NRS 222 Exam 4

the priority collaborative problem for pt's with acute pancreatitis

-acute pain due to pancreatic inflammation and enzyme leakage -weight loss due to inability to ingest food and absorb nutrients

CM of chronic pancreatitis

-intense abd pain that is continuous and burning or gnawing (major CM ) -abd tenderness -ascites -poss LUQ mass (if psuedocyst or abscess present) -resp compromise (adventitious or diminished breath sounds, dyspnea, orthopnea) -steatorrhea, clay colored stool -weight loss -jaundice -dark urine -polyuria, polydipisia, polyphagia (DM)

nursing care for acute pancreatitis

-manage pain -nonsurgical management : ---IV fluids (isotonic), NPO while acute, primary drug class is opioid (morphine or dilaudid) -promote nutrition -care coordination and transition management -evaluation : responding

common causes of cirrhosis

Chronic alcohol abuse, Chronic viral hepatitis (hepatitis B and C), and fat accumulating in the liver (nonalcoholic fatty liver disease)

A client is experiencing an attack of acute pancreatitis. Which nursing intervention is the highest priority for this client? Measure intake and output every shift. Do not administer food or fluids by mouth. Administer opioid analgesic medication. Assist the client to assume a position of comfort.

Administer opioid analgesic medication. Pain relief is the highest priority for the client with acute pancreatitis.Although measuring intake and output, NPO status, and positioning for comfort are all important, they are not the highest priority.

The nurse asks a client with liver disease to raise the arms to shoulder level and dorsiflex the hands. A few moments later, the hand begins to flap upward and downward. How does the nurse correctly document this in the medical record? Positive Babinski's sign Hyperreflexia Kehr's sign Asterixis

Asterixis The nurse documents asterixis when the client's dorsiflexed hands begin to flap upward and downward when outstretched for a few moments. Liver flap or asterixis is related to increased serum ammonia levels.Babinski's sign is positive when, as the sole of the foot is stroked, the great toe points up and the toes fan out. Hyperreflexia refers to deep tendon reflexes that are overactive. Kehr's sign is reflected by increased abdominal pain, exaggerated by deep breathing, and referred to the right shoulder.

3. A patient with late-stage cirrhosis develops portal hypertension. Which of the following options below are complications that can develop from this condition? Select all that apply: A. Increase albumin levels B. Ascites C. Splenomegaly D. Fluid volume deficient E. Esophageal varices

B. Ascites C. Splenomegaly E. Esophageal varices The answer are B, C, and E. Portal Hypertension is where the portal vein becomes narrow due to scar tissue in the liver, which is restricting the flow of blood to the liver. Therefore, pressure becomes increased in the portal vein and affects the organs connected via the vein to the liver. The patient may experience ascites, enlarged spleen "splenomegaly", and esophageal varices etc.

10. A patient who received treatment for pancreatitis is being discharged home. You're providing diet teaching to the patient. Which statement by the patient requires immediate re-education about the diet restrictions?* A. "It will be hard but I will eat a diet low in fat and avoid greasy foods." B. "It is very important I limit my alcohol intake to no more than 2-3 glasses of wine a week." C. "I will concentrate on eating complex carbohydrates rather than refined carbohydrates." D. "I will purchase foods that are high in protein."

B. "It is very important I limit my alcohol intake to no more than 2-3 glasses of wine a week." The answer is B. A patient with pancreatitis should AVOID any amount of alcohol because of its effects on the pancreas. Remember alcohol is a cause of both acute and chronic pancreatitis. All the other options are correct.

13. Which of the following is NOT a role of the liver? A. Removing hormones from the body B. Producing bile C. Absorbing water D. Producing albumin

C. Absorbing water The answer is C. The liver does not absorb water. The intestines are responsible for this function.

CM of acute pancreatitis

CM vary widely and depend on severity of inflammation -severe abd pain in the mid epigastric area or left upper quadrant -sudden onset of pain that radiates to the back, left flank or left shoulder and is described as intense and worsened by lying in supine position -weight loss -N/V relief in fetal position with knees drawn up to the chest an spine flexed or by sitting upright and bending forward

A client has undergone the Whipple procedure (radical pancreaticoduodenectomy) for pancreatic cancer. Which precautionary measures does the nurse implement to prevent potential complications? Select all that apply. Check blood glucose often. Check bowel sounds and stools. Ensure that drainage color is clear. Monitor mental status. Place the client in the supine position.

Check blood glucose often. Check bowel sounds and stools. Monitor mental status. To prevent potential complications after a Whipple procedure, the nurse would check the client's glucose often to monitor for diabetes mellitus. Bowels sounds and stools would be checked to monitor for bowel obstruction. A change in mental status or level of consciousness could be indicative of hemorrhage.Clear, colorless, bile-tinged drainage or frank blood with increased output may indicate disruption or leakage of a site of anastomosis but is not a precautionary action for the nurse to implement. The client should be placed in semi-Fowler's and not supine position to reduce tension on the suture line and the anastomosis site and to optimize lung expansion.

The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN? Client who is taking lactulose and has diarrhea Client with hepatitis C who requires a dressing change Client with end-stage cirrhosis who needs teaching about a low-sodium diet Obtunded client with alcoholic encephalopathy who needs a blood draw

Client with end-stage cirrhosis who needs teaching about a low-sodium diet The client with end-stage cirrhosis would be assigned to the RN. The RN is responsible for client teaching.Assisting a client with toileting and recording stool number and amount can be accomplished by nonprofessional staff. The LPN/LVN can provide dressing changes. Ancillary staff can perform venipuncture.

The nurse is caring for clients in the outclient clinic. Which of these phone calls would the nurse return first? Client with hepatitis A reporting severe and ongoing itching Client with severe ascites who has a temperature of 101.4°F (38°C) Client with cirrhosis who has had a 3-pound (1.4 kg) weight gain over 2 days Client with esophageal varices and mild right upper quadrant pain

Client with severe ascites who has a temperature of 101.4°F (38°C) The nurse will first call the client with severe ascites and a temperature of 101.4 (38°C).This client may have spontaneous bacterial peritonitis.Itching is anticipated with jaundice, so this client may be called last. Weight gain with cirrhosis is not uncommon owing to low albumin levels. Cirrhosis may cause mild right upper quadrant pain. This client would be called after the client with severe ascites.

A client who was awaiting liver transplantation is excluded from the procedure after the presence of which condition is discovered? Colon cancer with metastasis to the liver Hypertension Hepatic encephalopathy Ascites and shortness of breath

Colon cancer with metastasis to the liver Clients with metastatic cancers are not candidates for liver transplant. Transplantation is performed for hepatitis and primary (not secondary) liver cancers.Hypertension is a controllable factor and would not preclude the client from a liver transplant. Encephalopathy is a consequence of advanced liver disease, consistent with the condition of a client awaiting transplantation. It can be treated with lactulose and nonabsorbable antibiotics. Ascites and resulting shortness of breath are also consequences of advanced liver disease, consistent with the client awaiting transplantation. They can be managed with diuretics and paracentesis.

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

Consuming increased carbohydrates and moderate protein To repair the liver, the nurse recommends that the client adopt a high-carbohydrate and moderate-protein diet. Fats may cause dyspepsia.The client with hepatitis feels full easily and needs to 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.

11. The physician orders a patient with pancreatitis to take a pancreatic enzyme. What assessment finding demonstrates the pancreatic enzymes are working properly?* A. Abdominal girth is decreased B. Skin turgor is less than 2 seconds C. Blood glucose is 250 D. Stools appear formed and solid

D. Stools appear formed and solid The answer is D. Pancreatic enzymes help the body break down carbs, proteins, and fats because the body is not sufficiently producing digestive enzymes anymore. Hence, the stool will not appear as oily or greasy (decrease in steatorrhea) but appear solid and formed.

8. A 45 year old male has cirrhosis. The patient reports concern about the development of enlarged breast tissue. You explain to the patient that this is happening because? A. The liver cells are removing too much estrogen from the body which causes the testicles to produce excessive amounts of estrogen, and this leads to gynecomastia. B. The liver is producing too much estrogen due to the damage to the liver cells, which causes the level to increase in the body, and this leads to gynecomastia. C. The liver cells are failing to recycle estrogen into testosterone, which leads to gynecomastia. D. The liver cells are failing to remove the hormone estrogen properly from the body, which causes the level to increase in the body, and this leads to gynecomastia.

D. The liver cells are failing to remove the hormone estrogen properly from the body, which causes the level to increase in the body, and this leads to gynecomastia.

1. Which condition is NOT a known cause of cirrhosis? A. Obesity B. Alcohol consumption C. Blockage of the bile duct D. Hepatitis C E. All are known causes of cirrhosis

E. All are known causes of cirrhosis

The nurse suspects that a client may have acute pancreatitis as evidenced by which group of laboratory results? Deceased calcium, elevated amylase, decreased magnesium Elevated bilirubin, elevated alkaline phosphatase Elevated lipase, elevated white blood cell (WBC) count, elevated glucose Decreased blood urea nitrogen (BUN), elevated calcium, elevated magnesium

Elevated lipase, elevated white blood cell (WBC) count, elevated glucose Elevated lipase, along with increased WBC and increased glucose, suggests acute pancreatitis. Also, increased are serum amylase, serum trypsin, and serum elastase.Many pancreatic and nonpancreatic disorders can cause increased serum amylase levels. Bilirubin and alkaline phosphatase levels will be increased only if pancreatitis is accompanied by biliary dysfunction. Usually, calcium and magnesium will be increased and BUN increased, not decreased, in acute pancreatitis.

Which activity by the nurse will best relieve symptoms associated with ascites? Administering oxygen Elevating the head of the bed Monitoring serum albumin levels Administering intravenous fluids

Elevating the head of the bed The best action by the nurse caring for a client with ascites is to elevate the head of the bed. The enlarged abdomen of ascites limits respiratory excursion. Fowler's position will increase excursion and reduce shortness of breath.The client may need oxygen, but first the nurse would raise the head of the bed to improve respiratory excursion and oxygenation. Monitoring serum albumin levels will detect anticipated decreased levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.

Complications of acute pancreatitis

Hypovolemia Hemorrhage Acute kidney failure Paralytic ileus Hypovolemic or septic shock Pleural effusion, respiratory distress syndrome, pneumonia Multisystem organ failure Disseminated intravascular coagulation Diabetes mellitus

drug therapy for cirrhosis

Lactulose (laxitave) Diuretic (furosemide and or spironalactone) - to reduce fluid accumulation and prevent cardiac and resp probs. -potassium suplement -Quinolones such as floxacin drugs of choice for SBP if allergic bactrim may be given

complications of cirrhosis

Portal hypertension ascites and esophageal varices coagulation defects jaundice Portal-systemic encephalopathy (PSE) with hepatic coma hepatorenal syndrome spontaneous bacterial peritonitis hyponatremia

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

Requesting an injection of immunoglobulin The highest priority intervention to help prevent the health care worker from developing Hepatitis A after exposure to the disease is requesting the administration of immunoglobulin, antibodies to hepatitis A.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.

causes and risks for acute pancreatitits

cause is unknown but factors that can injure the pancreas include: trauma, surgical manipulation after biliary tract, pancreatic, gastric, and duodenal procedures such as cholecystectomy

lab assessment of meningitis

csf analysis ct scan blood cultures counterimmunoelectrophoresis polymerase chain reaction cbc xray to determine presence of infection

Acute pancreatitis

is a serious and at times life threatening inflammation of the pancreas

chronic pancreatitis

progressive destructive disease of the pancreas characterized by remission and exacerbation -the recurring destruction of the pancreatic tissue that results in atrophy, fibrosis, scarring, and the development of calcification within the gland

etiology and genetic risk for cirrhosis

*hepatitis C- second leading cause of cirrhosis and liver disease in the US * hepatitis B and D- most common cause of cirrhosis worldwide *NAFLD nonalcoholic fatty liver disease (assoc. with obesity, DM II, metabolic syndrome) most common cause of liver disease in the world * alcohol in excessive and prolonged use common cause of cirrhosis

3. Select-ALL-that-apply: In the pancreas, the acinar cells release:* A. Amylase B. Somatostatin C. Lipase D. Protease

A. Amylase C. Lipase D. Protease The answers are A, C, and D. Acinar cells secrete digestive enzymes into the pancreatic ducts. These enzymes are: Amylase: breaks down carbs to glucose, Protease: breaks down proteins to amino acids, Lipase: breaks down fats

9. A patient with acute pancreatitis is reporting excessive thirst, excessive voiding, and blurred vision. As the nurse, it is priority you?* A. Reassure the patient this is normal with pancreatitis B. Check the patient's blood glucose C. Assist the patient with drinking a simple sugar drink like orange juice D. Provide a dark and calm environment

B. Check the patient's blood glucose The answer is B. Patients with acute pancreatitis are at risk for hyperglycemia (the signs and symptoms the patient are reporting are classic symptoms of hyperglycemia). Remember the endocrine function of the pancreas (which is to release insulin/glucagon etc. is insufficient) so the nurse must monitor the patient's blood glucose levels even if the patient is not diabetic.

1. Inside the pancreas are special cells that secrete digestive enzymes and hormones. The cells that secrete digestive enzymes are known as ______________ cells.* A. Islet of Langerhans B. Protease C. Acinar D. Amylase

C. Acinar The answer is C. Acinar cells secrete digestive enzymes such as amylase, protease, and lipase.

A client has been discharged to home after being hospitalized with an acute episode of pancreatitis. The client, who is an alcoholic, is unwilling to participate in Alcoholics Anonymous (AA), and the client's spouse expresses frustration to the home health nurse regarding the client's refusal. What is the nurse's best response? "Your spouse will sign up for the meetings only when he is ready to deal with his problem." "Keep mentioning the AA meetings to your spouse on a regular basis." "I'll get you some information on the support group Al-Anon." "Tell me more about your frustration with your spouse's refusal to participate in AA."

"I'll get you some information on the support group Al-Anon." The nurse's best response involves putting the client's spouse in contact with an Al-Anon support group. This action may help with the spouse's frustration and help both to cope with the situation.Telling the spouse that the client will sign up for AA meetings when the client is ready and telling the spouse to keep mentioning AA do not address the spouse's frustration with the client's refusal to participate in AA. Encouraging the spouse to say more about his or her frustration may allow the spouse to vent frustration, but it does not offer any options or solutions.

Which statement by a client with cirrhosis indicates that further instruction is needed about the disease? "Cirrhosis is a chronic disease that has scarred my liver." "The scars on my liver create problems with blood circulation." "Because of the scars on my liver, blood clotting and blood pressure are affected." "My liver is scarred, but the cells can regenerate themselves and repair the damage."

"My liver is scarred, but the cells can regenerate themselves and repair the damage." The client's statement that, although his liver is scarred, the cells can regenerate and repair the damage indicates that further instruction is needed. Although cells and tissues will attempt to regenerate, destroyed liver cells will result in permanent scarring and irreparable damage.Cirrhosis is a chronic condition that leaves scars on the liver. Permanent scars form in response to attempts by the cells to regenerate and create problems in blood circulation moving through the liver. Liver scarring will create problems with blood clotting, cholesterol levels, and blood pressure, as well as with the metabolism of drugs and toxins.

A client has developed acute pancreatitis after also developing gallstones. Which is the highest priority nursing instruction for this client to avoid further attacks of pancreatitis? "You may need a surgical consult for removal of your gallbladder." "See your health care provider (HCP) immediately when experiencing symptoms of a gallbladder attack." "If you have a gallbladder attack and pain does not resolve within a few days, call your health care provider." "You'll need to drastically modify your alcohol intake."

"See your health care provider (HCP) immediately when experiencing symptoms of a gallbladder attack." The highest priority nursing instruction for the client to avoid more attacks of pancreatitis is to report symptoms of gallbladder attacks immediately to the HCP.The client may not require removal of the gallbladder. That decision is made by the HCP. The client must see the provider promptly when experiencing gallbladder disease and should not wait. Because this client's acute pancreatitis is likely related to gallstones, alcohol consumption need not be restricted.

The nurse is caring for a client recently diagnosed with type 1 diabetes mellitus who has had an episode of acute pancreatitis. The client asks the nurse how he developed diabetes when the disease does not run in the family. What is the nurse's best response? "The diabetes could be related to your obesity." "Look online for general information about diabetes." "Do you consume alcohol on a frequent basis?" "Type 1 diabetes can occur when the pancreas is affected or destroyed by disease."

"Type 1 diabetes can occur when the pancreas is affected or destroyed by disease." The nurse's best response is to tell the client that type 1 diabetes can occur when the pancreas is affected or destroyed by disease. This is the only response that accurately describes the relationship of the client's diabetes to pancreatic destruction.Type 2, not type 1, diabetes is usually related to obesity. Telling the client to look online for information is inappropriate because some information available online is incorrect at best.Many factors could produce acute pancreatitis other than alcohol consumption.

A client has just been diagnosed with pancreatic cancer. The client's upset spouse tells the nurse that they have recently moved to the area, have no close relatives, and are not yet affiliated with a church. What is the nurse's best response? "Maybe you should find a support group to join." "Would you like me to contact the hospital chaplain for you?" "Do you want me to try to find a therapist for you?" "Do you have any friends whom you want me to call?"

"Would you like me to contact the hospital chaplain for you?" Suggesting to contact the hospital chaplain is the best and most appropriate response for the nurse to take when talking with the cancer client's spouse.Suggesting that the client find a support group does not assist the client and the family with the problem. It is inappropriate for the nurse to suggest that the client and the family need a therapist. The spouse has already told the nurse that they have recently moved to the area, so it is unlikely that they have already made close friends.

pancreatic pseudocyst

"sterile abscess" collection of pancreatic enzymes that accumulate in the available space in the abdomen (usually in or near the pancreas) -risk factors acute pancreatitis, abd trauma, chronic pancreatitis -can be palpated as epigastric mass primary sx is epigastric pain radiating to the back complication: hemorrhage, infection, bowel obstruction, abscess, fistula formation, pancreatic ascites --may spontaneously resolve -surgical intervention after 6 weeks

physical assessment and CM of cirrhosis

-because cirrhosis has a slow onset many early sx are vague and nonspecific assess for --fatigue --significant change in weight --GI sx such as anorexia and vomiting --abd pain and liver tenderness late signs of advanced cirrhosis (end stage liver failure) --GI bleeding --jaundice --ascites --spontaneous bruising indicate poor liver fx and complications of cirrhosis

5. A patient is admitted with hepatic encephalopathy secondary to cirrhosis. Which meal option selection below should be avoided with this patient? A. Beef tips and broccoli rabe B. Pasta noodles and bread C. Cucumber sandwich with a side of grapes D. Fresh salad with chopped water chestnuts

A. Beef tips and broccoli rabe The answer is A. Patients who are experiencing hepatic encephalopathy are having issues with toxin build up in the body, specifically ammonia. Remember that ammonia is the byproduct of protein breakdown, and normally the liver can take the ammonia from the protein breakdown and turn it into urea (but if the cirrhosis is severe enough this can't happen). Therefore, the patient should consume foods LOW in protein until the encephalopathy subsides. Option A is very high in protein while the others are low in protein. Remember meats, legumes, eggs, broccoli rabe, certain grains etc. are high in protein.

9. You're providing an in-service to new nurse graduates about esophageal varices in patients with cirrhosis. You ask the graduates to list activities that should be avoided by a patient with this condition. Which activities listed are correct: Select all that apply A. Excessive coughing B. Sleeping on the back C. Drinking juice D. Alcohol consumption E. Straining during a bowel movement F. Vomiting

A. Excessive coughing D. Alcohol consumption E. Straining during a bowel movement F. Vomit The answers are A, D, E, and F. Esophageal varices are dilated vessels that are connected from the throat to the stomach. They can become enlarged due to portal hypertension in cirrhosis and can rupture (this is a medical emergency). The patient should avoid activities that could rupture these vessels, such as excessive cough, vomiting, drinking alcohol, and constipation (straining increases thoracic pressure.)

8. While assisting a patient with chronic pancreatitis to the bathroom, you note the patient's stool to be oily/greasy in appearance. In your documentation you note this as:* A. Steatorrhea B. Melena C. Currant D. Hematochezia

A. Steatorrhea The answer is A. Steatorrhea is an oily/greasy appearance of the stool which can occur in chronic pancreatitis. This occurs due to the inability of the pancreas to produce digestive enzymes which help break down fats. Fats are not being broken down; therefore, it is being excreted into the stool. Melena is used to describe tarry/black stool, hematochezia is used to describe red stools, and currant are jelly type stools.

4. Your patient with cirrhosis has severe splenomegaly. As the nurse you will make it priority to monitor the patient for signs and symptoms of? Select all that apply: A. Thrombocytopenia B. Vision changes C. Increased PT/INR D. Leukopeni

A. Thrombocytopenia C. Increased PT/INR D. Leukopenia The answers are A, C, and D. A patient with an enlarged spleen (splenomegaly) due to cirrhosis can experience thrombocytopenia (low platelet count), increased PT/INR (means it takes the patient a long time to stop bleeding), and leukopenia (low white blood cells). The spleen stores platelets and WBCs. An enlarged spleen can develop due to portal hypertension, which causes the platelets and WBCs to become stuck inside the spleen due to the increased pressure in the hepatic vein (hence lowering the count and the body's access to these important cells for survival).

It is essential that the nurse monitor the client returning from hepatic artery embolization for hepatic cancer for which potential complication? Right shoulder pain Polyuria Bone marrow suppression Bleeding

Bleeding A potential complication of hepatic artery embolization for hepatic cancer is bleeding. Prompt detection of hemorrhage is the priority.Discomfort such as right shoulder pain may be present, but the priority is to assess for hemorrhage. The nurse must assess for signs of shock, not polyuria. Embolization does not suppress the bone marrow. If chemotherapy or immune modulators are used, the nurse then assesses for bone marrow suppression.

2. From the pancreas and gallbladder, the common bile duct and pancreatic duct open into the ____________ where digestive enzymes and bile flow into the duodenum via the major duodenal papilla which is surrounded by a muscular valve that controls the release of digestive enzymes known as the ______________.* A. ampulla of vater, sphincter of Oddi B. papilla of vater, sphincter of Oddi C. minor duodenal papilla, ampulla of vater D. jejunum, sphincter of pylori

A. ampulla of vater, sphincter of Oddi The answer is A. Digestive enzymes from the pancreas duct and bile from the common bile duct flow through the ampulla of vater (this is where the pancreatic duct and common bile duct form together) into the duodenum via the major duodenal papilla (also called the papilla of vater) which is surrounded by the sphincter of Oddi. This sphincter is a muscular valve that controls the release of digestive enzymes/bile and prevents reflux of stomach contents into the pancreas and bile duct.

lab assessment in cirrhosis

AST (aspartate aminotranferase) ALT (alanine aminotransferase) LDH (lactate dehydrogenase) alkaline phsphatase and GGT (gamma-glutamyl transpeptidase) serum protein, albuminn bilirubin

When assessing a client for hepatic cancer, the nurse anticipates finding an elevation in which laboratory test result? Hemoglobin and hematocrit Leukocytes Alpha-fetoprotein Serum albumin

Alpha-fetoprotein The nurse anticipates finding an elevation in the laboratory test for alpha-fetoprotein. Fetal hemoglobin (alpha-fetoprotein) is abnormal in adults, and is a tumor marker indicative of cancers.Although anemia may be present, elevated hemoglobin and hematocrit are not diagnostic of hepatic cancer. White blood cells (leukocytes) are not used to specifically diagnose cancers. Serum albumin levels may be low in liver cancer and in malnutrition.

When preparing a client to undergo paracentesis, which action is necessary to reduce potential injury as a result of the procedure? Encourage the client to take deep breaths and cough Ask the client to void prior to the procedure Position the client with the head of the bed flat Assist the physician to insert a trocar catheter into the abdomen

Ask the client to void prior to the procedure To avoid injury to the bladder during a paracentesis, the client would be asked to void prior to the procedure (Chart 58-1).Taking deep breaths and coughing does not prevent complications or injury as a result of paracentesis. Clients would be positioned with the head of the bed elevated. The trocar catheter is used to drain the ascetic fluid and does not reduce the risk of damage to the bladder.

Drug therapy for meningitis

Broad-spectrum antibiotic Hyperosmolar agents Anticonvulsants Steroids (controversial) Prophylaxis treatment for those in close contact with meningitis-infected patient (rifampin, cipro, rocephin)

7. You are receiving shift report on a patient with cirrhosis. The nurse tells you the patient's bilirubin levels are very high. Based on this, what assessment findings may you expect to find during your head-to-toe assessment? Select all that apply: A. Frothy light-colored urine B. Dark brown urine C. Yellowing of the sclera D. Dark brown stool E. Jaundice of the skin F. Bluish mucous membranes

B. Dark brown urine C. Yellowing of the sclera E. Jaundice of the skin The answers are B, C, and E. High bilirubin levels are because the hepatocytes are no longer able to properly conjugate the bilirubin because they are damaged. This causes bilirubin to leak into the blood and urine (rather than entering the bile and being excreted in the stool). Therefore, the bilirubin stays in the blood and will enter the urine. This will cause the patient to experience yellowing of the skin, sclera of the eyes, and mucous membranes ("jaundice") and have dark brown urine. The stools would be CLAY-COLORED not dark brown (remember bilirubin normally gives stool it brown color but it will be absent).

11. The physician orders Lactulose 30 mL by mouth per day for a patient with cirrhosis. What findings below demonstrates the medication is working effectively? Select all that apply: A. Decrease albumin levels B. Decrease in Fetor Hepaticus C. Patient is stuporous. D. Decreased ammonia blood level E. Presence of asterixis

B. Decrease in Fetor Hepaticus D. Decreased ammonia blood level The answer is B and D. A patient with cirrhosis may experience a complication called hepatic encephalopathy. This will cause the patient to become confused (they may enter into a coma), have pungent, musty smelling breath (fetor hepaticus), asterixis (involuntary flapping of the hands) etc. This is due to the buildup of ammonia in the blood, which affects the brain. Lactulose can be prescribed to help decrease the ammonia levels. Therefore, if the medication is working properly to decrease the level of ammonia the patient would have improving mental status (NOT stuporous), decreased ammonia blood level, decreasing or absence of asterixis, and decreased ammonia blood level.

6. Your patient with acute pancreatitis is scheduled for a test that will use a scope to assess the pancreas, bile ducts, and gallbladder. The patient asks you, "What is the name of the test I'm going for later today?" You tell the patient it is called:* A. MRCP B. ERCP C. CT scan of the abdomen D. EGD

B. ERCP The answer is B. ERCP (Endoscopic Retrograde Cholangio-Pancreatography) is used to diagnosis and sometimes treat the causes of pancreatitis. It will assess the pancreas, bile ducts, and gallbladder. In addition, the doctor may be able to remove gallstones, dilate the blocked ducts with a stent or balloon, drain presenting cysts etc.

10. While providing mouth care to a patient with late-stage cirrhosis, you note a pungent, sweet, musty smell to the breath. This is known as: A. Metallic Hepatico B. Fetor Hepaticus C. Hepaticoacidosis D. Asterixis

B. Fetor Hepaticus

2. The liver receives it blood supply from two sources. One of these sources is called the _________________, which is a vessel network that delivers blood _____________ in nutrients but ________ in oxygen. A. hepatic artery, low, high B. hepatic portal vein, high, low C. hepatic lobule, high, low D. hepatic vein, low, high

B. hepatic portal vein, high, low The answer is B. Majority of the blood flow to the liver comes from the hepatic portal vein. This vessel network delivers blood HIGH in nutrients (lipids, proteins, carbs etc.) from organs that aid in the digestion of food, but the blood is POOR in oxygen. The organs connected to the hepatic portal vein are: small/large intestine, pancreas, spleen, stomach. Rich oxygenated blood comes from the hepatic artery to the liver.

5. Which patient below is at MOST risk for CHRONIC pancreatitis?* A. A 25 year old female with a family history of gallstones. B. A 35 year old male who reports social drinking of alcohol. C. A 15 year old female with cystic fibrosis. D. A 66 year old female with stomach cancer.

C. A 15 year old female with cystic fibrosis. The answer is C. Patients in options A and B are at slight risk for ACUTE pancreatitis not chronic. Remember the main causes of ACUTE pancreatitis are gallstones and alcohol consumption. In option C, the patient with cystic fibrosis is at MAJOR risk for CHRONIC pancreatitis because they are lacking the protein CFTR which plays a role in the movement of chloride ions to help balance salt and water in the epithelial cells that line the ducts of the pancreas. There is a decreased production of bicarbonate secretion by the epithelial cells. Therefore, this leads to thick mucus in the pancreatic ducts that can lead to blockage of the pancreatic ducts which can cause the digestive enzymes to activate and damage the pancreas. Overtime, the pancreas will experience fibrosis of the pancreas' tissue and will no longer produce digestive enzyme to help with food digestion.

6. During your morning assessment of a patient with cirrhosis, you note the patient is disoriented to person and place. In addition while assessing the upper extremities, the patient's hands demonstrate a flapping motion. What lab result would explain these abnormal assessment findings? A. Decreased magnesium level B. Increased calcium level C. Increased ammonia level D. Increased creatinine level

C. Increased ammonia level The answer is C. Based on the assessment findings and the fact the patient has cirrhosis, the patient is experiencing hepatic encephalopathy. This is due to the buildup of toxins in the blood, specifically ammonia. The flapping motion of the hands is called "asterixis". Therefore, an increased ammonia level would confirm these abnormal assessment findings.

The RN has just received the change-of-shift report for the medical unit. Which client should the RN see first? Client with ascites who had a paracentesis 2 hours ago and is reporting a headache Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse Client with hepatic cirrhosis and jaundice who has hemoglobin of 10.9 g/dL (109 mmol/l) and thrombocytopenia Client with hepatitis A who has elevated alanine aminotransferase (ALT) and aspartate aminotransferase (AST)

Client with portal-systemic encephalopathy (PSE) who has become increasingly difficult to arouse The nurse would first see the client with PSE who is now difficult to arouse. A change in the level of consciousness (LOC) of the client with PSE is the greatest concern. Actions to improve the client's LOC must be rapidly implemented.Although uncomfortable, a headache in the client with ascites is not likely related to liver disease and does not pose an immediate threat or complication. A hemoglobin of 10.9 g/dL (109 mmol/L) and thrombocytopenia are expected findings in a client with cirrhosis and do not pose an immediate threat. Elevated ALT and AST levels are expected for the client with hepatitis A and do not indicate a risk for severe complications.

7. A patient is admitted to the ER with the following signs and symptoms: very painful mid-epigastric pain felt in the back, elevated glucose, fever, and vomiting. During the head-to-toe assessment, you notice bluish discoloration around the belly button. As the nurse, you know this is called?* A. Grey-Turner's Sign B. McBurney's Sign C. Homan's Sign D. Cullen's Sign

D. Cullen's Sign The answer is D. This is known as Cullen's Sign. It represents retroperitoneal bleeding from the leakage of digestive enzymes from the inflamed pancreas into the surrounding tissues which is causing bleeding and it is leaking down to umbilicus tissue. Remember the C in Cullen for "circle" and the belly button forms a circle. The patient can also have Grey-Turner's Sign which is a bluish discoloration at the flanks (side of the abdomen). Remember this by TURNER ("turn her" over on her side) which is where the bluish discoloration will be.

4. You're caring for a 45 year old patient who is admitted with suspected acute pancreatitis. The patient reports having extreme mid-epigastric pain that radiates to the back. The patient states the pain started last night after eating fast food. As the nurse, you know the two most common causes of acute pancreatitis are:* A. High cholesterol and alcohol abuse B. History of diabetes and smoking C. Pancreatic cancer and obesity D. Gallstones and alcohol abuse

D. Gallstones and alcohol abuse The answer is D. Main causes of acute pancreatitis are gallstones and alcohol consumption. Heavy, long-term alcohol abuse is the main cause of CHRONIC pancreatitis.

12. ________ reside in the liver and help remove bacteria, debris, and old red blood cells. A. Hepatocytes B. Langerhan cells C. Enterocytes D. Kupffer cells

D. Kupffer cells The answer is D. Kupffer cells perform this function and are one of the two types of cells found in the liver lobules (the functional units of the liver). These cells play a role in helping the hepatocytes turn parts of the old red blood cells into bilirubin.

When caring for a client with portal hypertension, the nurse assesses for which potential complications? Select all that apply. Esophageal varices Hematuria Fever Ascites Hemorrhoids

Esophageal varices Ascites Hemorrhoids Potential complications of portal hypertension include esophageal varices, ascites, and hemorrhoids. Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid).Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.

A client is scheduled to undergo a liver transplantation. Which nursing intervention is most likely to prevent the complications of bile leakage and abscess formation? Preventing hypotension Keeping the T-tube in a dependent position Administering antibiotic vaccinations Administering immune-suppressant drugs

Keeping the T-tube in a dependent position The nursing intervention most likely to prevent the complications of bile leakage and abscess formation is keeping the T-tube in a dependent position and secured to the client. This action will likely prevent bile leakage, abscess formation, and hepatic thrombosis.Preventing hypotension will help to prevent the complication of acute kidney injury. Administering antibiotic vaccinations will help to prevent infection. Administering immune-suppressant drugs will help to prevent graft rejection.

When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)? Kidney failure Refractory ascites Fetor hepaticus Paracentesis scheduled for today

Kidney failure The nurse would question the use of neomycin for a client with kidney failure. Aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and must not be taken by clients with hepatic encephalopathy.Cirrhosis and hepatic failure cause both ascites and encephalopathy; no contraindication for neomycin is known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels. The client may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.

A client who had been hospitalized with pancreatitis is being discharged with home health services. The client is severely weakened after this illness. Which nursing intervention is the highest priority in conserving the client's strength? Limiting the client's activities to one floor of the home Instructing the client to take an as-needed (PRN) sleeping medication at night Arranging for the client to have a nutritional consult to assess the client's diet Asking the health care provider for a request for PRN nasal oxygen

Limiting the client's activities to one floor of the home Limiting the client's activities to one floor of the home is the highest priority nursing intervention. This will prevent tiring the client unnecessarily with stair climbing.A PRN sleeping medication will not increase the client's strength level or conserve strength.Arranging for a nutritional consult or placing the client on PRN nasal oxygen will not necessarily result in an increase in the client's strength level or conserve strength. No information suggests that the client has any history of breathing difficulties.

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

Members of the household must not share toothbrushes. The nurse teaches the family of a client with Hepatitis C that toothbrushes, razors, towels, and any other items may spread blood and body fluids and must 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 needs to be avoided.

When providing community education, the nurse emphasizes that which group needs to receive immunization for hepatitis B? Clients who work with shellfish Men who engage in sex with men Clients traveling to a third-world country Clients with elevations of aspartate aminotransferase and alanine aminotransferase

Men who engage in sex with men 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.

Pancreatic abscess

Most serious complication of acute narcotizing pancreatitis Always fatal if untreated!! High fever Blood cultures Drainage via percutaneous method or laparoscopy Antibiotic treatment alone does not resolve abscess

When providing discharge teaching to a client with cirrhosis, it is essential for the nurse to emphasize avoidance of which of these? Vitamin K-containing products Potassium-sparing diuretics Nonabsorbable antibiotics Nonsteroidal anti-inflammatory drugs (NSAIDs)

Nonsteroidal anti-inflammatory drugs (NSAIDs) The nurse must emphasize avoidance of NSAIDs when providing discharge teaching to a client with cirrhosis. The client with cirrhosis has an increased risk of hemorrhage. Clients who have cirrhosis must not take NSAIDs because they may predispose to bleeding.Products containing vitamin K can decrease bleeding, so it is not necessary to restrict this in the diet. Potassium-sparing diuretics are used to reduce ascites. Nonabsorbable antibiotics are used to decrease ammonia levels.

A client with a history of esophageal varices has just been admitted to the emergency department after vomiting a large quantity of blood. Which action does the nurse take first? Obtain the charts from the previous admission. Listen for bowel sounds in all quadrants. Obtain pulse and blood pressure. Ask about abdominal pain.

Obtain pulse and blood pressure. When caring for a newly admitted client with esophageal varices and vomiting of blood, the nurse would first assess vital signs to detect hypovolemic shock caused by hemorrhage. Assessment for adequate perfusion is the highest priority at this time.Obtaining charts from the previous admission, assessing bowel sounds, and pain assessment can be delayed until the client has stabilized.

The RN is caring for a client with end-stage liver disease who has ascites. Which action does the RN delegate to unlicensed assistive personnel (UAP)? Assessing skin integrity and abdominal distention Drawing blood from a central venous line for electrolyte studies Evaluating laboratory study results for the presence of hypokalemia Placing the client in a semi-Fowler's position

Placing the client in a semi-Fowler's position The nurse delegates the client who needs to be placed in a semi-Fowler's position to the UAP. Positioning the client in this position is included within UAP education and scope of practice, although the RN will need to supervise the UAP in providing care and will evaluate the effect of the semi-Fowler's position on the client's comfort and breathing.Assessment of skin integrity and abdominal distention, obtaining blood from a central line, and evaluation of laboratory results must be done by the RN.

Which problem for a client with cirrhosis takes priority? Insufficient knowledge related to the prognosis of the disease process Discomfort related to the progression of the disease process Potential for injury related to hemorrhage Inadequate nutrition related to an inability to tolerate usual dietary intake

Potential for injury related to hemorrhage Potential for injury related to hemorrhage is the priority client problem because this complication could be life threatening.Insufficient knowledge of the prognosis of the disease process, discomfort, and inadequate nutrition are not priorities because these issues are not immediately life threatening.

Which set of assessment findings indicates to the nurse that a client may have acute pancreatitis? Absence of jaundice, pain of gradual onset Absence of jaundice, pain in right abdominal quadrant Presence of jaundice, pain worsening when sitting up Presence of jaundice, pain worsening when lying supine

Presence of jaundice, pain worsening when lying supine Pain that worsens when lying supine and the presence of jaundice are the only assessment findings indicative of acute pancreatitis.Pain associated with acute pancreatitis usually has an abrupt onset, is located in the mid-epigastric or upper left quadrant, and lessens with sitting up. Also, jaundice is present.

When caring for a client with Laennec's cirrhosis, which of these does the nurse expect to find on assessment? Select all that apply. Prolonged partial thromboplastin time Icterus of skin Swollen abdomen Elevated magnesium Currant jelly stool Elevated amylase level

Prolonged partial thromboplastin time Icterus of skin Swollen abdomen Clients with Laennec's cirrhosis have damaged clotting factors, so prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The client with cirrhosis may develop ascites, or fluid in the abdominal cavity.Elevated magnesium is not related to cirrhosis. Amylase is typically elevated in pancreatitis. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. The client with cirrhosis may develop hypocalcemia and/or hypokalemia. It is also consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase.

A client has been placed on enzyme replacement for treatment of chronic pancreatitis. In teaching the client about this therapy, the nurse advises the client not to mix enzyme preparations with foods containing which element? Carbohydrates High fat High fiber Protein

Protein The nurse tells the client not to mix enzyme preparations with foods containing protein because the enzymes will dissolve the food into a watery substance. Pancreatic-enzyme replacement therapy (PERT) is the standard of care to prevent malnutrition, malabsorption, and excessive weight loss (Chart 59-3). Pancrelipase is usually prescribed in capsule or tablet form and contains varying amounts of amylase, lipase, and protease.No evidence suggests that enzyme preparations should not be mixed with carbohydrates, food with high fat content, and food with high fiber content.

The nurse is assessing a client who has recurrent attacks of pancreatitis and is concerned about possible alcohol abuse as an underlying cause of these attacks. To elicit this information, what will the nurse do initially? Ask the client about binge drinking. Question the client whether drinking increases on weekends. Provide privacy and use the CAGE questionnaire (Cut down, Annoyed by criticism, Guilt about drinking, and Eye-opener drinks) Ask the client's spouse to describe the client's drinking

Provide privacy and use the CAGE questionnaire (Cut down, Annoyed by criticism, Guilt about drinking, and Eye-opener drinks) Initially, the nurse needs to provide privacy and establish a trusting relationship to help obtain information from the client about alcohol use. The CAGE questionnaire is useful as well.Topics such as binge drinking or tending to drink more on holidays or weekends may put the client on the defensive rather than provide the desired information. It has not yet been determined whether the client engages in binge drinking. Asking the client client's spouse will decrease nurse-client trust.

How does the home care nurse best modify the client's home environment to manage side effects of lactulose (Evalose)? Provides small frequent meals for the client Suggests taking daily potassium supplements Elevates the head of the bed in high-Fowler's position Requests a bedside commode for the client

Requests a bedside commode for the client The home care nurse best modifies the client's home environment to manage side effects of lactulose by making a bedside commode available to the client. Lactulose therapy increases the frequency of stools. A bedside commode is especially necessary if the client has difficulty reaching the toilet.Small frequent meals and elevating the head of the bed will not have any effect on the side effects of lactulose. Although lactulose produces excessive stools and could potentially result in loss of potassium, it is inappropriate for the nurse to suggest that the client take potassium supplements.

The nurse is attempting to position a client having an acute attack of pancreatitis in the most comfortable position possible. In which position does the nurse place this client? Supine, with a pillow supporting the abdomen Up in a chair between frequent periods of ambulation High-Fowler's position, with pillows used as needed Side-lying position, with knees drawn up to the chest

Side-lying position, with knees drawn up to the chest The side-lying position with the knees drawn up has been found to be the most comfortable possible position to relieve abdominal discomfort related to acute pancreatitis.No evidence suggests that supine position, sitting up in a chair, or high-Fowler's position has any effect on abdominal discomfort related to acute pancreatitis.

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

Tea-colored urine Right upper quadrant tenderness itching Assessment findings the nurse expects to find in a client with Hepatitis B include brown, tea-, or cola-colored urine, right upper quadrant pain due to inflammation of the liver, and itching, irritating skin caused by deposits of bilirubin on the skin secondary to high bilirubin levels and jaundice.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, and not typically brown.

Following paracentesis, during which 2500 mL of fluid was removed, which assessment finding is most important to communicate to the health care provider (HCP)? The dressing has a 2-cm area of serous drainage. The client's platelet count is 135,000/mm3 (135 × 109/L). The client's albumin level is 2.8 g/dL (28 g/L). The client's heart rate is 122 beats/min.

The client's heart rate is 122 beats/min. After a paracentesis with 2500 ml of fluid removed, the assessment finding of the client's heart rate is the most important finding to communicate to the HCP. Rapid removal of fluid may cause symptoms of shock, including tachycardia, and are especially associated with hypotension.A small amount of serous fluid may leak, so the dressing would be reinforced. Platelets will be checked before the procedure. These are slightly low, but this is not a cause for concern. An albumin level of 2.8 g/dL (28 g/L) is an expected finding for a client with cirrhosis and is not life threatening.

The nurse is caring for a client who has cirrhosis of the liver. The client has exhibited hand flapping and mental confusion for several weeks. Although the mental confusion is worsening, the client has stopped exhibiting hand flapping movements. How will the nurse interpret these findings? The client's symptoms are progressing and getting worse. The client's serum ammonia levels are decreasing. The client probably has a decrease in serum proteins. The client is showing signs of improvement.

The client's symptoms are progressing and getting worse. The nurse interprets these findings as an indication that the client's is getting worse. Clients with cirrhosis who exhibit asterixis or hand flapping, may eventually stop exhibiting this sign as they worsen. The fact that the client's mental confusion is worsening indicates that this is the case.Increased mental confusion is related to elevated, not decreased, ammonia levels, as well as other serum proteins. The client is worsening, not improving.

The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose? To aid in digestion of dairy products To reduce portal pressure To promote gastrointestinal (GI) excretion of ammonia To reduce the risk of GI bleeding

To promote gastrointestinal (GI) excretion of ammonia In a client with cirrhosis, the administration of lactulose reduces serum ammonia levels by causing the client to excrete ammonia through the GI tract.Lactase, not lactulose, is the enzyme that aids in the digestion of dairy products. The mechanism of action of lactulose is not to reduce portal pressure. Lactulose does not affect bleeding.

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

Turkey sandwich on wheat bread Turkey is an appropriate low-fat selection for this client. High fiber, from the wheat bread, also helps reduce the risk. Typically, diets high in fat, high in calories, low in fiber, and high in refined white carbohydrates place clients at higher risk for developing gallstones.Steak, French fries, fried chicken and mashed potatoes, and sausage are too fatty. Eggs are too high in cholesterol for a client with gallbladder disease.

The nurse is preparing to instruct a client with chronic pancreatitis who is to begin taking pancrelipase (Cotazym). Which instruction does the nurse include when teaching the client about this medication? Administer pancrelipase before taking an antacid. Chew tablets before swallowing. Take pancrelipase before meals. Wipe your lips after taking pancrelipase.

Wipe your lips after taking pancrelipase. The nurse will instruct the client to wipe the lips after taking pancrelipase. Pancrelipase is a pancreatic enzyme used for enzyme replacement for clients with chronic pancreatitis. To avoid skin irritation and breakdown from residual enzymes, the lips should be wiped.Pancrelipase should be administered after, and not before, antacids or histamine2 blockers are taken. It should not be chewed to minimize oral irritation and allow the drug to be released more slowly. It should be taken with meals and snacks, and not before, and followed with a glass of water.

After receiving change-of-shift report on these clients, which client does the nurse plan to assess first? Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min Adult client admitted with cholecystitis who is experiencing severe right upper quadrant abdominal pain Middle-aged client who has an elevated temperature after undergoing endoscopic retrograde cholangiopancreatography Older adult client who is receiving total parenteral nutrition after a Whipple procedure and has a glucose level of 235 mg/dL (13.1 mmol/L)

Young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min The nurse would first assess the young adult client with acute pancreatitis who is dyspneic and has a respiratory rate of 34 to 38 breaths/min. Airway and breathing are the two most important criteria the nurse will use to determine which client to assess first. The dyspneic client is at greatest risk for rapid deterioration and requires immediate assessment and intervention. Acute respiratory distress syndrome is a possible complication of acute pancreatitis.The client with cholecystitis and the client with an elevated temperature will require further assessment and intervention, but these are not medical emergencies requiring the nurse's immediate attention. The older adult client's glucose level will require intervention but, again, is not a medical emergency.

imaging assessment cirrhosis

abd xray CT, MRI Ultrasound arteriography EGD (esophagogastroduodenoscoy) ERCP (endoscopic retrograde cholangiopancreatography)

cirrhosis assessment

assess for exposure to alcohol, drugs, herbs, chemicals -determine if there has ever been a needle stick injury, tattoo placement, imprisonment or employment as healthcare worker, firefighter, or police officer, sexual orientation -inquire about family history of alcoholism and or liver disease -collect previous medical history

Cirrhosis

extensive, irreversible scarring of the liver, usually caused by a chronic reaction to hepatic inflammation and necrosis -develops slowly and has a progressive prolonged, destructive course resulting in end stage liver disease

CM of meningitis

fever, nuchal rigidity (neck stiffness), photophobia, phonophobia (noise sensitve), hA, myalgia (muscle aches), N/V confusion, alt mental. -a maculopapular rash is seen when the causative organism is an enterovirus. -a petechia rash is assoc with N.meningitidis meningitis classic nuchal rigidity and positive kernigs and brudzinskis signs traditionally used to dx meningitis, these findings occur in a small percentage of pts with definitive dx.

Meningitis

inflammation of the meninges specifically the pia mater and arachnoid -bacterial and viral organisms are most often responsible

Nutrition therapy for cirrhosis

low sodium diet initially to control fluid accumulation in abd cavity. vitamin supplements such as thiamine (due to alcohol withdrawal), folate and multivitamin typically added to IV fluids because liver cannot store vitamins

nursing care for chronic pancreatitis

manage pain, maintain sufficient nutrition, prevent recurrence Nonsurgical management: -drug therapy (opiods) -analgesic admin -enzyme replacement (pancrelipase) -insulin therapy -nutrition therapy

liver failure CM

obvious jaundice and scerae dry skin rashes petechiae ecchymoses warm and bright red palms of the hands vascular lesions with red center and radiating branches known as spider angiomas ascites peripheral dependent edema of ext and sacrum vitamin deficiency (especially A, D, E an K)