Obesity/ Diabetes/ Liver disease

Client edu for liver disease

-abstain from alcohol and engage in recovery program (think about how this is also the case for hepatitis) -help prevent further scarring and fibrosis of liver -allows healing -prevents irritation -help decrease risk of bleeding (think about how fill further cause esophageal varisces and will also cause splenomagaly) -prevents encephalopathy or kidney damage consult with provider prior to any***nsaids or otc DIET GUIDELINES: -high calorie, moderate fat diet -low sodium diet (if there is excessive fluid/ overload-less than 2g a day) low protein (if encephalopathy and ammonia is severely elevated) -small frequent well balanced nutritional meals (since beginning symptoms is anorexia, upper right tenderness, malaise, weight loss, etc) -nutritional supplements or shakes -replacement and admin of vitamins -fluid intake restrictions if sodium is low (less than 1,500) hepatic encephalopathy: unable to convert ammonia into urea which resuls in toxic form (agitation, then lethargy, then stupor and then coma) t/x with lactulose (help by excretion via the stool and usually taken with water-bm within 24-48 hours) -reductions in dietary protein are indicated****** ACTIONS: admin lactulose -admin neomycin if concerns about bacterial infection (only 2 weeks and watch for neuro manifestations-seizures, tremors, parathesia) -monitor labs (potassium, become hypkalemic since lactulose helps wtih bm and pulls out potassium) -assess for changes in oreination -report*** asterixis (flapping of hands which is early finding), fetor hepaticus is late finding (think about how pungeant breath) MEANS WORSENING**

PATIENT CENTERED CARE FOR CIRRHOSIS

-liver biopsy through jugular vein if suspect severe damage (most definitive) especially if clotting is greater than 3 -respiratory status: monitor 02 levels and distress (especially since ascites and fluid buildup can occur) -provide com-can be compromised by plasma colume excess and ascites) -have sit in chair or elevate hob w/ feet elevated (think about how helps produce some venous return back up to the heart) skin integrity: monitor for breakdown (think about how swelling occurs in the legs), pruruitus can occur (associated w/ jaundice and why those with hepatitis have it too), will cause the client to scrath -wash with cold water and apply lotion to decrease itching**, also pat instead of rub, avoid extreme temperatures, wear cotton, use warm not hot water, reduce time in the bathtub or shower, maintain cool/ normal room temperature fluid balance: monitor for indications of fluid volume excess (r/t right sided hf, ascites, poor osmotic pressure) -fluids less than 1,500 -daily weights -and assess ascites and peripheral edema -restrict sodium (less than 2g) vs: pain level -monitor liver enzymes (ast is 0-36, alt is 4-35 and alp is 30-120)-usually not found in hepatitis but elevates during periods of inflammation and declines when no longer can inflame anymore (not the greatest indicator) vs and pain level: can cause pulm htn due to shunting, bounding pulse and dysrhtyhmias nutritional status: high-carb, high-protein (unless presence of encephalopathy, then have to be very careful), moderate-fat and low-sodium w/ vitamin supp (b12, thiamine, folate, a, e, d and k) gi status: maeasure girth daily -mark location for consistency pain: admin analgesics (think need to be cautious about dosage due to difficulty of excreting-especially opioids, sedatives and barbituates) -want to avoid nsaids, ibuprofen, tyleonol, aspirin (think about how th epatient with liver disease only had opiods on board, no otc meds)

Education for hepatitis

-screening is necessary if pregnant or planning to be if positive with the hbv antigen, need to abstain from kissing and sex until negative -incubation period is 2-12 weeks (usually takes 2 months to 6 months to heal and reach last stage of recovery) Other risk factors for contracting hep b and c: if partners test positive, if someone in houshold -have had unsafe sex practices with many partners -have had sex w/ someone with hep b, gay, h/x of sexually transmitted illnes have hiv or hep c (think about how hiv or long-term dialysis is risk factor for hep c) -have liver enzyme test w/ abnormal results -kidney dialysis (hep c) -take meds to suppress immune for organ transplant (hep c) -blood donation after 1992 (hep c) -kidney dialysis -illicit drugs both hep b and c -in prison TREATMENT AFTER EXPOSURE: if have been exposed, contracted one or demonstrate acute symptoms (call provider immediately) -KNOW WHETHER OR NOT IF YOU ARE VACCINATED AND WHEN EXPOSED/ WHAT EXPOSURE (IV USE, UNSAFE SEX, ILLICIT DRUG USE, ETC) -injection of immunoglobulin is given within 24hrs of exposure to virus -only provides short temr protectino (given hep b vaccine at the same time****): AT RISK RESCIEVE X3 WITHIN 6 MONTHS treatment for acute hep b infection: -short lived and goes away on its own by month 2 usually (2-12 weeks) -MAY NOT REQUIRE T/X -MIGHT RECOMMEND REST (TO RELIEVE THE LIVER), PROPER NUTRITION, PLENTY OF FLUIDS AND CLOSE MONITORING WHILE BODY FIGHTS -SEVER CASES WHERE PROGRESSES TO CHRONIC (onset of jaundice, fatigue, right upper quadrant pain, fatigue and malaise, severe weight loss-early signs of liver disease and need to treat promptly) w/ supportive therapy for lifelong management -interferons and antiviral medications -liver transplantation if failure occurs CHRONIC: NEED TREATMENT FOR THE REST OF THEIR LIVES (DECISION DEPENDS ON MANY FACTORS: IF VIRUS IS CAUSING INFLAMMATION OR SCARRING THE LIVER/ cirrhosis--identified early with right upper quardant pain, malaise, weight loss, and may have elevated alt (0-35 if getting into chronic, ast-0-35 and alp 30-120) and elevated bilirubin (0.3-1.2?) -with chronic: if have other infections such as hep c or hiv (think c is far more severe and harder to combat due to absence of immunogolbulins and hiv-means immunocompromised and often comes with hep c infection) this kind requires: antiviral medications or interferon injections: interferon alfa is verion to help the body fight the infection (mainly for young people with hep b who wish to aovid long-term t/x or women who want to get pregnant (think they dont want this chronic hep b problem to interfere with later life since young or if wanting to get pregnant) should not be used during pregnancy: can cause n/v, difficulty breathing (interferes with breathing) and depression

CLIENT EDUCATION FOLLOWING BERIATRIC SURGERY

1. NOTIFY IF EXPERIENCE: oliguria (less than 30mL/hr, tachycardia, agitation, back/ shoulder and stomach pain following surgery (life threatening and sign of fluid leakage from intestinal vessels) 2. six small meals a day, fluid of 30mL at a time up to 120mL a day 3. do not move ng tube 4. adhere to limited diet of liquids or pureed foods for first 6 weeks (think smaller in size compared with food and doesnt require as much bowel motility)--DO NOT EXCEED A CUP (SINCE VOLUME IS EITHER 15-20 OR 20-30 OR 85% OF STOMACH IS LOST) -WALK DAILY FOR 30 MINS (other means of weight reductoin) -overeating can dilate the surgically created pouch (which is why no more than 1 cup a day for 6 weeks) -take vitamin and mineral supplements (especially b12, thiamine, folate and iron**)

diagnosisfor obesity and priotization

COMPLICATIONS OF OBESITY: cardiovascular problems: arteriosclerosis/ hypercholesterolemia, heart failure (pushing against increased resistance within the bloodstream), hypertension (due to increased resistance from fatty plaques) -stroke -dvt -vericosities (think vericose veins can occur due to fatty plaques, not as able to constrict and dilate=risk for clots, risk for thrombus and risk for stroke or hf or mi) ENDOCRINE: endometrial cancer (due to response with estrogen, usually obesity increases estrogen levels--THINK ABOUT HOW MEN ARE MORE PRONE TO HAVING LARGER WAIST-GREATER THAN 40 BUT WOMEN POST MENOPAUSE OR MORE PRONE TO HAVING THIS PROBLEM WHICH CAN ALSO CAUSE ENDOMETRIAL CANCER TYPE 2 DIABETES (due to hyperinsulimia (more of a upper body problem) GI: can cause constipation -colon cancer (insulin resistance, hyperinsulinemia and chronic inflammation from gerd etc can increase risk for cancer)--think about how insulin impairment results, thyroid hormones altered and leptin changes -gallstones (due to increased fatty lipids--think about how gallstones are a risk factor for common bile duct occlusion and injury to the pancreas=further causing diabetes for them and fat intolerance and risk for infection) -hieatal hernia (think so much abdominal pressure, ends up pushing on the hietus and results in hernia--this further causes gerd: mi type symptoms-pain in jaw, neck and back, hurts swallowing-relieved with lidocaine solution, can vomit up blood due to ulcerations of esophagus, frequency about 4-5 xs a week) genitourinary: -CANCERS OF BREAST, UTERUS AND PROSTATE (due to increase in estrogen that often occurs) -stress incontinence (increaes abdominal pressure which pushes on bladder, also think about how this relates to gerd as well) musculoskeletal: low back pain (think increase in breast tissue and upper body mass), joint pain (due to weight on the bones that causes degeneration--not enough muscle to counteract that), muscle strains/ sprains (think about how not enough muscel strength to support back, bones and other locatons) -osteoarthritis reproduction: cancers of uterus, breast tissue and other reproductiv tissues can cause complications of pregnancy, decreased sperm (due to prostate issues) and polysystic overy (due to development of endometrium from estrogen alterations) resp: sleep apnea (also a risk factor for gerd) and why shouldnt eat 2hrs before bed -depression, bing eating and post op complications (due to sleep apnea-remmeber osa precautions with clients when giivng sedation) obesity increases risk for dvt, vericose veins, stroke, heart failure or mi -increaes risk for endometrial cancer, for prostate cancer, for breast/ ovarian and other reproductive cancers -increased risk for fatty liver disease, for obstructive sleep apnea -for colon cancer (due to hyperinsulinemia, changes in hormones and gered0 -hietal hernia which can further negate gerd -diabetes mellitus type 2, gallbladder disease/ gallstone formation -htn -back pain/ bone pain/ osteoarthritis/ muscle sprains risk for perioperative complications and labor complications (difficulty with sedatives especially) -want h.o.b at 15-30 for these patients reduced life expectancy due to all of these comorbidities class 1 obesity: which is 30-34.9 bmi and high waist to hip circumference (0.8 for females and 0.95 for males, for upper greater than 1 or 0.8 and lower less than 0.8 -expectancy is reduced by 2-4 years bmi of 40-50 (requires bariatric surgery) is 8-10 (think you are decades behind my friend in when to stop eating) other complications: nonalcholic fatty liver disease, polycystic ovary synrome, gastroesophageal reflux disease (due to hietal hernia and osa)

pharmacological t/x options for obesity

Orlistat: think oral and stat of lipids (prevent digestion of fats) phentermine: suppresses appetite and induces and induces a feeling of satiety (think phinally dtermines satiety since leptin can no longer do that nor does the hypothalmus) adverse: dry mouth (THINK SUPRESSES HYDRATION, CONSTIPATINO-CREATES FEELING OF FULLNESS W/ FECAL IMPACTION, NAUSEA-TRYING TO ESTABLISH SOME UNPLEASANT FEELING -CHANGE IN TASTE (ANOTHER ESTABLISHMENT OF UNPLEASANT FEELING), INSOMNIA (waking up hungry), numbness and tingling contraindications: hyperthyroidism, taking mao inhibiter and glaucoma (THINK HYPERTHRYOID DOESNT RESPOND WELL TO THESE THINGS AND THYROID LEVELS ARE ALREADY BIZARRE)

Medications you would expect to be prescribed for someone w/ liver disease

lactulose: promote excretion of ammonia from the body through the stool (think lactate is a waste product, so u lose, alright time for you to lose that waste product ammonia--prevents encephalopathy) a. used to t/x chronic constipation (think about how early signs of cirrhosis includes diarrhea and constipatoin which will aid with that) -help prevent encephalopathy by removing ammonia through the stool (hitting two birds with one stone) SHOULD PRODUCE A BOWEL MOVEMENT WITHIN 24-48 HOURS (THINK USUALLY TAKES A DAY AFTER EATING TO HAVE A BM) SIDE EFFECTS: BLOATING/ GAS (THINK CONSTIPATED, SLOWED MOTILITY NOW TOLD TO MOVE FASTER WHICH CAN RESULT IN BLOATING/ GAS) -STOMACH PAIN (DUE TO MOTILITY) AND DIARRHEA OR N/V call the doctor if have severe diarrhea*** that is prolonged (think bm in 24-48hrs buts shouldn't be persistent for that long) neomycin: neomycin (think my o my thats a lot of bacteria causing buildup of ammonia. provide this to reduce the amount of ammonia forming bacterium in the liver) -think about how with liver disease at increased risk for septicemia due to reduced spleen function and lack of wbcs) -prevents bacterial infection in the intestines and reduce hapatic coma by helping with excretion of ammonia THINK ABOUT HOW A LOT OF ANTIBIOTICS CAN CAUSE TINNITUS -DO NOT TAKE IF HAVE BLOCKAGE IN INTESTINES (THINK ABOUT HOW LACTULOSE HELPS WITH CONSTIPATION TOO) -never take for longer than 2 weeks or risk for hearing loss**** NEVER SKIP DOSES OR CAN BECOME RESISTANT (LIKE ANTIVIRALS), DRINK PLENTY OF WATER (HELP WITH EXCRETION AND HELPS WITH LOOSER STOOL) -HEPATIC COMA: taken for only 5-6 days -avoid eating foods high in protein (why? think about how when ammonia levels are high, waste product of protein breakdown which should not have protein in this case) -USUALLY PROTEIN RESTRICTION IS NOT AS COMMON IS MALNUROUISHED (plant protein is preferred-think stmming away from bad cholesterol) WHEN ENCEPHALOPATHY RESOLVES, CAN HAVE DIET WITH PROTEIN (THINK want to give some of these medications prior to giving them protein) -tpn if unable to digest SIDE EFFECTS: numbness or tingling (think neomycin is being nice and reducing pain sensation), tinnitus, muscle twitching/ seizures (think although removing brain quite not ready=seizures) -kidney problems (swelling/ urinating less, feeling tired and sob) WHY THIS MED IS ONLY GIVEN FOR 2 WEEKS MAXIMUM BECAUSE REPROCUSSION OF KIDNEY PROBLEMS AND NEURO MANIFESTATIONS (SEIZURES AND OLIGURIA/ SOB) WILL BE A POOR OUTCOME -call the doctor if they have these**** because do not want them to seize, sustain resp injury due to aki, have hearing loss, or parethesia or oliguria) common: n/v and diarrhea (like lactulose because removing excess ammonia) -do not want persistent diarrhea though nadolol: beta blocker (used for clients who have varices to prevnet bleeding) -think about how shunting of blood results in -slows heart rate which decreases force of contraction and helps with t/x of esophageal varices*** -watch for bradycardia, hypotension -WATCH FOR DIZZINESS (ESPECIALLY SINCE ASCITES IS OCCURING, OFTEN WITH FLUID RESTRICTIONS TO LESS THAN 1500L/DAY AND SODIUM LESS TAHN 2G AND POTENTIAL CONSTIPATION OR PROLONGED URINATION) -also often taking diuretics so relaly watch for this -WITHHOLD WITH LOW HR OR BP OR HYPOGLYCEMIA (can delay feeling of low blood sugar, think about how liver cannot release/ break down glycogen which results in hypoglycemia and why need to be cognizant of this) calcium carbonate oazepam: since one of the major risk factors (high risk behaviors) is alcohol abuse want to give them oxazepam to reduce anxiety and t/x alcohol withdrawal which can cause delerium tremens if persists) -s/sx: can cause severe drowsiness, light headed feeling, changes in mood, confusion/ memory or paranoia (think about how brian is suspecting something is altering its functioning) -tremors or slurred speech (appears like a stroke) or seizure (NOTIFY THE DOCTOR IF THEY DISPLAY THESE SYMPTOMS: TREMORS OR SLURRED SPEECH, STUPOR, PARANOIA, UNUSUAL CHANGES IN BEHAVIOR OR SEVERE DROWSINESS) iodine

Lab tests you would expect to be ordered for someone with liver disease and expected findings

want to look at alp, ast and other liver enzymes (elevated initially**) -ldh, alt and ast are elevated due to hepatic inflammation (think lactate is a waste product) alt and ast return to normal when liver cells are no longer able to create an inflammatory response (think thats when it enters nodules and decrease in size) -ALP INCREAES DUE TO CIRRHOSIS AND DUE TO INTRAHEPATIC BILIARY OBSTRUCTION (THINK BILIARY OBSTRUCTION IS YELLING hALP, IM STUCK) which causes elevation ALT (these levels halt when no longer can produce inflammatory response); 4-36 u/l ast: 0-35 (think 35 year olds should not have liver disease but many women develop with alcoholism faster so i guess 35-36 is feasible) alp: 30-120 (think this one is yelling halp when biliary duct is obstructed so elevated more) BILIRUBIN: WOULD BE ELEVATE BECAUSE CANNOT PROPERLY EXCRETE THIS IN BILE DUCTS -unconjucaged is 0.2-0.8 total bilirubin is 0.3-1.0 (think different from enzymes which are crazy high, alt being 4-36, alp 30-120 and ast (think not as fast as alp which is 0-35) BLOOD PROTEIN: decreased due to lack of synthesis hence why hydrostatic pressure is not maintained and why ascites occurs blooda lbumin decreaed hematocrit: rbc: decreased hemoglobin: decreased hematocrit: decreased and platelet is decreased (ALL RELATE TO SPLENOMEGALY) PT/INR: DECREASED AMMONIA: increased (this results in agitation, then lethargy, then stupor and then coma) -will see liver flap (flapping of hands) and parethesia as consequence blood creatinine: elevated due to potential kidney injury r/t shunting of blood USUALLY LIVER ENZYMES ARE NOT ELEVATED WITH ACUTE HEPATITIS (ONLY WITH CIRRHOSIS) ultrasound: used to detect ascites, hepatomegaly and plenomegaly (think can visualize structures this way) -ct scans: visualize hepatomegaly, ascitse and splenomegaly mri: mass lesions LIVER BIOPSY: MAY NOT ALWAYS BE NECESSARY (BUT USUALLY DONE IF BLEEDING TIME IS MORE THAN 3 SECONDS) -perform bipsy through the jugular vein to minimize hemorrhage MOST DEFINITIVE WAY TO KNOW THE EXTENT OF DAMAGE (done through the jugular vein-think after getting the diagnosis of liver disease progression, person goes oh man you hit me in the jugular) -can get other tests like alp (usually 30-120), ast (0-35) and alt which is (4-36) and are helpful for cirrhosis but not for acute hepatitis and usually DO NOT SHOW EXTENT OF DAMAGE TO THE LIVER -THE BEST WAY TO KNOW EXTENT AND IF BLEEDING TIME IS GREATER THAN 3 SECONDS (RELATING TO POOR VITAMIN K LEVELS AN DPLATLETS, WILL DO THIS THORUGH JUGULAR TO DETERMINE EXTENT) -bilirubin is also gathered (usually elevated w/ severe cirrhosis) unconj: 0.2-0l8 and total (will be greater 0.3-0.8) ultrasounds may be done: this visualizes all the organs and if swelling and detects ascites (remember when the lady did that for parasentesis) esophagogastroduodenoscopy (remember how this is used for gerd because helps visualize patency of everything and for ulcerations) -pH is the best way to know

Complications that result from splenomegaly

due to hepatic portal hypertension, the blood is shunted into other places (the rectum, abdomen and esophagus resulting in ascites and esophageal varisces) -the spleen can also be occluded (due to shunting in the splenic vein) which results in a large decrease blood products and rapid destruction (this leads to poor wbcs count, increased chance of infection, immunocompromised, poor clotting and reduced rbcs)

CIRRHOSIS-SPLENOMEGALY CONSIDERATIONS

establish isolation techniques for enteric and resp infections (effective hand washing) -abcd are through blood/ blood products; needle punctures, open wounds and contact with saliva, urine, stool and semen -think isolation is usually 2-14 weeks -monitor visitors (understand safegoard themselves and others can lessen feelings of isolatin and stigmatizaton -may last 2-3 weeks from onset of illness (THINK USUALLY AFTER 5-10 DAYS INTERIC PHASE OCCURS WHICH DOESN'T ENCROACH ON RECOVERY UNTIL 2-3 WEEKS -give info regarding gamma globulin isg, hb vaccine (both are needed after exposure) antiviral: chronic active hepatitis interferon: for women planning to be pregnant or young adults and treats crhonic or hep c

Convalescent phase:

occurs within 2-3 weeks of acute illness (when the incubation period is and usually requires contact and isolation precautions--EPSEICALLY IF INCONTINENT OF STOOL) -USUALLY DISAPPEARANCE OF ABDOMINAL PAIN IN UPPER RIGHT QUADRANT, IMPROVMEENT IN APPETIE AND DECREASED LEVELS OF JUANDICE (MAY TAKE UP TO 6 MONTHS WHICH IS WHY SHOULD AVOID ALCOHOL OR OTHER HEPATIC TOXIC SUBSTANCES)

Treatment for hepatitis B

Hepatitis B: most commonly transmitted by body fluids -transmission route: is most commonly through intercourse and intravenous drug use** and through pregnancy (passed from the mother to the baby) -spread via the birthing process if mother is hep b positive DIAGNOSTICS FOR HEPATITIS B: HBSAG: this is presence of the antigen-detected 2 weeks after exposure and 1 week before (think about how want to know immediately and usually prodromal stage is when they experience the acute phase of the disease: fever, bone pain, jaundice, malaise anf fatigue, pruritus (skin itchiness), abdominal pain (in right upper quadrant) or epigastrium area, anorexia, n/v and myalagia/ arthralgia -shows infetious (education: WHEN POSITIVE WITH THIS WHICH APPEARS 2 WEEKS AFTER EXPOSURE, AVOID SEXUAL INTERCOURSE AND INTAMICY LIKE KISSING UNTIL ITS NEGATIVE) treatment: none (just supportive therapy including rest, nurtition-since often anorexia and vomiting which causes body to lose all electrolytes fluid and liver unable to break down nutrients=hypoglycemia, inability to breakdown fats, buildup of ammonia if it progresses) etc PREVENTION: handwashing, vaccine for all infants (3-4 doses over 6-18 months) and healthcare workers (3 doses over 6 months) -sharp precautions, pregnant women tested if pregnant or planning to (post exposure hepatitis b immune globulin within 24hrs of exposure or 12 hours after birth) Deficient fluid volume: r/t nausea/ vomiting and fever -can cause third spacing (think about how when gets inflamed, shunts it to other areas like the rectum, the stomach and the esophagus which can casue vasricses) -causes altered clotting due to poor release of vitamin k 1. monitor i and o (compare w/ periodic weight) -note diarrhea or vomiting -diarrhea may relate to flu or problem with portal flow (causing gi congestion and constipation or diarrhea)--MAY REQUIRE NEOMYCIN WHICH REDUCES CHANCE OF INFECTON BUT PRECAUTIONS WITH _____ AND LACTULOSE WHICH AIDS IN CONSTIPATON AND REDUCES SERUM AMMONIA -ASSESS VS, PULSES, CAP REFILL AND TURGOR (indicates dehydration and hypovolemic crisi) -check for ascites and edema (this is progressing into the icteric phase where jaundice appears or chronic phase (common with hep c) -use small guage needles for injections (think about increased risk for bleeding) -use cotton swabs (due to increased risk for bleeding due to splenomegaly) -observe for bleeding (hematuria, melena, ecchymosis and oozing--all signs of spelnomeglay: pt are reduced-think greater than 3 usually is liver biopsy which is best way to determine liver disease and progression-vitamin k is altered) monitor albumin levels (can decrease which changes location of flids\ =proide iv fluids in acute toxic state (think want to rid of aamonia and why supportive therapy for acute: is nutrition since highest risk factor at this moment in time along with vitamin supplements and avoidance of toxic AVOID OTC MEDICATIONS LIKE AMINOPHEN, ASPIRIN AND IBUPROFEN FATIGUE: 1. ENSURE BED REST OR CHAIR REST druing toxic state (think about high levels of pneumonia can cause lethargy, decreased metabolic energy, altered body chem) 1. promote rest and relaxation (activity and upright belieed to decrease hepatic blood flow which prevents circulaton- 2. frequently change positions (instruct good skin care): promotes optimal resp function and minimizes pressure areas to reduce tissue breakdown--think abotu wnat to elevate legs because often with cirrhosis experience drainage in the legs -determine and prioritze role responsibilities -energy conserving techniques: sitting to shower and brush teeth, planning steps of activity -rom exercises durin gbed rest -MONITOR FOR RECURRENCE OF ANOREXIA: INDICATES LACK OF RESOLUTION AND EXACERBATION OF DISEASE AMDIN ANTIDOTE/ LEVAGE IF TOXIC HEPATIITIS IS OCCURING

Later stages/ complications of portal htn

-asterixis is early symptom of hepatic encephalopathy due to inability to convert ammonia into urea -fetro heapticus: very fowl, sweet and pungeant smell of the breath (due to buildup of toxins and usuallly bypassed to the lungs) -esophageal varisces (swelling which increases risk for massive hemorrhage due to thin-walled swelling0 -jaundice -loss of appetite (very beginning along wtih malaise, diarrhea/ constipation, right upper quadrant weakness), and diarrhea or constipation consequence of spleenomegaly: reduced platelets and wbcs -low platelets and wbcs which increases risk for infection encephalopathy: results in confusion, coma with high toxin level -can cause beginning which is agitation (brain is agitated there are toxins in the brain, lethargy--getting tired of being agitated-stupor which is losing function and then coma) -parethesias -sensory disturbances -and liver flap which results in flapping hands hematologic due to splenomegaly: decreased clotting factors, increased risk for hemorrhage, anemia and dic (think about how poor immune function, ascites is occuring and bacteria can enter in blood vessels and cause sepsis=dic)

Nursing care/ diagnoses priorities with obesity

1. los fowlers position to maximize chest expansion 15-30 (think allows both abdomen and chest to be in equilibrium) 2. monitor respiratory status frequently w/ pulse ox (remember how client with osa had to have pulse ox, usually positive pressure because had apnea)-lots of fat obstructing the airway 3. supplemental o2 as needed 4. monitor bp (since risk for hf due to narrowing of arteries, watch for dvt especially when bed bound, watch for symptoms of a stroke) 5. monitor for medication adverse efects -use bariatric equipment edu:follow prescribed diet

Treatment for acute versus chronic hepatitis

Acute hepatitis: no pharmacological treatment is necessary at the moment -is considered the prodromal phase after 2 weeks of exposure EXPERIENCE: -anorexia, n/v, reduced peristalsis and bile stasis (think about how liver can be inflamed -abdominal pain and cramping due to development of ascites -loss of weight and poor muscle tone -presence of hbeAG indicates high degree of hbv infection, hbsag indicates that antigen is there -need to be incubated (about 2-and 12 weeks) -think about how can last as long as 2 moths or six months 1. nutrition: monitor ditary intake and caloric count (several small feedings and largest meal at breakfast-similar to many other malabsorption disorders): anorexia may worsen during the day which is why in the morning is the best time 2. encourage mouth care before meals (stimulates appetie, like in chemotherapy treatments) 3. eating upright (think about gastric bypass too, want to sit upright for 30 mniutes) 4. intake of fruit juices, carbonated beverages and hard candy (supply extra calories)-hard candy helps with appetite and need high sugar to help with healing -AOVID ALCOHOL AND DIET DRINKS (THINK ABOUT WHY JUST SODA OR JUICE BECAUSE ADDS TO GI DISTRESS) -consult dietition with nutritional needs: fat metabolism varies and usually require fat restriction--think about how its the case for liver disease as well and also need caution when providing protein when ammonia levels are hihg -protein may help if ammonia levels are normal, but will need to not if sever liver disease (can potentiate hepatic encephalopathy) Monitor serum glucose as indicated (hyperglycemia or hypoglycemia may develop--may require insulin since usually glycogen isnt properly released or broken down)

diagnostic lab criteria for obesity

BMI measurements compare weight to ehigh to estimat the effect of individual's body weight -for client sw/ large muscle will have highe rbmi bmi should be between 18.5-24.9 Obesity: is considered a BMI greater than or equal to 30 (think about when obesity occurs, increased risk for GERD due to increaed abdominal pressure and increased risk for cirrhosis due to excessive triglycerides) USUALLY WAIST TO HIP RATIO IS MOST IMPACTFUL UPPER BODY WITH GREATER THAN 1IN IN MEN OR 0.8 IN WOMEN EXPLAINS OBESE and risk for heart disease, htn, hyperlipidemia, hyperinsulinemia and other complicatoins Lower body ratio: less than 0.95 or 0.8 for men and women which is harder to treat and risks of htn, cad and hyperinsulinemia is less likely but harder to treat other labs: screening for cad, diabetes (due to alterations in insulin) fatty liver disease (think about how elevated triglycerides and obesity increases risk for cirrhosis and obstruction of bile ducts which causes inflammation and necrosis

surgical t/x for obesity

Bariatric surgery: treatment for obesity when other weight control methods have failed (diet, exercise and behavioral medication along with pharmacotherpay mainly when brink on diagnosis of obesity bmi of 30 or diagnostic of less than 0.8 for leg and greater than 0.8 or 1 for upper waist ratio -can use pharmacological medication for weight loss prior to surgery orlistat: prevents digestion of fats -can have oily discharge, reduced food and vitamin absorption and decreased bile flow (due to reduced action of bile) phentermine: supresses appetite and feeling of satiety -can cause dry mouth, constipation, nausea, insomnia, change in taste (other alteration to aid in not wanting to eat) and numbness or tingling CONTRAINDICATED: HYPERTHRYOIDISM, GLAUCOMA OR MAO INHIBIOTR (think acts on brain and usually dont want to take with mao) RESTRICTIEVE SURGERIES: via laparascope (similar to procedures for babies that use the laparoscope to help open the pyloric sphincter( to reduce the stomach volume capacity (limits amount of food the client can eat at one time) -GASTRIC BYPASS BASICALLY -wieght loss is often regained after a period of time LAGB: think band for lagb involves adjustable band at the proximal portion of the stomach to restric stomach volume to 10-15mL LSG: think s for taking a section off removes portion of the stomach that secretes ghrelin (hunger hormone) up to 85% of stomach is removed (different from the lagb where 10-15mL of stomach volume remaining vertical banded gastroplasty: involves creation of a new smaller stomach puch using staples (think should staple vertically, looks better) malabsorption surgeries: or gastric bypass (kind of like the lagb where removes 85% of the stomach and ghrelin stimulating hormones to reduce hunger or hagb which places a band to have only remaining volume of 10-15L -interfere w/ absorption of food and nutrients from gi tract -some maintain 60-70% weight loss even 20 years postprocedure (since bascially removing 85% of its function -restrict volume to 20-30mL (which is more than the lagb which is 10-15)-stomach lag in volume -section of jejunum isanastomed to smaller section of stomach bypassing majority of stomach and duodenmum (which is where majority of nutrients are absorbed INDICATIONS FOR BARIATRIC SURGERY (BYPASS WHERE 60-70% OF WEIGHT LOSS IS SUSTAINED AND 20-30ML OF VOLUME REMAINING AND PLACED TO JEJUNEM RATHER THAN DUODENUM) A. bmi greater than 40 (usually 30 or greater is pharmacological t/x with __ and ___ whcih cannot be taken if have hyperthyroidism, glaucoma and ___ or greater than 35 with comorbidities (hf, mi, dvt, stroke, colon cancer, reproductive cancer, diabetes type 2, etc) PREPROCEDURE: 1. encourage to express emotions about eating behaviors and desires to lose weight (think about how want to personalize visit first) 2. ensure that client understand needed diet and lifestyle changes (otherwise will not work) 3. arrange for bariatric bed and mechanical lifts (above 35 usually requires bariatric lift) 4. assess with pertinent lab results (cbc, electrolytes--since usually experience less absorption especially with bypass that is attached to jejunum with only 20-30ml residual volume and not attached to duodenum=risk for malapbsorption of iron, vitamin b12, thiamine and folate think about how those with liver disease are also deficient in thiamin, folate and iron and of b12) apply scd and stockings to prevent dvt (since hyperlipidemia) POST PROCEDURE: 1. MONITOR FOR LEAK OF ANASTOMOSIS--leak of vessels adjacent or apart of teh intestine (INCREASED BACK pain--think about how occurs with other disorders like pancreatitis, shoulder pain, abdominal pain, restlessness, tachycardia since fluid is cmopressing in abdomen and in shoulder which is near heart, oliguria--think no longer perfusing to kidneys as well) NOTIFY PROVIDER IMMEDIATELY-LIFE THREATENING (THINK ITS CAUSING OLIGURIA WHICH MEANS POOR PERFUSION, TACHYCARDIA WHICH ALSO MENAS POOR PERFUSION, BACK/ SHOULDRE AND ABDOMINAL PAIN CAN INDICATE MI BUT PROBABLY DUE TO FLUID) -if have ng tube, do not resposition it (can disrupt sutures, think already placed in tiny ass stomach-either the 15-20mL residue one which is the banded, the stapled or the removal of ghlelin prodcuing cells of stomach which is 85% or change of stomach bypass to jejunum and lmitation to 20-30ML) -Monitor development of post op complication due to increased risk (atelectasis--tink osa and gerd both increase risk for aspiration pneumonia which places at risk for pulmonary edema, thromboemboli due to hypercoagulability, skin fold breakdown-harder to see, and incisional hernia due to increased abdominal/ fat pressure and peritonitis -WANT TO ASSESS FOR TACHYCARDIA, BACK PAIN, STOMACH PAIN, AGITATION/ RESTLESSNESS, AND OLIGURAI) -ASSESS AIRWAY AND 02 SAT (semi fowlers for lung expansion to prevent buildup of fluids) -monitor bowel sounds and measure girth daily -apply abdominal binder to preven tdehiscence (also do not move the ng tube or can cause damge and ruin the sutures) -ambulate asap (in the mean time have scds, but want them standing to prevent clot/ stroke/ mi) -resume fluids restricted to 30mL at a time (think about residual volume of 20-30ml for bypass and wouldnt wnat to overload and up to 120ml day for first few days (4xs a day, think 3meals and one snack) -provide six small meals a day when can resume oral nutrients (gag reflex and bowel sounds return--think gastric volume is small and don't want to pop it again also similar to only 30ml at a time up to 120 a day OBSERVE FOR DUMPING SYNDROME (CRAMPS, DIARRHEA, TACHYCARDIA, DIZZINESS AND FATIGUE--think removing everything in teh body including fluids which causes hypotensive crisis=tachycardia and dizziness and fatigue) case manageent: for health resources/ mental health

Pathophysiology of liver disease that leads to portal htn and complications from portal htn PATHOPHYSIOLOGY THAT LEADS TO HEPATIC ENCEPHALOPATHY Risk factors Prevention

Cirrhosis is extensive scarring of the liver caused by necrotic injury (similar to pancreatitis, repeated results in chronic pancreatitis) or chronic reaction to inclammation for prolonged periods of time NORMAL TISSUE IS REPLACED W/ FIBROTIC TISSUE THAT LACKS FUNCTION (SIMILAR TO LUNG INFECTIONS, ETC) portal and periportal areas of the liver ARE PRIMARILY INVOLVED*** (portal problems main cause) -affecting the liver's ability to handle the flow of bile by nodules blocking the bile ducts and normal blood flow to the liver (like aki because ability to filter granules depletes and lack of perfusion occurs)** The development of new bile channels causes an overgrowth of tissue (trying to heal itself but instead it's a diservice and leads to scarring/ enlargment (JAUNDICE IS FOUND BECAUSE THE LIVER CANNOT REMOVE BILE/ PROPERLY REGULATE BILE) HEALTH PROMOTION AN DISEASE PREVENTION: 1. prevent infection w/ viral hepatitis (leadinc cause of posthepatic cirrhosis***** in th eUS-think more gay movements.) a. how to prevent? frequent hand washing, do not share toothbrushes/ towels/ the same bathroom/ cups (have individuals recieve immunoglobin post-exposure after 24hrs or 12hrs after birth, heb b vaccine first at birth and 3 more doses until 16 months), get tested and avoid sexual intercourse -prophylactic t/x in all members in household -use standard precautions and contact isolation if incontinent of stool -do not share utensils, abstain from sexual relations during acute infection, using barrier protection if patient or partner is carrier or has chronic infection -avoid hepatic toxins (like nsaids, aspirin, ibuprofen) -avoid excessive alcohol intake postnecrotic (caused by viral hepatitis due to infection of the liver) or some medications or toxins (think about why those with hepatitis b or c need to abstain from toxic medications and alcohol) alcoholic cirrhosis (laennec-think being lazy with alchol cessation so now have): repeated injury leads to triglyceride and fatty acid synthesis and increase which becomes inffiltrates, which causes inflammation, necrosis, fibrosis and destruction of the tissue biliary: chronic biliary obstruction or autoimmune: caues infalmmation, firbosis and final stage nodules and shrinking RISK FACTORS: 1. alcohol se disorder (causes inflammation, release of triglycerides that become infiltrates-can heal if stop alcohol, then inflammation, fibrosis and finally nodules and shrinking) 2. viral hepatitis (hep b, c or d)--hep b is acquired through blood contact (commonly sexual contact w/ bodily fluids, iv exposure or through pregnancy), hep c is commonly acquired through iv/ drug exposure (can also be blood products before 1992, organ transplants, illicit drug use, prolonged dialysis, etc) 3. steatohepatitis (fatty liver disease causing chronic inflammation--think thats steep having that much fat) 4. damage to liver caused by medications, susbtances toxins -chronic biliary cirrhosis (bile duct obstruction, bile stasis, inflammatin and fibrosis) CARDIAC CIRRHOSIS: SEVERE RIGHT HEART FAILURE INDUCING NECROSIS AND FIBROSIS DUE TO LACK OF BLOOD FLOW) --think about how right sided causes back up into the body and results in RISK FACTORS: HEP C OR B -ALCOHOL CONSUMPTION -BILIARY DUCT OCCLUDSION -TOO MUCH FAT IN THE LIVER: OBESITY (think too fat and liver realizes that too), hyperlipidemia and diabetes (occludes things) -autoimmune -liver takes substances in our blood, metabolizes and detoxifies them (why cannot have liver toxins while with hepatitis since often not treated and why it can get damaged. stores an dprodcues substances to help w/ digestion, clotting and immune health Recieves majority of the blood**** from the hepatic portal vein (delivers blood high in nutrients (lipids, proteins, carbs and glucose) from organs that aid in digestion of food but blood is poor in oxygen) hepatic artery: delivers rich oxygenated blood to liver but poor in nurtriens (theink vein, is in vein theres no oxygen but contains nutrients) -mix together as they deliver Portal htn: PORTAL VEIN BECOMES NARROWED DUE TO SCAR TISSUE IN THE LIVER--THINK ABOUT HOW SCAR TISSUE CAN DEVELOP FROM; hyperlipidemia, obesity, right sided heart failure, diabetes, alcoholism, hepatitis c and b and biliary duct occlusion -RESTRICT SBLOOD TO THE LIVER AND INCREASE PRESSURE (will affect the spleen, vessels to the gi structure when this occus, the blood is rerouted***/ shunted into other vessels (the ones it rereoutes to becomes engorged/ congested--located in the esophagus, rectum and abdomen--think of everything r/t digestion -because of increased pressure, eventually is pushed out and reuslts in ascites******* SPLENOMEGALY: the spleen stores platelets and wbcs (with portal htn, the platelets and wbcs are kept in the spleen, they can't leave which leads to low platelet and wbcs -additionally, the rate in which they are destroyed increases which leads to pancytopenia esophageal varices: because the hepatic portal htn is because of hyperlipidemia, hepatitis, excessive alcohol use and shunting of blood occurs into the rectum, esophagus and abdomen -this results in esophageal varices -the increased pressure causes the viens to become weak and rupture***** -life threatening: WHY? PLATELET COUNT IS LOW DUE TO SPLENOMEGALY AND RAPID DESTRUCTION OF ALL BLOOD PRODUCTS AND LEVELS OF VITAMIN K ARE DECREASED RESULTING IN RISK FOR HEMORRHAGE**** (think with esophageal manifestations, survival rate varies) Fluid overload in legs and abdomen (due to shunting of blood due to portal htn, this results in fluid and high osmotic presure which causes fluid to be pushed out and as consequence, ascites) -WITH ASCITES: risk for infection from bacteria in the gi system (think about how it is hemorrhaged now and how in pancreatitis often require antibiotic t/x for severe cases) and can leak into the vessels -immune system is also compromised (spleen is enlarged, blood products are building and more rapid death of blood products and lack of release of wbcs and clotting factors)--means unable to fight off infection as effectively -swelling in the legs and ascites is happening due to venous congestion and low albumin (THINK ABOUT HOW LIVER IS RESPONSIBLE FOR BREAKING DOWN NUTRIENTS, STORING VITAMINS WHICH IS WHY LOW LBUMIN OCCURS WHICH MAINTAINS HYDROSTATIC PRESSURE) JAUNDICE: yellowing of sclera (due to hepatocytes leaking bilirubin inot th eblood rather than bile) -think about how in hepatitis have the prodromal phase which is usually flu like symptoms (fever, bone pain, nausea/ vomiting, anorexia, malaise, pruritus--itchy skin--cut fingernails, pat dry, use tepid water, myalagia) after 2 weeks of exposure, then symptoms begin to subside and in replacement, begin to experience jaundice symptoms 5-10 days, along with upper right abdominal pain, bone pain, fatigue) and then begin to subside which can take 2 months to 6 months (for hp b) -for itchy skin, pat dry, warm not hot water, limited time bathing or showering, do not rub skin, apply alcohol free lotion after bathing to retain skin moisture, wear cotton, reduce room temp to prevent sweating and infection due to water loss, prevent overheating Hepatic encephalopathy: liver is unable to detoxify properly (think about how it converts ammonia into urea) and ammonia builds up along with other toxins that collect in the brain --supposed to be excreted via the urine (much less toxic to the brain than ammonia*** if it isn't converted to urea, can damage the brain and cause asterixis (liver flap: muscle tremore that interferes with the ability to maintain a fixed position--early sign of portal systemic encephalopathy******** =think aster cannot remain fixed in her position, she keeps squirming/ jerking about which means she has encephalopathy**** INVOLUNTARY HAND FLAPPING) AND HEPATIC FOETER (pungent, musty, sweet smell to the breath)--think foeter, her breath is fowl and also sign of late stage) renal failure can occur: liver cancer and bone fractures (low vitamin d): think about how vitamins a,d, k and e are all not absorbed properly which leads to bone degeneration and poor clotting and poor menstruation

early s/s of liver disease

Early s/s of hepatic encephalopathy is asterixis (jerky hand movements), later signs is ____ Early stages: patients may be asymptomatic (think about how usually gradual progression into chronic stages is very subtle) -other early signs include weight loss (think about how the liver helps metabolize glucose by releasing glycogen if blood glucose is low and due to inability to do this, they are unable to have these nutrients along with breakdown of lipids and proteins, and availability of b12, a, e, d and k) -FAT SOLUBLE (OFTEN WITH PANCREATITIS AND OTHER DIGESTIVE DISORDERS, CANNOT HAVE ACCESS TO A, D, E AND K RESULTING IN INCREASED RISK FOR BLEEDING AND BONE DEGENERATION) -ANOREXIA (think about how gradual ascities is occuring which is causing a sense of fullness and lack of appetite), right upper quadrant is tender, and weakness/ anorexia (due to malnutrition) and diarrhea or constipation (either absence of bowel sounds or gi distress) and inability to digest as effectively

APPETITE REGULATION WITHIN THE BODY

Obesity is a chronic condition caused by calorie intake in excess of energy expenditure -can be caused by culture--think availability of certain foods, metabolism--genetically determined and by stressors, enviornment, socioeconomics and individual behaviors obesity can be linked to protective masures within the body to prevent weight loss during calorie restriction (think about how when individuals starve themselves it causes release of glycogen which results in holding of body fat) can secrete hormones that stimulate the appetite to maintain a specific weight -usually the hypothalamus (REMEMBER THIS IS A VERY PRIMAL PART OF THE BRAIN) REGULATES HUNGER AND SATIATION WITH NORMAL LEVELS OF APPETITE REGULATION, the hypothalmus timulates appetite in response to hypoglycemia -as nutrient levels rise, the satiety level increases and hormones are produced and gastric filling occurs (which sends message to stop eating and assist in that) with obesity, eat often due to depression or for feelings of well-being -this causes resistance to leptin (sounds like pepsin, think lets be done man and stop appetite) and thyroid hormone alterations (think about how thyroid levels increase and cause tachycardia--also explains hf) and insuling which reulgate body fat -as weight increaes, the bodya ccepts a higher weight as the expected weight and seeks to maintain it (hence resistance to leptin and insluin and thyroid changes and less regulation of the full response-gastric filling an dhromones)

complications associated w/ obesity

Risk factors for obesity: genetic predisposition (poor bmr rate, hyperlipidemia, high thryoid levels, resistance to leptin which suppresses appetite) hromones (leptin-suppresses appeteite and ghrelin causes the growlin-increases appetite0 poor sleep patterns sedentary lifestyle (diet choices) BMI: greater than 30 overweight is consdiered over 25 -not as accurate because females waist circumferance (greater than 35 inches** think shouldnt have cardiac issues over 35 and also alt and ast are 0-35/ 4-36) -waist to hip ratio: measurement of difference between lower body and central obesity (think its a sratio thing-determining differences between peripheral and central obesity) -predictor of CAD (think high risk factors is obesity or bmi greater than 30, females waist circumference greater than 35 and males greater than 40) -indicates excess fat at the wasit and abdomen -males: 0.95 or greater and females: 0.8 or greater (think females 80% you passed and have obesity, males think they are more superior 95% you passed and have obesity--hip greater than 40 inches and females greater than 35 inches UPPER BODY OBESITY (IN REGARDS TO WAIST-TO-HIP RATIO) IS USUALLY ASSOCIATED WITH GREATER THAN 1 (MEN SO SUPERIOR THINK 100% NEEDS TO DETERMINE OBESITY) AND FEMALES GREATER THAN 0.8 (higher risk for htn, cad, -have more intra-oabiminal fat -risk of hrn, abonral lipid levels (predisposition for cirrhosis), heart disease (modifiable risk factor), stroke and elevated insulin levels (think about how insulin regulates fat distribution) LOWER BODY: when lower body is less than 0.8 or 0.95 in males and usually harder to treat risk for hyperinsulinemia (due to changes in thryoid levels, insulin levels and resitance to leptin) and heart disease is lower than those with upper body (think about how upper body has triglycerides closer to the heart**) -Lower body more difficult to treat RECOMMEND: EXERCISE, DIET AND BEHAVIORAL MODIFICATIONS sURGICAL: BMI OVER 40

Treatment/ considerations for hepatitis C

Since it is more severe and can be contracted especially with HIV, recieved immunosuppression/ organ transplant, long term dialysis, MAINLY CAUSED BY IV DRUGS -SEXUAL CONTACT, BLOOD PRODCUTS BEFORE 1992, SHARP INJURIES (NEEDLE OR INSTRUMENTS) INCREASES RISK ACUTE: high percentage become chronic (think c for chronic) and require interferon treatment -usually have anti-hcv for chronic (indicates dealing with for long time) -hcv-rna is viral rna and indicates the virus** Treatment: antiviral medication is given -handwashing, no vaccine and no immuen globulin 24hrs after exposure, blood and organ donation screening (since can lose blood products due to splenomegaly associated with hepatic portal htn)

Treatment for hepatitis/ and education regarding exposure to hepatitis

With exposure via needlestick, recommend treatment for exposure w/ immunoglobulin and b vaccine (think about how health care workers or those at risk take x3 doses within 6 months)

COMPLICATIONS OF BARIATRIC SURGERY:

dEHYDRATION: related to decreased abilty to drink (no more than 30ml up to 120ml a day) an dreduced stomach content or risk of fluid leaking=oliguria/ tachycardia) -warn excessive thirst or concetntrated urine can be indication of dehydration and notify surgeon****(could cause hypovolemic crisis especially since for 6 weeks pretty lmited0 malabsoroton; reduce size of stomach and bypass intestinal (duodenum and instead jejunom) 1. mointor for tolerance of increasing amount of food and fluids (after 6 weeks with 1 cup per six meals0 2. refer to dietary mangement 3. encourage to assume low folwers (15-30) for 30 mins after eating to delay stomach and minimize dumping syndrome (evidenced with dizziness, tachycardia, orthostatic hypotension and diarrhea-gets upset no lonver large so gives up and dumps it all) edu: 1. eat 2 servings of protein a day (aid in healing0 -eat only nutrition dense foods (avoid empty calories-cola and fruit)