absorption (liver)
Disorders of the Gallbladder
*Cholecystitis*: inflammation of the gallbladder wall Usually caused by gallstones obstructing the cystic and/or common bile ducts Bile backs up and gallbladder becomes inflamed *Cholelithiasis*: formation of stones in the gallbladder *Acalculous cholecystitis* Present in 5% of cases of cholecystitis Due to OR, hyper alimentation(TPN), extended fasting Inflamed gallbladder but no stones Change the composition of the bile so what happens is all the extra cholesterol in the body is put into the bile and that caused the bile to change composition and become more of a sludge it's thicker in consistency(don't have stones but can become inflamed)
Nursing Care-Cirrhosis fluid vol excess and nutrition
*Fluid volume excess* Daily weight and abdominal girth measurement I&O Monitor VS Cardiac and pulmonary assessment (fluid; third spacing) Administer diuretics, as ordered and necessary(spirilactone) *Nutrition* High calorie, high carb, moderate to low fat Protein restriction w/ episodic hepatic encephalopathy Hepatic aide-easily digested PRO supplement Low sodium (if edema/ascites to prevent fluid retention) Fat-soluble & B-complex vitamins Replace electrolytes Avoid alcohol and other hepatotoxic agents(also includes sedatives, cuz u need to assess neuro level)
Identify the rationale for the following interventions in treating the cirrhotic patient with hepatic encephalopathy.
*Lactulose (Cephulac) or Neomycin-* Decrease the absorption of NH3 or ammonia from the bowel, So that will help with the symptoms of encephalopathy and confusion *Eliminating blood from the GI tract* And you can remove the red blood cells As a protein source Then the ammonia levels are going to go down which is going to decrease the encephalopathy and confusion So someone has a GI bleed that can increase ammonia level so if you decrease the GI bleed then you can help decrease the ammonia level So the red blood cells and the protein cant be broken down by the liver which causes an increase in ammonia level
Hepatitis-Prevention/Treatment(B)
. Hepatitis B immunization for infants and adults. (routine in new born's and high risk groups like IV drug users, people with high risk behaviors) 2. Post exposure prophylaxis with vaccine and Hepatitis B Immune Globulin (HBIG)=antibodies to HBV → passive immunity(preferred to be given within 24 hours of exposure and has to be given 2 week max: greater than 95% effective)
Chronic Hepatitis
.Results from HBV, HCV, or HDV 2. Hepatomegaly, fatigue, malaise result, often requiring cessation of work and complete rest 3. Diagnosis confirmed by biopsy 4. Increases the patient's risk for cirrhosis and liver CA
Hepatitis-Prevention/Treatment(A)
1. HA immune globulin (IG) for post-exposure protection for patients ˃40, ˂12 mos, immunosuppressed or chronic liver disease IGG would give passive immunity for 1-2 months)(effective in prevention if given within 2 weeks of exposure; might decrease level of illness) 2. Hepatitis A vaccine (inactivated viruses: Havrix or Vaqta for post exposure prevention for all other groups; (people not in age group will use active immunity)
What might the nurse ask the patient when assessing for s/s of Hepatitis?
1. Past History: exposure to infected person, any hepatotoxic substances, any infected fluid or food, needles, recent travel have they had a blood transfusion before 1992, current nutrional status, 2. Medications: OTC meds with acetaminophen 3. Current Status: a.Nutrition: small frequent meals, any n/v, oral care, wt loss right upper quadrant fullness ● b.Elimination: light stools, dark urine ● c.Activity Exercise: fatigue, arthralgia, ● d.Knowledge Deficit: avoid hepatotixc things, ways to care for puritis, hand washing with anything(eating preparing food)
Phases of Hepatitis
1. Pre-icteric(pre-jaundice) Phase ("flu-like symptoms") Malaise, fatigue Nausea/vomiting, diarrhea, anorexia Headache, muscle aches, polyarthritis (max infectiveness more likely to spread to other in this phase) 2. Icteric Phase Jaundice, pruritus Light stools(liver obstruction and bile cant get to stools), dark urine Decrease in pre-icteric manifestations ("feels better") 3. Post-icteric/Convalescent Phase Lab values return to normal(ASL/ALT; bilirubin); no clinical manifestations; can get normal in 2-4 months
Hepatitis-Diagnostic Tests
1.Diagnostic "markers" for specific virus(anti-HAV, IgG, IgM, etc.) 2.Alanine aminotransferase (ALT), Aspartate aminotransferase (AST) both are elevated with liver cell damage 3.Bilirubin (indirect and direct) elevated 4. PT/INR- prolonged *IgM= acute, early convalescence(have it) *IgG= had in past or(recovered or vaccine) *anti= made antibodies to (i.e. anti-HBs) PT and INR are prolonged (more prone to bleeding)
Fulminant Hepatitis
1.Extremely progressive form of viral hepatitis (usually related to presence of HBV + HDV) 2.Severe liver failure within hours or days of symptoms of hepatitis 3.Requires Supportive care
Cirrhosis- Lab Tests
1.Liver Enzymes (AST, ALT)- elevate initially due to hepatic inflammation- eventually return to normal when liver can no longer create an inflammatory response 2.Bilirubin- elevated due to lack of excretion by liver 3.Protein and albumin decreased due to the lack of hepatic synthesis 4.RBC, H&H, Plt. Count decreased due to increased destruction by liver/spleen 5.PT/INR are prolonged(decreased clotting, risk for bleeding) 6.Ammonia level is elevated(cuz cant be converted to urea) 1.Ultrasound(look at size of liver) 2.CT(looks at ascites and hepatomegly) 3.MRI(maliganacy) 4.Liver Biopsy- most definitive- under fluoroscopy for safety due to increased risk for bleeding(tells cirrhosis or cancer etc.) 5.Esophogastroduodenoscopy (EGD)
Alcoholic (Laennec's, portal) types of cirrhosis
50% is Laennec's Caused by chronic alcohol abuse May be reversed w/ early treatment Starts w/ 'fatty liver" and hepatomegaly; prognosis is good if drinking stops at this stage Malnutrition is a frequent concurrent issue
*A.I plan to eat small, frequent meals(T)* *B.I will eat easy-to-digest foods with limited spice(T)* *C.I will use skim milk when cooking(T)(low fat)* D.I plan to drink regular cola(F) E.I will limit alcohol intake to two drinks per day(F) ● You want to decrease anything that stimulates the system (caffine and alc, spices)
A nurse is completing nutrition teaching for a patient who has pancreatitis. Which statements by the patient indicates an understanding of the teaching? Select all that apply. A.I plan to eat small, frequent meals B.I will eat easy-to-digest foods with limited spice C.I will use skim milk when cooking D.I plan to drink regular cola E.I will limit alcohol intake to two drinks per day
A.The scope will be passed through your rectum B.*You might have shoulder pain after surgery(correct)* C.You will have a Jackson-Pratt drain in place after surgery(only for an open chole and its not a JP drain) D.You should limit how often you walk for 1 to 2 weeks(you want them to ambulate because you want that free air(CO2) out of their belly because that can cause pain post-op)
A nurse is completing preoperative teaching for a patient who is scheduled for a lap chole. Which of the following should be included in the teaching? A.The scope will be passed through your rectum B.You might have shoulder pain after surgery C.You will have a Jackson-Pratt drain in place after surgery D.You should limit how often you walk for 1 to 2 weeks
A.This medication is used to decrease acute biliary pain B.This medication requires thyroid function monitoring every 6 months(not thyroid monitoring but UltraSound of the gallbladder every 6 months to make sure the medication is working) C.This medication is not recommended for patients who have DM D.*This medication dissolves gallstones gradually over a period of up to 2 years(correct)*
A nurse is reviewing a new prescription for ursodiol with a patient who has cholelithiasis. Which information would the nurse include in the teaching? A.This medication is used to decrease acute biliary pain B.This medication requires thyroid function monitoring every 6 months C.This medication is not recommended for patients who have DM D.This medication dissolves gallstones gradually over a period of up to 2 years
A.*Brownie with nuts(correct; anything with high fat content will trigger the gall bladder)* B.Bowl of mixed fruit C.Grilled turkey D.Baked potato
A nurse is reviewing nutrition teaching for a patient who has cholecystitis. The nurse should identify that which of the following food choices can trigger cholecystitis? A.Brownie with nuts B.Bowl of mixed fruit C.Grilled turkey D.Baked potato
A.*Limit physical activity(T)* B.*Avoid alcohol(T)* C.Take acetaminophen for comfort(F) D.Wear a mask when in public places(F) E.*Eat small frequent meals(T)*
A nurse is teaching a patient who has hepatitis B about home care. Which instructions should the nurse include in the teaching? Select all that apply A.Limit physical activity B.Avoid alcohol C.Take acetaminophen for comfort D.Wear a mask when in public places E.Eat small frequent meals
*a.Have the patient take the preparations with meals and snacks(correct)* b.Dissolve the tablets in water before administration to activate the enzymes(not dissolved in water) c.Monitor the patient's blood glucose levels to evaluate the effectiveness of the enzymes(stools check) d.Administer liquid enzymes through a straw to eliminate contact with the oral mucous membrane
A nursing intervention that is indicated in administration of pancreatic enzymes to the patient with chronic pancreatitis is to a.Have the patient take the preparations with meals and snacks b.Dissolve the tablets in water before administration to activate the enzymes c.Monitor the patient's blood glucose levels to evaluate the effectiveness of the enzymes d.Administer liquid enzymes through a straw to eliminate contact with the oral mucous membrane
a)*Monitor the patient's level of consciousness(T)* b)*Monitor the patient's protime (PT)(T)(liver failure causes bleeding)* c)Institute droplet precautions(F)(universal precautions) d)Maintain patient in low fowlers position(F)(probs high fowlers) e)*Provide low-protein feedings(T)*
A patient diagnosed with viral hepatitis develops liver failure and hepatic encephalopathy. Which of these measures should the healthcare provider include in this patient's plan of care? Select all that apply. a)Monitor the patient's level of consciousness b)Monitor the patient's protime (PT) c)Institute droplet precautions d)Maintain patient in low fowlers position e)Provide low-protein feedings
a)Initiate oxygen therapy at 2L/min to increase gas exchange. (not caused by decreased hemoglobin) b) Notify the health care provider so that a paracentesis can be performed.(not the first thing you do) c) Ask the patient to cough and breathe deeply to clear respiratory secretions. d)* Place the patient in Fowler's position to relieve pressure on the diaphragm.(correct)* Which invasive and makes the most sense
A patient with advanced cirrhosis who has ascites is short of breath and has an increased respiratory rate. The nurse should a)Initiate oxygen therapy at 2L/min to increase gas exchange. b) Notify the health care provider so that a paracentesis can be performed. c) Ask the patient to cough and breathe deeply to clear respiratory secretions. d) Place the patient in Fowler's position to relieve pressure on the diaphragm.
A. Transmitted from fecal-oral route(A) B. May develop liver cancer later in life(B,C) C. Preceded by hepatitis B(D) D. Transmitted through sexual contact(B mainly but all 3 can) E. Uncommon in developed countries, like the U.S.(E) F. Common in developing countries(A) G. Usual transmission is from the blood(C, circulation) H. Has vaccination for prevention method(A,B)
A. Transmitted from fecal-oral route B. May develop liver cancer later in life C. Preceded by hepatitis B D. Transmitted through sexual contact E. Uncommon in developed countries, like the U.S. F. Common in developing countries G. Usual transmission is from the blood H. Has vaccination for prevention method
Hepatic Encephalopathy
AKA Portal Systemic Encephalopathy (PSE) Inability to convert ammonia and other waste products to a less toxic form. Products are carried to the brain and cause neurological symptoms Bacteria in GI tract will breakdown the protein component of blood into nitrogen which is converted to NH3-caution in pts. with GI bleed!! Ammonia is toxic to the brain!!!!!! When ammonia builds up in the bloodstream and causes confusion (hepatic encephalopathy) They cant convert the protein to urea causing increased ammonia levels If they have a GI bleed then that blood will also be converted to ammonia
Cirrhosis Treatment
Abstain from alcohol, aspirin, and irritating (coarse) foods(hard on varicose veins) Diuretics may be used to reduce ascites spironolactone (Aldactone) - aldosterone antagonist 1st choice(k sparing) furosemide (Lasix)- loop diuretic Substances to promote clotting Vitamin K (administered intravenously), infused slowly, diluted and given no greater than 1mg/min Platelets (blood product; requires consent for blood administration) Antacids to prevent irritation to GI tract from NH3(ammonia) (i.e.. ranitidine, aluminum hydroxide) Avoid hepatotoxic medications Cant slow cirrhosis but can help prevent/treat complications and help with SE
Acute Pancreatitis-Pathophysiology
Alcohol excess can cause duodenal edema increasing pressure in sphincter of Oddi & obstructing pancreatic outflow.(pancreatic enzymes) Obstruction of common bile duct by stones w/ retrograde movement of bile and pancreatic enzymes back into pancreas. When gallstones start blocking this area and causing the enzymes to go back in the pancreas that can cause the pancreas to digest itself so instead of the enzymes are activated cuz of the foods but instead of them digest food they digest the pancreas causing damage, since your enzymes are in the pancreas and not in the GI system that can cause the pancreas to get digested when they're activated instead of food in the GI system Excess HCl acid causes spasms of Sphincter of Oddi & ampulla of Vater, obstructing pancreatic flow into duodenum. Results in release of activated pancreatic enzymes into the pancreas w/ auto digestion of pancreatic blood vessels and tissue Its causing bleeding inside the pancreas or fat necrosis(breakdown of tissue inside the pancreas)
Pharmacological Treatment-Hepatitis
Alpha Interferon(it interferes with virus replication)- (ATI Med Sheet) blocks viral replication cycle and augments bodies immune response SQ 3x/week SEs: flu like- fever, chills, h/a, myalgia, fatigue Antivirals: Decrease viral load and subsequently liver enzymes and liver damage HBV: Lamivudine (Epivir) (SE depression) HCV: Ribavirin (Virazole)
Biliary Lab Values
Aspartate aminotransferase (AST): 0 to 35 units/L Alanine aminotransferase (ALT): 4 to 36 units/L Alkaline phosphatase (ALP): 30 to 120 units/L Amylase: 30-122 units/L Lipase: 31-186 units/L Pancreatic: Amylase: 30-122 units/L Lipase: 31-186 units/L Don't worry abut numbers!! It'll just say elevated or decreased *Total bilirubin: 0.3 to 1.0 mg/dL* Direct (conjugated) bilirubin: 0.1 to 0.3 mg/dL(is not water soluble) Indirect (unconjugated) bilirubin: 0.2 to 0.8 mg/dL(is water soluble) *Albumin: 3.5 to 5.0 g/dL* *Total protein: 6.4 - 8.3 g/dL* *Ammonia: 15 to 45 mcg/dL* 2 to 3 times in bilirubin in jaundice Nutrition: *Albumin: 3.5 to 5.0 g/dL* *Total protein: 6.4 - 8.3 g/dL* ALT AST ALP: liver enzymes Amylase, lipase: pancreas enzymes
A.Pruritus and malaise(no, caused by high bilirubin) B.Dark urine and easy fatigability(no, caused by high bilirubin) C.*Anorexia and RUQ discomfort(true, correct)* D.Constipation or diarrhea with light colored stools(no, high bilirubin) ● High bilirubin is in itreric phase not incubation phase
During the incubation period of viral hepatitis, the nurse would expect the patient to report A.Pruritus and malaise B.Dark urine and easy fatigability C.Anorexia and RUQ discomfort D.Constipation or diarrhea with light colored stools
Nursing Care-Pancreatitis
Bed rest (side-lying or semi-Fowler's with knees flexed)(Decreasing the pressure and the tension On the pancreas and on the abdomen Monitor blood glucose & administer insulin per order Monitor respiratory function(Respiratory failure can occur because of the fluid shift and Pressure on the abdomen With the enlarged pancreas and the Fluid that's in the peritoneum NPO until pain the Reason for the NPO Is they want to keep that duodenum empty So the pancreas isn't pushing out any enzymes that are activated and then getting pushed back Into the pancreas, so NPO so no enzymes are released Calm environment Monitor stool for fat= Shows are not digesting fat in their diet and then you pancreatic enzymes to Help with absorption Steatorrhea
Nursing Care—Acute Viral Hepatitis
Bedrest (reduces metabolic demand & allows regeneration) Adequate nutrition and hydration(high cal, high carb, low fat, low to moderate protein and small frequent meals) Counseling and teaching about precautions to avoid transmission to others(don't share personal items) Avoid hepatotoxic substances(alc, acetaminophen, NSAIDs any meds hard on liver) Supportive drug therapy (antiemetics) Recovery of uncomplicated hepatitis usually takes 3-16 weeks
types of cirrhosis Biliary Cirrhosis
Follows chronic biliary tract obstruction Cancer-cause Gallstones-cause Adhesions-cause Jaundice is the primary symptom
Cirrhosis
Chronic progressive disease of the liver characterized by extensive degeneration and destruction of the liver cells- normal tissue is replaced with fibrous tissue that lacks function Any chronic liver disease, fatty liver disease chronic alcholism, chronic hep c and alc can cause exacerbation of liver damage(synergistic effect-makes damage worse)
Hepatitis-Definition
Definition: widespread inflammation of the liver & loss of normal liver function Cause: drugs (includes Acetaminophen-see alert p. 979), alcohol, chemicals, virus (most common) Treatment: depends on the type of hepatitis and cause of disease
Cirrhosis- Pathophysiology
Destruction of hepatic tissue results in loss of normal liver functions with multisystem manifestations Pressure on the portal circulation, resulting in increased pressure in the blood vessels of the GI tract and abdomen. These become engorged, dilated, and in some case can rupture and bleed. PORTAL HTN Creates new BVs that turn varicose and start bleeding
Esophageal varices
Dilated vessels in the esophagus; vessels are weak Cause: portal hypertension secondary to cirrhosis Client teaching: avoid coarse foods, regurgitation(indigestion can cause this, alc, aspirin, things that irritate the stomach), strenuous coughing, Valsalva, constipation Treatment Gastric lavage w/ cold water (vasoconstriction) IV vasopressin (DDAVP) Monitor BP, also decreased HR and coronary blood flow Blood transfusion per health care provider order May do fresh frozen plasma Antacids to prevent irritation/bleeding from reflux of acid gastric contents
Hepatic Encephalopathy Treatment & Nursing Care:
During acute phase—Low protein diet!! Administer lactulose or neomycin (binds w/ ammonia and allows for excretion) Monitor lab results (ammonia and potassium) Assess patient for confusion or changes in LOC Report asterixis and fetor hepaticus ASAP!!!! (clinical sign of worsening encephalopathy) Assess patient for confusion or changes in LOC: subtle at first; high ammonia levels can lead to cerebral edema, increased intracranial pressure and death Can be subtle at first like a change of Personality or agitation Restlessness Patient can become incoherent If the ammonia levels get high enough they can get cerebral edema Which can cause increased intracranial pressure Cerebral hypoxia and death
types of cirrhosis Postnecrotic Cirrhosis (Posthepatic)
Follows hepatitis B or C most often Broad bands of scar tissue form within the liver
Endoscopic Retrograde(backwards) Cholangio-Pancreatography(liver & pancreas) (ERCP)
ERCP- Endoscope orally → duodenum → common bile duct & pancreatic duct cannulated; contrast dye for visualization (remember precautions with dye; push fluids check Bun and creatinine, monitor kidney labs). After the acute phase may use same procedure to retrieve stones from the common bile duct.
Cholelithiasis/Cholecystitis Labs
Elevated alkaline phosphatase, AST, ALT (liver involvement or CBD obstruction) Elevated lipase & amylase (pancreas involvement) Elevated WBC (inflammation) Elevated serum bilirubin (CBD obstruction) Abdominal US (NPO for 8 to 12 hours prior to test) ERCP/MRCP- visualize GB & ducts & sample bile for culture Cholangiogram- dye introduced into biliary ducts percutaneously or during OR Hepatobiliary scan (HIDA scan): Nuclear scan outlines liver and biliary tract, identify obstructions
Clinical Manifestations- Cholelithiasis / Cholecystitis
Epigastric pain, nausea/vomiting Heartburn RU abdominal pain, may radiate to subscapular area Intense pain after ingestion of fatty foods( Usually happens after a fatty meal because That stimulates the gallbladder to squeeze and there's a stone there Then it's going to hurt Abdominal guarding, rebound tenderness Dyspepsia(bloating), eructation (belching) Murphy's sign (pain w/ deep inspiration during right subcostal palpation)(So they breathe in and you push on there below Rib cage on the right side And they will end up having pain with that Fever Jaundice (obstruction of CBD/common bile duct) Clay-colored stools and dark urine may result Steatorrhea Pruritis (accumulation of bile salts)(goes along with jaundice usually) *"Biliary colic"*- severe intermittent abdominal pain when stone is migrating through cystic duct Abdominal rigidity (peritonitis)(inflammation of peritoneum)
Risk Factors for Gallbladder Disorders
Females>Males Contraceptives, hormone treatment High-fat diet Obesity Genetic predisposition Older than 60 Type I DM(higher triglycerides) Low-calorie, liquid protein diet Rapid weight loss
Nursing Care Post Cholecystectomy
Fowler's or Semi-Fowler's position Assess bowel sounds (should return w/in 48 hrs) TCDB (every 2 hrs) and IS (every hr while awake) Early ambulation (prevent DVT) Will start them on a low fat diet but then gradually add fats back into the diet Monitor urine and stool color Assess for nausea Analgesics for pain Assess site for infection Monitor fluid and electrolyte (NGT to LIWS may alter electrolytes) Will start them on a low fat diet but then gradually add fats back into the diet Where's the bile going to come from now since the gallbladder is now gone? Going to come straight from the liver down through the common bile duct Into the duodenum
Surgical Procedures-Gallbladder disease: Cholecystectomy *Laparoscopic*
GB removed through 1 of 4 small puncture sites in the abdomen Grasping forceps retrieve/dissect GB Minimal post-op pain; same day discharge and back to work in 1 week Common problem after any laparoscopic OR is shoulder/abdominal pain due to CO2 in abdomen- treat with ambulation, repositioning and NSAID's
What might the nurse teach the patient with Hepatitis?
Hand washing hand washing with anything(eating preparing food) 5. Infection Control A- enteric precautions (stool precautions), gown and gloves, private room, no sharing towels or washcloths B- universal precautions C-universal precautions 6. Home Care: (B): good hygiene, condoms and vaccinate household members, ( c): don't share any items that could possible have blood or body fluids on them, 7. Skin Care: for puritis(bile salt on skin from high bilirubin)- warm water, mild soap, loose clothing because if sweaty that can worsening itching, cut nails short so they don't scratch; also tell them if they wanna known if jaundice is getting worse it's in the sclera first then the skin
Portal Hypertension
Hepatomegaly and destruction of normal liver structure causes partial obstruction of the portal vein which increases venous pressure in the portal vein=portal hypertension Complications Gastric & esophageal varices (most common life-threatening complication)(can get esophageal bleed; hard to stop) Splenomegaly Caput medusa(varicose veins on abdomen) Hemorrhoids Ascites If bleeding u watch for: hematemesis, dark stools(melema), pale, drop BP, hypovolemia
Complications of Acute Pancreatitis
Hyperglycemia(damage to islet of Langerhans) Tetany (hypocalcemia)(early symptoms: numbness around mouth and twitching(chovecks and trousosseu signs;treated with Ca gluconate) Hemorrhage and shock(highest mortality) pancreatic pseudocyst in abdominal cavity(A cyst on the outside of the pancreas and it gets filled with necrotic exudate; They usually resolve spontaneously, may require surgical drainage as well if they get bad enough ) Pancreatic abscess(Cavity inside the pancreas and will require surgical drainage )
Pancreatic Cancer-Nutritional Concern
Immediate and "long term" nutritional concerns: What happens to digestion and absorption if a. part of the stomach is removed? b. the duodenum is removed? c. part (or all) of the pancreas is removed? d. part of the jejunum is removed? This is what happens in the Whipple's procedure for pancreatic cancer. They are nutritional problems because there's a lot removed in surgery with part of the stomach removed they need Small well-balanced meals Cuz they have a small stomach and they can't take a lot of food at once . with duodenum removed As well as the pancreas they're doing enzyme replacement to help Absorb those nutrients So there are pancreatic and some digestive enzymes they may take, They're going to possibly diabetic teaching because of the lack of insulin, And then with the jejunum removed there is less area for absorption
Cholelithiasis- Location
Location of Stones: Gallbladder Cystic duct-bile can continue to flow into duodenum from liver Common bile duct-some bile absorbed directly into bloodstream from liver so patient exhibits obstructive jaundice with dark urine and clay color stools
Pancreas
Long, slender gland behind the stomach Exocrine and endocrine function Makes enzymes (amylase & lipase) to digest fats, proteins, & carbohydrates in the intestines Produces the hormone insulin and glucagon
Collaborative Care for gallbladder
Low-fat diet Avoid gas forming foods Weight reduction Take fat-soluble vitamins as prescribed NPO during acute stages NG tube w/ low intermittent suction (decreases gastric distention that stimulates gallbladder)
a.Surgery to remove the inflamed pancreas b.Replacement of pancreatic enzymes with meals(chronic pa pancreatitis) c.*NG suction to prevent gastric contents from entering the duodenum(correct)* d.Endoscopic pancreatic sphincterectomy using ERCP(stone removal) You want to decrease distention and prevent gastric acid content from Entering the duodenum It's going to help to rest the pancreas And avoid the pancreatic enzymes for going back to the pancreas and causing damage to the pancreas
Management of the patient with acute pancreatitis includes: a.Surgery to remove the inflamed pancreas b.Replacement of pancreatic enzymes with meals c.NG suction to prevent gastric contents from entering the duodenum d.Endoscopic pancreatic sphincterectomy using ERCP
Nursing Care-Esophageal Varices
NG esophageal tube provides direct pressure to esophageal varices to stop bleeding (balloon tamponade) Types: Sengstaken-Blakemore and Minnesota tubes, triple lumen (suction, balloon pressure on esophagus, balloon pressure in stomach) Problem is risk of rebleeding if they pull it out Deflate esophagal ballon first the stomach otherwise esophageal ballon can block airway Prevent aspiration (suction prn & semi-Fowlers position) Maintain a patent airway!! Maintain pressure in balloons as ordered Deflate balloon according to protocol to prevent necrosis (usually 5 to 10 minutes every 8 hours) Monitor for signs of bleeding(if bleeding ammonia level goes up) Watch for symptoms of hepatic encephalopathy Treatment: beta blocker like Propranolol (Inderal) (decreases the incidence of bleeding by decreasing pressure); endoscopic ligation or sclerotherapy(do we have to know this?) You want to deflate the esophageal Tube before you displayed the stomach tube if you deflate the stomach to First that air will go into the esophageal to causing it to get bigger and block off the airway So they go down with an endoscope And ligation means they tie off the vessel that's bleeding And schleorotherapy means they inject substance Into the bleeding vessels That causes them to Clot off or stop bleeding
Nutritional Requirements-Pancreatitis
NG tube and TPN(feed through veins(IV bag with calories and nutrients) called total parenteral nutrition) initially (rest pancreas; NG will decrease gastric acid to decrease pancreatic stimulation)(Keep gastric acid out of the duodenum So the pancreas doesn't release Amylase and lipase Because those would go back into the pancreas and auto digestive pancreas causing damage; also avoids hemorrhage) Start oral feedings when serum amylase WNL, bowel sounds present, & pain free Start w/ clear liquid diet and progress to low fat, high carbohydrate diet(Carbohydrates are the least stimulating to the exocrine system of the pancreas ) No alcohol or smoking Small meals(Small meals because the less bolus less than enzymes in the pancreas has to produce to digest them) Weigh regularly If they are having trouble absorbing fats at first and they're going to put them On the pancreatic enzymes until The pancreas kicks back in and is able to Digest those fats Avoid substances that stimulate the pancreas Alcohol Fatty foods Spicy foods High caffeine u\Smoking Weigh regularly; Monitor I & O
Hepatitis-Prevention/Treatment(C)
New medication: Harvoni (ledipasvir and sofosbuvir)(class: direct acting antiviral)(DAA)(block protein needed for hep C replication)(12 week treatment w/ oral medication and majority are cured) 1. S/E: headache, fatigue, bradycardia when given w/ amiodarone 2. Can cure patients with HCV
Cirrhosis-Clinical Manifestations objective
Objective Symptoms 1. Dermatologic a. spider angiomas (estrogen) b. palmar, facial erythema (estrogen & alcohol-induced vasodilation) c. jaundice (hyperbilirubinemia) d. gynecomastia(male boobs, axillary & pubic alopecia (estrogen) 2. Hematologic a. bleeding (decrease in liver-synthesized clotting factors; platelet destruction from splenomegaly)- petechiae, GI bleed b. anemia (bleeding and splenomegaly) c. leukopenia (splenomegaly) 4.Nervous System Symptoms: encephalopathy secondary to ↑ ammonia level a. Asterixis (flapping hand tremor) b. Fetor hepaticus (liver breath)(sweet odor to breath c. Cognitive changes, emotional lability 5.Nutritional a. thiamine and folic acid deficiency b. vitamin deficiency c. hypoalbuminemia- because not metabolisng proteins; albumin helps with osmotic pressure and when its low fluid leaks out causing peripheral edema and ascities(big belly & pt swollen) d. malnutrition, muscle wasting Can also c hyperaldosteronism because liver can metabolize steroids well, sodium goes up potassium goes down, holding onto water, vericose veins, 6. Pulmonary a. dyspnea/ cyanosis (ascites) 7. Gastrointestinal a. peptic ulcers, gastritis (increased NH3) b. esophageal, gastric, or rectal varices (from portal hypertension) C. ascites (hypoalbuminemia & portal hypertension) d. dilation of abdominal wall veins (caput medusa- caused by portal hypertension Ammonia is a by product of protein and is turned into urea by the liver but because liver does not work it builds up since its not working
Pharmacological Treatment-Pancreatitis
Opioid analgesics: morphine sulfate or hydromorphone for acute pain Antibiotics (infection): Imipenem Monitor for signs of infection Antacids, H2 blockers, and proton pump inhibitors (decrease gastric acid secretion) Anticholinergic: dicyclomine (Bentyl) (decrease motility) the pain and restlessness can increase their metabolic rate And when the metabolism speeds up then that can stimulate the pancreatic enzyme So you give pain meds to avoid That Get those antibiotics started early because They can have that necrosis inside there Pancreas Anticholinergic: dry mouth is a SE so good oral care is important
Medications-Cholecystitis & Cholelithiasis
Oral stone dissolvers Dissolves cholesterol-based stones gradually over a period of up to 2 years ursodiol chenodiol Monitor hepatic enzymes Report abdominal pain, diarrhea, or vomiting Requires gallbladder UltraSound every 6 months to determine effectiveness Smooth Muscle Relaxant (decrease biliary spasm) Bile salt binders Increase elimination of bile salts in feces to decrease pruritis from biliary obstruction cholestyramine (Questran)- helps with severe itching and lower high cholesterol levels Fat-soluble vitamins (A, D, E, K) (cuz they cant absorb them naturally) Antiemetics Analgesics-NSAIDs-ketorolac Opioids- morphine sulfate; hydromorphone
Meds to ↓ Ammonia Level Lactulose (Cephalac or Chronulac)
Osmotic laxative administered rectally or orally Accelerates the passage of stool to decrease NH3 absorption (2-3 soft stools/d) pH of colon is changed to decrease absorption of NH3 Goal: to expel NH3 through the stool Diarrhea is expected effect Monitor electrolytes (esp. K), fluid balance, bowels sounds Assure adequate fluid intake
Clinical Manifestations-Acute Pancreatitis
Pain Continuous, severe, mid-epigastric or LUQ May radiate to back Usually occurs after fatty meal or excessive alcohol intake Sitting up and leaning forward may offer relief Nausea/vomiting Abdominal rigidity (if fluid accumulating in peritoneum) Decreased bowel sounds Tachycardia/hypotension/cold, clammy skin Mild jaundice Bleeding in peritoneum Turner's sign Cullen's sign Mark abdominal distension-Their belly gets bigger because of the decreased peristalsis Mild jaundice this is possible if that duct is blocked Bile is not getting through, Remember if that bile cannot get through Then it can't be absorbed and I'll come out in the urine come out in the skin come on the sclera causing the yellowing of skin and sclera Turner and Cullen signs are just general terms for bleeding into the abdomen. You do not just see Turner and Cullen signs in pancreatitis. Can see these signs with any type of abdominal bleed. So Turner means theres bruising on the flank, Cullens means there's bruising around the umbilicus. with these types of patients shock can occur secondary to hemorrhaging. They can get those pancreatic activated enzymes into their system and it can cause toxemia Or infection in their bloodstream, Or hypovolemia Because of the fluid shifting into their peritoneal space.
Pharmacologic Treatment- Pancreatitis-Pancrelipase
Pancreatic enzyme replacement- (aide w/ digestion of fats and protein)- for chronic pancreatitis Take with every meals and snacks Contains protease, amylase, and lipase (may sprinkle capsule content on non-protein foods) Monitor stools and body weight Drink full glass of water after Clean mouth and lips afterwards (prevent breakdown & irritation of skin) These meds are taken lifelong There are two different types of delayed released tab and theres sprinkles if you have the sprinkles then you open it up and you sprinkling on non protein food For example applesauce You want them to swallow the particles but not chew, Need to be taken with every meal and snack Need to have it in the stomach at the same time the food is in the stomach So it will help absorb the fat and the protein, Monitor stools and bodyweight cuz what you're looking for And expecting is Stools will improve in texture and they will not have the stenorrhea anymore. their body wt will go up because They're absorbing proteins and fats You want them to drink a full glass of water after because You want to make sure they don't have any of those enzymes in their oral muscosa And clean their mouth and stuff afterwards to prevent skin breakdown Cuz as of an enzymes can cause skin breakdown
Surgical Treatment- Pancreatic Cancer
Pancreatoduodenectomy (Whipple's Procedure) Remove: 1. head of pancreas 2. entire duodenum 3. distal end of stomach 4. portion of jejunum 5. lower half of the common bile duct
Liver Transplantation
Patient must meet stringent transplant criteria to be eligible Monitor liver function following transplantation Immunosuppressive drugs will be used (lifelong) Patient teaching regarding avoidance and assessment of infection Long-term steroid use Post transplant Encourage alcohol recovery program Abstinence from alcohol Dietary guidelines
Peritonovenous Shunt (LaVeen)
Perforated tube placed in peritoneum space End of tube placed in superior vena cava One-way valve prevents fluid from draining backwards into peritoneal space- ↓ ascites fluid so less pressure build-up With it fluid goes sodium and water Ascities decides compensated and decompesated(which is which?) Common complication of advanced cirrhosis and it marks the transition from compensate or decompensate liver failure So that means that the patient's body was compensating For it by absorbing Fluid other places And it's gone to decompensated liver failure Which means it's no longer Compensating for the fatty liver ability to do things moves ascites fluid into inferior vena cava to get fluid out of belly
Lab Results in Acute Pancreatitis
Serum amylase and lipase increase with pancreatic damage "aces are high" Erythrocyte sedimentation rate (ESR) ↑(inflammation Serum glucose increased Serum bilirubin and liver enzymes ↑ (if liver affected) WBC ↑ (infection/inflammation) Serum calcium and magnesium ↓ (fat necrosis) Platelets ↓ Ultrasound CT w/ contrast Chest X-Ray (diaphragm would be elevated on the left side) ERCP (diagnostic and treatment)- next slide Biopsy of pancreas
Identify the prophylactic immunologic agents that are used for the following:
Pre-exposure protection to HBV Hepatitis B vaccine series B. Post-exposure protection to HBV Hepatitis B Ig(passive immunity) Hepatitis B vaccine series(to make own antibodies)(active immunity)
Paracentesis
Pre-procedure: VS, abdominal girth, weight Have patient void immediately prior to procedure(get bladder out of way so it doesn't get poked) Assist patient to sit (or follow MD order/instructions) Local anesthesia is used at site of needle insertion Connect needle to tubing and collection device Follow MD order regarding monitoring volume of fluid withdrawn Post-procedure: place dressing over puncture site; monitor weight, VS, fluid balance, puncture site for bleeding Fluid specimen to lab for analysis, if ordered Helpful if fluids from asities is putting pressure on the resp system Give albumin for getting fluids back into vascular system When they monitor the fluid withdrawn 500ml a day can Decrease electrolyte problems. But often when you see this done you will see patients get a lot more fluids withdrawn If it's severe ascites they can have fluid withdrawn of 4 to 6 liters But the thing is after the procedure is done they may have to give IV albumin In order to get the osmotic pressure back to normal Remember that's when the fluid leaves the intravascular Goes out to the interstitial space So they give IV albumin to bring some of that fluid back to the vascular system
Liver Biopsy- Nursing Care
Preprocedure: check coagulation labs, platelets, VS NPO 4 to 6 hrs prior to biopsy; 2 hrs after biopsy Empty bladder immediately before test Position pt supine, head turned to left, right arm extended above the head Local anesthesia (biopsy takes 10-15 seconds) Have pt take a slow deep breath, exhale, and hold while needle is inserted Apply pressure to the puncture site afterwards Post-procedure, position the pt on the right side & monitor site for bleeding(to put pressure on site and make sure drainage does not go into peritoneum) Patient teaching: avoid lifting, straining for 2 weeks. Notify health care provider if persistent abdominal pain. Take vital signs post op complications happen soon after if they are there Post op complications: hemorrhaging, pain decreased BP and pneumothorax)
Liver Cancer
Primary hepatocellular cancer seen secondary to Hepatitis _B_ & _C_and chronic alcohol abuse Most liver cancer is secondary to metastasis Results in liver failure and hemorrhage Survival rate is low; treated w/ surgery, transplantation, and/or chemotherapy
Chronic Pancreatitis
Progressive replacement of normal tissue with fibrotic tissue Irreversible Pancreatic insufficiency and malabsorption Diabetes mellitus Causes: calcifying/fibrotic from chronic alcohol abuse; obstructive resulting from gallstones
Surgical Procedures-Gallbladder disease: Cholecystectomy *Open*
Right subcostal incision T-tube if common bile duct (CBD) exploration Keep drainage tube below surgical site (gravity) Record drainage maximum of 500 mL in 1st 24 hrs Will taper off next 2-3 days & change from blood tinge to bile Avoid tension on tubing Clamp tube according to policy and M.D. orders, once drainage decreases and stools are normal Tube may be clamped for 1hr before and after meals and kept at level even with abdomen per MD orders to aid with digestion and prevent total loss of bile
Hepatitis- Manifestations
See handout- Hepatitis Table- for summary information Hepatitis A, B, and C Hepatitis D- requires the presence of Hepatitis B for replication Hepatitis E- transmitted via fecal/oral route. Epidemics with contaminated food or water primarily in developing countries; rare in US. No progression to chronic state or cancer. Hepatitis with a vowel comes from the bowel(A) C circulation B body fluids Put an X through Incubation period(on ABC of hep) cross off numbers too in columns next to it Replace with: Hep A: acute onset and they have mild flu like symptoms) hep B: insidious onset and then symptoms become more severe; its severity is in acute or chronic infection) hep C: asymptomatic or mild symptoms
Collaborative Care after Whipple Procedure
Semi-Fowler's position (lung expansion & reduce stress on anastomosis(suture line)) NG suction at low intermittent suction (decrease pressure on suture line & prevent hemorrhage) *DO NOT IRRIGATE without an order!!!* Medications for pain( Need to have adequate pain control because they will Not be able to turn cough and deep breathe if they do not have pain control And then they can help with respiratory issues on top of their current issues) TCDB every 2 hours Incentive spirometer Monitor for hemorrhage, shock, hepatorenal failure Replace pancreatic enzymes and insulin per order Chemotherapy may be ordered if metastasis
symptoms of jaundice
Yellowing skin and eyes, Dark urine, Light colored stools, n/v Loss of appetite Extreme fatigue
Clinical Manifestations-Pancreatic Cancer
Slow onset General symptoms: weight loss, epigastric pain, possible jaundice (w/obstruction of common bile duct; (they should go in), anorexia, nausea, flatulence (others are so nonspecific that they don't go in) Location Head of pancreas (most common site): results in obstruction of CBD w/ jaundice, flatulence, dull epigastric pain may see clay-colored stools and dark urine The elevated bilirubin levels Body of pancreas: causes pressure on celiac ganglion; results in back pain(A large level of nerve Network around this area So patient may have more pain with this one Tail of pancreas: few symptoms experienced until metastasis
Blood Supply to the Liver
Stomach, intestine, pancreas, gall bladder and spleen all bring blood supply to the liver. Prolonged portal hypertension leads to varicose veins in the esophagus, stomach and rectum; enlarged spleen; and ascites fluid in the abdomen.
Cirrhosis-Clinical Manifestations subjective
Subjective Symptoms 1.Insidious onset 2.GI disturbance: anorexia, n/v, abdominal pain, distension 3.Dull, heavy feeling RUQ 4.Enlarged, palpable liver 5.Pruritis (intense itching) 6.Confusion, personality changes
Therapeutic Procedures-Cirrhosis(TIPS procedure)
Surgical bypass shunting procedures Transjugular intrahepatic portosystemic shunt (TIPS procedure)- shunts blood from portal circulation to superior and inferior vena cava bypassing liver Surgical connection between portal vein and vena cava (portocaval shunt) to bypass liver Both bypass liver so more ammonia in bloodstream(can cause more neuro s/s) but less blood flow to liver so decreased portal HTN
Interferon - interferon alfa-2a (Roferon-A), interferon alfa-2b (Intron A)
THERAPEUTIC USE • Treats the following cancers: • Hairy cell leukemia • Chronic myelogenous leukemia (interferon alfa-2a) • Malignant myeloma (interferon alfa-2b) • Kaposi's sarcoma • *Interferon alfa-2a treats chronic hepatitis C and interferon alfa-2b treats chronic hepatitis B and C.* ADVERSE DRUG REACTIONS • *Flu-like symptoms: fever, fatigue* • CNS symptoms: dizziness, insomnia, depression, tremor, headache • *Bone marrow suppression (all cell types):* usually mild and self-limiting • Gastrointestinal symptoms: abdominal pain, anorexia, weight loss, diarrhea INTERVENTIONS • *Medicate with acetaminophen if prescribed*. • Monitor for flu-like symptoms. • *Monitor for and report CNS symptoms.* • *Monitor CBC before treatment begins and periodically thereafter*. • Monitor and report persistent gastrointestinal symptoms. • *Assure client is well-hydrated for treatment, especially in presence of gastrointestinal symptoms.* ADMINISTRATION • *Available for subcutaneous, IM, and IV use*. • Give the prescribed biologic response modifier to the client; also, verify doses, as they are usually prescribed in million units (MU), which should not be confused with mg or mL. • Route of administration and amount of dilution depends on disorder. • Inject diluent into vial and gently rotate vial until contents are clear before withdrawing dose. CLIENT INSTRUCTIONS • If approved by provider, instruct client to premedicate with acetaminophen if flu-like symptoms occur. • Report CNS symptoms to provider. • Avoid hazardous activities, such as driving, until effects are known. • Instruct client to notify provider for easy bruising, bleeding, fatigue. • Report abdominal pain, weight loss, loss of appetite, and persistent diarrhea to provider. CONTRAINDICATIONS • Allergy to interferon alfa • Inflammation of the colon or pancreas • Suicidal ideation PRECAUTIONS • History of depression or suicidal ideation • Cardiac, renal, or liver disorders • Chronic lung disease, such as COPD • Diabetes mellitus • Clotting disorders • Bone marrow suppression INTERACTIONS • Other anticancer drugs and zidovudine (Retrovir) may increase bone marrow suppression. • May increase theophylline blood levels • May increase toxicity of doxorubicin • When given with vinblastine, may increase neurotoxicity
A.No immunization is available for HAV nor are you likely to get the disease(F) B.Only individuals who have had sexual contact with the patient should receive immunization(F, not sexual its fecal/oral) C.All family members should receive the Hep A vaccine to prevent or modify the infection(F, no close contacts) D.*Those who have had household or close contact with the patient should receive either the vaccine or immune globulin (Ig) depending on their age and health status(true, correct)*
The family members of a patient with HAV ask if there is anything that will prevent them from developing the disease. The best response by the nurse is: A.No immunization is available for HAV nor are you likely to get the disease B.Only individuals who have had sexual contact with the patient should receive immunization C.All family members should receive the Hep A vaccine to prevent or modify the infection D.Those who have had household or close contact with the patient should receive either the vaccine or immune globulin (Ig) depending on their age and health status
A.I should avoid alcohol completely(T) B.*I must avoid all physical contact with my family until the jaundice is gone(F, correct)* C.I should use a condom to prevent spread of the disease to my sexual partner(T) D.I will need to rest several times a day gradually increasing my activity as I tolerate it(T, how you treat hepatitis)
The nurse identifies a need for further teaching when the patient with HBV states A.I should avoid alcohol completely B.I must avoid all physical contact with my family until the jaundice is gone C.I should use a condom to prevent spread of the disease to my sexual partner D.I will need to rest several times a day gradually increasing my activity as I tolerate it
a)Anorexia(F)(cirrhosis not HE) b)*Change in orientation(T)* c)*Asterixis(T)* d)Ascites(F)(Cirrhosis not HE) e)*Fetor hepaticus(T)*
The nurse should identify which of the following findings as indicators of hepatic encephalopathy in the patient with advanced cirrhosis? Select all that apply. a)Anorexia b)Change in orientation c)Asterixis d)Ascites e)Fetor hepaticus
When a Patient has Liver Problems:(Hepatitis, Cirrhosis, Liver Failure)
They experience a loss of normal liver function: *storage of vitamins and minerals *production of blood clotting factors(if messed up they have a tendency to bleed) *production of plasma proteins (albumin & globulin) *production of bile *production of lipoproteins (cholesterol, etc.) *metabolism of steroid hormones (estrogen, cortisol)(can get man boobs if messed with sex hormones) *immune defense *detoxification of drugs and alcohol *production and storage of carbohydrates *conversion of ammonia
HEP A
VOWEL BOWEL *Routes of Transmission*: Fecal-oral route. HAV is transmitted through: • Close person-to-person contact with an infected person • Sexual contact with an infected person • Ingestion of contaminated food or water *Potential for Chronic Infection after Acute Infection:* none acute onset and they have mild flu like symptoms Serologic Tests for Acute Infection: IgM anti-HAV(M means they have got it) *Vaccination Recommendations*: • All children at age 1 year, Household members, People with direct contact with anyone who has hepatitis A
a)Increased serum albumin level (no) b)Decreased indirect bilirubin level (no) c)Improved alertness and orientation (no itll make it work) d)*Fewer episodes of bleeding varices(correct)*(not as much blood flow going to the liver so it decreases bleeding)(but do have increased ammonia level)
Which finding indicates to the nurse that a patient's transjugular intrahepatic portosystemic shunt (TIPS) placed 3 months ago has been effective? a)Increased serum albumin level b)Decreased indirect bilirubin level c)Improved alertness and orientation d)Fewer episodes of bleeding varices
a)*Diuretic(T)(holding on fluid, spirolactone)* b)*Beta-blocker(T)(relieve high Bp on liver)* c)Opioid analgesic(F)(don't want to give them anything that will decrease LOC) d)*Lactulose(T)(decrease ammonia level)* e)Sedative(F)(don't want to decrease LOC or mental function)
Which of the following medications can the nurse expect to administer to the patient with cirrhosis? Select all that apply a)Diuretic b)Beta-blocker c)Opioid analgesic d)Lactulose e)Sedative
HEP B
blood/fluids *Routes of Transmission:* Percutaneous, mucosal, or nonintact skin exposure to infectious blood, semen, and other body fluids, HBV is transmitted primarily through: • Birth to an infected mother • Sexual contact with an infected person • Sharing contaminated needles, syringes, or other injection drug equipment insidious onset and then symptoms become more severe; its severity is in acute or chronic infection) *Potential for Chronic Infection after Acute Infection:* Chronic infection develops in: • 90% of infants after acute infection at birth • 25%-50% of children newly infected at ages 1-5 years • 5% of people newly infected as adults *Serologic Tests for Acute Infection*:HBsAg,(G means gone) *Vaccination Recommendations:* All infants, Health care and public safety personnel with reasonably anticipated risk for exposure to blood or blood-contaminated body fluids, People with chronic liver disease (including cirrhosis, fatty liver disease, alcoholic liver disease, autoimmune hepatitis, and an ALT or AST level greater than twice the upper limit of normal) • People living with HIV • People who are incarcerated, *Vaccination Schedule:* Adults: 2 doses, 1 month apart; or 3 doses over a 6-month period (depending on manufacturer) HBV vaccine 95% effective
HEP C
circulation *Routes of Transmission*: Direct percutaneous exposure to infectious blood. • Sharing contaminated needles, syringes, or other equipment to inject drugs *Potential for Chronic Infection after Acute Infection:*Chronic infection develops in 75%-85% of newly infected people asymptomatic or mild symptoms *Serologic Tests for Acute Infection*: No serologic marker for acute infection *Testing Recommendations for Chronic Infection*: People who received a blood transfusion or organ transplant before July 1992, People who get an unregulated tattoo, Chronic: over 90% of people with hepatitis C can be cured regardless of HCV genotype with 8-12 weeks of oral therapy
Meds to ↓ Ammonia Level Neomycin antibiotic (Neotabs)
u\Poorly absorbed from intestines so acts locally to decrease bacterial flora that are producing ammonia in the GI tract (↓ ammonia formation) Can be administered orally or rectally "mycin"=ototoxic(ears) and nephrotoxic Check for tinnitus, dizziness, or hearing loss Monitor BUN, creatinine, and urine output
