abdominal girth, weight, and V/S ** Pt. remains high fowler during entire procedure ** NPO is NOT required for this procedure and performed @ bedside.

A patient diagnosed with chronic hepatitis is admitted to the medical unit with ascites. Which of the following mechanisms will the healthcare provider identify as contributing to the development of ascites in this patient?

- Increased serum aldosterone - Increased liver fibrosis - Decreased production of vitamin K - Decreased venous hydrostatic pressure - Decreased serum albumin ------------------------------------- - Increased serum aldosterone, increased liver fibrosis, Decreased serum albumin

Spironolactone

- K+ sparing diuretic --> HYPERKalemia - Tx. effects may take 12-48 hours - Route: Oral * Monitor: - K level >5.0 - D/C medication, restrict K in diet, administer insulin to drive K back into cell * Caution with: - ACE Inhibitors, ARB's can cause hyperkalemia - DO NOT ADMINISTER if pt. has severe kidney failure and ANURIA *** pt. CANNOT urinate DO NOT ADMINISTER !!! CHECK URINE OUTPUT. ** Avoid salt substitutes --> contain K. Effectiveness: - Weight loss, Decrease B.P. and edema

Hepatitis A (Medications)

- LATEX ALLERGY !! - Immunization - Immunoglobulin --> Post Exposure - >40 y.o. - < 12 months - Chronic liver disease - Immunosuppressed - Allergic to vaccine ** Hep A Vaccine is recommended for those traveling ESPECIALLY military personnel and also @ risk groups

The nurse assesses a pt. with suspected acute pancreatitis and anticipates the pt. reporting pain in which anatomical area?

- Left flank radiating to the left groin area - Left upper quadrant radiating to the back - Periumbilical area shifting to the right lower quadrant - Right upper quadrant radiating to the right shoulder ---------------- Left upper quadrant radiating to the back ** Pt. with Acute Pancreatitis will report a sudden onset of LUQ or midepigastric pain that often radiates to the back ** The pain is referred to the back as the pancreas is a retroperitoneal organ. ** Pain improves with leaning forward and worsens with lying flat. ** Pain is ofter preceded or made worse by a high fat meal ** N/V are common due to severe pain ** Patients are at R/F dvlp. hypovolemia due to 3rd spacing ** ARDS due to intense systemic inflammatory response ** HypoCalcemia due to necroses fat binding calcium

A patient is being cared for by a HHNurse. The patient has jaundice and is complaining of pruritus. Which of the following interventions can the patient implement to reduce pruritus ?

- Maintain a cool house temperature - Use alkaline soap to remove dead skin - Use tepid water for bathing - Wear tight clothing ------------- Maintain a cool house temp, Use tepid water for bathing ** To reduce pruritus related to bile salt accumulation, the pt. should keep his house cool, wear loose clothing, use tepid water, use MILD soaps, and take antihistamines ** HOT water, alkaline soaps, and tight clothing can irritate the skin and make it worse.

Pancreatitis (Opiods)

- Morphine - Hydromorphone * Used for Acute pain

Pancreatitis (Nutrition)

- NPO - Until Pain Free - TPN - SEVERE Pancreatitis - DO NOT USE if Paralytic Ileus is present - Resumed Diet: - Bland - High Protein - Low-Fat - NO STIMULANTS - Small Frequent meals

Pancreatitis (Nursing Care)

- No ETOH - Alcohol consumption is the MAJOR CAUSE of chronic pancreatitis in the U.S. - Encourage pt. to participate in support groups - AA --> ETOH disorder - No Smoking - Limit Stress - Pain management - Position Patient for Comfort: - Fetal - Side-lying - Elevated HOB - Sitting up - Leaning Forward - Administer Analgesics - Morphine - Hydromorphone - Administer Medications - Antibiotics - Histamine Receptor antagonist - PPI's - Pancreatic Enzymes - Monitor Glucose - Potential for Hyperglycemia due to destruction of pancreatic beta cells - Provide Insulin - Monitor Hydration --> Due to 3rd spacing up to 6L can be lost, loss of protein rich fluid = fluid shift. --> Hypovolemic Shock - B.P. - I&O - Lab Values - Administer IV Fluids

Chronic Hepatitis

- Ongoing Inflammation of the liver cells - Results from Hep. B,C,D (Blood borne) - Increases risk for liver cancer

Pancreatitis (Medication)

- Opiods - Acute Pain - Antibiotics - Necrotizing Pancreatitis - Histamine Receptor antagonist - Gastric Acid secretion reduced - PPI - Gastric Acid Secretion reduced - Pancreatic Enzymes - Aids with digestion of fats and proteins when taken with meals and snacks.

A nurse is caring for a pt. who is to undergo a liver biopsy for a suspected malignancy. Which of the following should the nurse monitor prior to the procedure ?

- PT - Serum Albumin - AST - H&H ------------- ** PT, because the liver is extremely vascular a major complication is HEMORRHAGE Along with PTT and a Platelet count should be monitored. ** Liver dysfunction decreases production of blood clotting and factors are reduced ** Increased bruising is seen, nosebleeds, bleeding from wounds, and GI bleeds. ** Deficient absorption of Vitamin K is seen from GI tract because liver cells are unable to use vitamin K to make prothrombin.

Pancreatitis (Pancreatic Enzymes)

- Pancrelipase ** Helps with digestion of fats and proteins when taken with meals and snacks. - NURSING: - SPRINKLE contents on NON-PROTEIN FOODS - Drink a FULL GLASS OF WATER - WIPE LIPS and RINSE MOUTH after taking - Prevents skin breakdown/Irritation - Pancrelipase AFTER antacid OR Histamine Receptor agonist - Take with EVERY MEAL AND SNACK

Cirrhosis of the liver

- Permanent scarring of the liver that is usually caused by chronic inflammation.

Ascites Physiological Reasons

- Portal HTN - Decreased Albumin - Hyperaldosteronism - Decreased renal blood flow - due to decreased intravascular volume (Hypotension) - Decreased GFR

Hepatitis (Nursing Care)

- Pt. cared for at home - Contact precautions - High-Carbohydrate AND High- Calorie - LOW Fat AND LOW Protein - Small Frequent meals - Promotes healing and nutrition - Due to presence of anorexia - HEPATIC REST - ONLY Necessary medications - NO Acetaminophen --> Metabolized in Liver - AVOID OTC meds - AVOID Herbal meds - AVOID ETOH - Limit Physical Activity - Educate pt. AND family --> prevent transmission - AVOID SEX - HAND HYGIENE ** Standard Precaution --> Transmissions via blood ** DAILY weights --> Monitor Fluid status ** Abdominal girth is measured around the LARGEST part of the abdomen and VARIES per PATIENT.

The nurse is caring for a client with acute pancreatitis. Which subjective and objective assessments would the nurse report immediately ?

- Pt. is lying with knees drawn up to the abd. and trunk flexed - Pt. states. lips are tingling and numb - Foul-smelling fatty stool - Temp of 102.2 and increasing abdominal pain -------------------------- ** A high grade fever or abrupt increase in temp with worsening abd. pain could be an indication PANCREATIC ABSCESS, a significant complication of acute pancreatitis. ** A pancreatic abscess requires immediate intervention with antibiotics and surgical drainage to reduce risk of rupture and sepsis and a HCP should be notified immediately ** Fetal positioning decreases pain ** Hypocalcemia (early) = numbness and tingling of the lips and fingers.Further evaluation should be made for possible signs of tetany by assessing for a positive Chvostek's sign or Trousseau's sign ** Stool in acute pancreatitis is expected to be fatty and foul-smelling

A patient diagnosed with hepatitis is undergoing a liver biopsy. When caring for the patient, which of these actions would be essential for the healthcare provider to take?

- Review the patient's baseline liver function tests - Monitor the patient's vital signs after the procedure - Provide a mechanical soft diet for before the procedure - Ensure the patient has an empty bladder before the procedure - Help the pt. assume a left lateral position after the procedure - Ensure the patient's clotting profile is within normal limits. ---------------------------------- - Monitor V/S, ensure pt. has an empty bladder before procedure, clotting factors are within limits. ** To manage bleeding, the patient's CLOTTING PROFILE should be within normal limits and the patient should be positioned on the right side after the procedure to provide pressure to the site. VITAL SIGNS are checked afterwards to detect changes that could signal hemorrhage. An EMPTY BLADDER before the procedure will ensure it isn't damaged. The patient is usually advised to have nothing to eat or drink (NPO) for six hours before the procedure.

Esophageal Varices

- Seen in Liver Failure / Portal HTN

A patient diagnosed with chronic hepatitis has developed hepatic encephalopathy. When assessing the patient, the healthcare provider looks for which of the following clinical manifestations characteristic of this condition

- Slurred speech - Involuntary hand tremor - Bloody emesis - Shortened attention span - Retroperitoneal bleeding - Hypersomnia ---------------------- - Slurred speech, involuntary hand tremor, shortened attention span, hypersomnia **Hepatic encephalopathy characterized by progressive cognitive deficits and impaired neuromuscular function, so the healthcare provider would anticipate assessing symptoms such as sleep disturbances, confusion, impaired attention span, slurred speech, and asterixis (flapping tremor). Esophageal varices often result in bloody emesis, and retroperitoneal bleeding is a symptom of pancreatitis.

Lactulose (Cephulac)

- Synthetic Sugar --> watch for hyperglycemia (DM patients) - Acidifies fecal content --> preventing ammonia diffusion - Increases water content = Soft stool - Watch for: - Diarrhea complications - Dehydration, - Electrolyte imbalance - HypoKalemia and Hypernatremia

A nurse is assessing a pt. who has acute pancreatitis, which of the following findings is the highest priority ?

- WBC cound - Generalized jaundice - Absent bowel sounds - N/V ----------- **Absent bowel sounds indicate pt. is @ R/F paralytic ileus; therefore a priority finding. ** Increased WBC, gen. jaundice, and N/V are expected findings of pancreatitis.

The nurse prepares to admit a patient for worsening cirrhosis who is on the waiting list for a liver transplant. Based on the pt.'s lab results, the nurse anticipates which assessment findings? SATA

LABS: Albumin 1.5 Ammonia 112 INR 1.9 Bilirubin 22 Platelets 55,000 ---------------------------------- - Ascites - Bruising - Constipation - Itching -Lethargy ---------------------------------- - Ascites, Bruising, Itching, Lethargy ** Common lab abnormalities include: - Low Albumin = Ascites - Elevated INR = Bruising/Bleeding - Elevated serum ammonia = Lethargy/Confusion - Increased bilirubin = Jaundice and itching

Albumin

Lab Value: 3.5 - 6 - Synthesized in the liver, expands circulating blood volume. Tx: - Hypovolemia, Hypoalbuminemia - Keeps fluids within the blood -Lab value helps determine: - Liver function, nutrition status - Low in Liver disease - Monitor: - K level prior --> hyperkalemia

Early Signs of Hepatitis

Nonspecific Flu like symptoms Diarrhea/N/V WEIGHT LOSS

PT/INR

Range : 11 - 12.5 Prolonged in Liver Failure INR: Range: 0.8 - 1.1 Prolonged in Liver Failure

Ammonia

Reduce Protein you reduce ammonia which helps with hepatic encephalopathy