AMS exam 4

Treatment for hepatic encephalopathy

Lactulose: pulls ammonia into stool Rifaximin: antibiotic kills ammnoia- producing bacteria low protein and alcohol diet

is there a hep c vaccine?

No

Diagnosis of hepatic encephalopathy

EEG ammonia levels

Treatment for liver cancer

Surgical resection and liver transplant = best long term survival chemotherapy (palliative) Transarterial chemoembolization PleurX catheter

What is a cutaneous liver biopsy

biopsy that is riskier bc it is closer to the diaphragm and lungs - potential for puncture and bleeding

How is Hep B transmitted?

blood and body fluids

how is hep c transmitted

blood to blood

What is jaundice ?

buildup of bilirubin causing yellowish discoloration on skin, sclera, and secretions

target therapy for breast cancer?

chemo agents that target specific characteristics of cancer cells; decreases harm to normal cells with fewer side effects

non surgical treatment for breast cancer?

chemotherapy systemically; may be given prior to surgery for tumor reduction Radiation and tamoxifen

How to treat hep C

chronic hep c Combo therapy Harvoni, epscula PO tablet; side effects: nausea/vomiting, GI distress, headaches Pegasys +rebetol Subq injection given once a week adverse effects: neutropenia, thrombocytopenia, heart damage

When is albumin and globulin decreased

chronic liver disease

cause of portal hypertension

cirrhosis

will platelets be increased or decreased in liver dysfunction

decreased r/t stimulating factor is decreased in liver dysfunction

What is the general hepatitis treatments?

depends on type of hep Pruritis: antihistamines Nause and vomiting: antiemetics High carb/ calorie Moderate fat and proteins Small frequent meals

What is hepatic encephalopathy

disease of the brain resulting from the liver

What is a portacaval shunt?

diverts portal venous blood flow from the liver to the inferior vena cava

When will alkaline phosphatase be elevated

during times of injury enzyme that leaks into the blood with a DAMAGED liver

Diagnostic tests for chronic pancreatitis

endoscopic retrograde cholangiopancreatography (ERCP); can cause acute exacerbation r/t simulation MRI,CT,US Glucose tolerance test; evaluates pancreatic islet cell function amylase and lipase may be elevated

risk factors of breast cancer

female gender age reproductive history -nulliparous: have not had children diet high in fat History breast cancer excessive ETOH menstrual history: early menses and late menopause obesity family hx - BRCA 2 gene oral contraceptives

surgical treatment for breast cancer

goal: to remove as much tumor as possible and to leave as much "good tisse" simple mastectomy modified radical mastectomy lumpectomy reconstruction

Will PT/INR be increased or decreased with liver dysfunction

increased r/t decreased prothrombin being produced

risk factors for hepatitis A

ingestion of contaminated food / water especially shellfish person to person contact sexual poor hygenic practices advanced age and pre existing liver disease virus survives on human hands

Signs and symptoms during exacerbations

intense abdominal pain; continuous, burning, or gnawing abdominal tenderness acites vomiting respiratory compromise r/t of inflammation towards the lungs (adventitious or decreased breath sounds, dyspnea, orthopnea) steatorrhea clay colored stools weight loss jaundice dark urine can present as a diabetic pt r/t injury to pancreas

Inflammatory Breast Cancer

invasive form of breast cancer gets into lymphatic channels of breast and can infiltrate into the skin. skin has an orange peel appearance, r/t swelling and edema that elongates the pores of the breast prevents lymph drainage cancer cells replace skin which causes ulceration rare, very poor prognosis

infiltrating ductal carcinoma

invasive form of breast cancer originates in the mammary ducts. grows into the surrounding tissue in an irregular. can spread to lymph nodes.

AST, ALT, LDH

liver enzymes ALT only enzyme specific to liver AST comes from muscle; elevated in heart or kidney disease All 3 will be elevated in any liver condition by 3-4 x

Cause of hepatic encephalopathy

liver failure post tips cirrhosis

What can the ultrasound with doppler be used for

looking for thrombus in the portal vein system

What can the ultrasound with transient elastography

looks at stiffness of the liver to determine cirrhosis

What does malabsorption cause in chronic pancreatitis?

malabsorption of fats leads to pale, bulky, frothy, odorous stool.

Signs and symptoms of hep c

many are asymptomatic. virus not cleared and chronic infection results chronic infection can lead to cirrhosis.

Signs and Symptoms of hepatic

mental status changes (neuro assessment q2) mood changes sleep distrubances late complications - coma and death ALL DUE TO HIGH AMONIA

Treatment for ascites

monitor I/O daily weights abd girth daily low sodium and no alc diet Monitor for dyspnea (HOB> 30) Diuretics (lasix & spironolactone) Paracentesis 1-4L

what is lobular carcinoma in situ

non invasive form of breast cancer affects both breasts and have multiple sites in each breast does not show up on a mammogram- resides in milk producing glands stage 0 cancer and does not metastasize

what is ductal carcinoma in situ

noninvasive breast cancer does not metastasize stage 0 cancer and highly treatable seen in women approaching menopause

Signs and symptoms of hep A

not life threatning mild flu like upper resp with low grade fever killed by bleach and high temps

Nursing care for cutaneous liver biopsy

nurse must be monitoring for bleeding after cutaneous bc liver has less clotting factors

Treatment for chronic pancreatitis?

pain relief, PERT, insulin, anti - diabetic agents nutritional therapy

What is portal hypertension

persistent increases in pressure within the portal vein; major complication of cirrhosis of liver

Signs of endometrial (uterine) cancer

post menopausal bleeding bloody vaginal discharge low back pain, abdominal pain or low pelvic pain

Diagnosing portal HTN

presence of ascites/ varices Doppler US CT MRI Angiography

goal for pancreatic cancer

prevent the spread of the tumor, palliative care to keep the pt comfortable

What is chronic pancreatitis

progressive and destructive disease characterized by remissions and exacerbations that leads to pancreatic insufficiency and decreased function

hormonal therapy for breast cancer?

reduced estrogen available to stop or reduce growth or tumor ex: tamoxifen which is taken for 5 years after breast cancer treatment

whatis a modified radical mastectomy

remove entire breast/ lymph nodes, and armpit

What is a lumpectomy?

remove the tumor and surrounding areas with clean borders and may involve removing the lymph nodes

manifestations of ascites

rounded abdomen translucent skin may see fluid shifting in abdomen

albumin is decreased in what

severe liver disease (acute or chronic)

Risk factors for hep c

sexual contact needle sharing blood products before 1992 or organ transplants Contaminated needle sticks or unsanitary tattoo equipment

What is an angiography used for

shows pressure in portal vein

What is a trans jugular intrahepatic porta systemic shunt (TIPS)

shunt between portal and hepatic vein to decrease pressure + decreased risk for bleeding Helpful for portal HTN lifelong

risk factors for pancreatic cancer includes

smoking 60-80 years old jaundice weight loss usually presents at late stages acites and metastatic disease

treatment for breast cancer

surgery radiation chemotherapy hormonal vs target therapy

What is simple mastectomy

surgery to remove the whole breast which may include the nipple and areola

Incubation period for hep B

symptoms occur within 25-180 days of exposure

How do diagnose acute pancreatitis?

Labs

Signs and symptoms of acute pancreatitis

-abdominal pain; severe and sudden in the left upper quadrant r/t large meal or alc take (pain will often radiate to back) -weight loss -rigid abd -abdominal guarding -jaundice d/t bilirubin -intermittent hyperglycemia -cullens sign (gray-blue discoloration of the abd and peri-umbilical area) -turners sign (gray-blue discoloration of the flanks)

What are risk factors of acute pancreatitis

-biliary tract disease with gallstones - alcoholism - trauma to the abdomen (ERCP) -mostly occurs in middle aged men -medication toxicities -viral infections -gastric or duodenal ulcers leading to peritonitis

What is a perioteovenous shunt ?

1 way valve that drains ascites into the superior vena cava directly

Incubation period for hep A

15- 50 days peaks 25-30 days

how long does it take for hep c to start showing s/s

7 weeks

Signs and symptoms of portal hypertension include

Acites r/t low albumin and low serum osmotic pressure Splenomegaly r/t thrombocytopenia Esophageal and hemorrhoidal varices

Signs and symptoms of Hep B

Anorexia, nausea, vomiting, fever, fatigue, right upper quadrant pain, dark urine and light stools, joint pain, and jaundice Most will develop immunity after infection

Treatment of portal hypertension

Beta blockers Vasoconstrictors octreotide sandostatin vasopressin

Diagnostic tests for liver cancer

Biopsy to determine staging level Xray, CT, MRI, US Liver scan PET scan shows uptake glucose and hypermetabolic areas

Diagnostics for pancreatic cancer

CT, MRI , ERCP Increased CEA occurs in most, increase in amylase and lipase , ALP

Total bilirubin

Elevated in liver dysfunction Normally excreted through the stool if can not be excreted stool will be pale/ gray colored gets excreted through urine creating dark urine

treatment for pancreatic cancer

External beam radiation: shrink tumor cells which alleviates obstruction which then improves food reabsorption ; does not improve survival rate Pancreaticoduodenectomy: Whipple procedure or resection -radical : removal of entire pancreas and some of the gastric parts

How is hepatitis A transmitted

Fecal-oral route - usually through contaminated food.

How to treat hep B post exposure

HBIG within 7 days of percutaneous exposure and 2 weeks for sexual exposure HBV vaccine can be given within 12-24 hours with 70-90% success in prevention

Treatment for hep A

PEP- immediate immunoglobulin (within 14 days) or 1 does of hep A vax

Cause of ascites?

PORTAL HYPERTENSION

Causes for liver cancer

Smoking alcohol use toxins - arsenic and vinyl chloride

What are the medications for hep B

Tenofovir (viread) - side effects: weakness, Headache, GI distress; usually well tolerated Lamivudine (epivir) Adefovir (Hepsera) - monitor renal function! All are taken PO and have risk for lactic acidosis and hepatomegaly

Risk factors for hep b

Unprotected sex birth blood transfusion sharing needles Immunosuppression Dialysis patient Healthcare workers Direct contact with open sores/infected blood

What does the upper GI series look at

X ray of the esophagus, stomach, and duodenum, may see liver

is there a vaccine for hep A

YES generally recommended if going over seas.

Is there a vaccine for hep B

Yes: a series of 3 injections. Initial, 1 month after initial, and 6 months after initial.

When is albumin and globulin increased

`acute liver disease

What imaging is done for acute pancreatitis

abd ultrasound specifically looking for gallstones. contrast CT chest Xray will see inflammation of hemidiaphragm.

What is ascites?

accumulation of fluid in the peritoneal cavity

What is acute pancreatitis?

acute inflammation of the pancreas that leads to a decrease in the patients immunity and hypocalcemia and hypomagnesemia

Post op care for shunts

all shunt post op care the same watch for fluid volume overload and bleeding disorders Measure abd girth every shift give diuretics bc risk of right sided HF due to increased pressure Lactulose Rifaximin

Cause of endometrial (uterine) cancer?

associated with prolonged estrogen exposure without progesterone reproductive years family hx of endometrial or colon cancer obesity late menopause NULLIPARITY Smoking tamoxifen

Ammonia

increased in liver dysfunction can give lactulose normally excreted as urea in normal functioning livers

Where is the most common site for pancreatic cancer?

head of the pancreas

What is liver cancer associated with

hepatitis B and C chronic liver disease cirrhosis

Cause of jaundice

hepatocellular disease: cannot metabolize bilirubin so it builds up Obstruction: clogs bile ducts so excretion is not possible hemolytic: increased destruction of RBCs hereditary hyperbilirubinemia

when are acute pancreatitis most common?

holiday season/ vacations due to high fat diet and consuming more alcohol

decreased labs for acute pancreatitis

hypocalcemia and hypomagnesemia

Labs for liver cancer

increase of bilirubin levels, AST, GGT (gamma-glutamyl transpeptidase) LDH (lactic dehydrogenase) alpha-fetoprotien

increased Labs for acute pancreatitis

increased amylase, lipase, trypsin, elastase (amylase will be the FIRST lab to be elevated 12-24hr for 2-3 days) increased glucose d/t lack of insulin not being able to escape the pancreas increased bilirubin/ ALT increased WBC

what is an IR liver biopsy

trans jugular and used ultrasound to find liver - monitor for bleeding

If a patient is diagnosed with gallstones, is it best to get the gallbladder removed? true or false?

true

Early signs of liver cancer

usually asymptomatic besides jaundice

Late signs of liver cancer

weight loss anorexia weakness gi disturbances Pain: RUQ, back , epigastric, (feels dull, achy) Hepatomegaly upon palpitation Jaundice

What is the deal with reconstruction?

women have to be presented with the option to have reconstruction surgery may be implemented at the time of surgery use of tissue expanders under the muscles and may gradually expand over time over several weeks renal implant will be placed

Signs and symptoms of jaundice include

yellow / orangish colored skin: causes pruritis (itching) Yellow sclera Yellow tinged secretions Dark urine (tea colored, brown) Clay or white colored stool

is there a vaccine for hep B

yes