Exam 2 for N241

Nursing care pancreatitis

* Positioning - fetal position sitting out of bed with feet on stool Head of bed elevated, sitting or leaning forward * NG tube which decreases the pancreatic enzyme formation * NPO * No alcohol

Clinical manifestations of pancreatitis

* Severe abdominal pain * Hypotension * Acute renal failure * Respiratory distress * Cullens sign and grey turners sign * Nausea and vomitting * Paralytic ileus * Hypocalcemia * Hyperglycemia * DIC * Steatorrhea * Generalized jaundice * Fever

Issues from auto-digestion of pancreas

* Micro emboli which leads to necrosis * Vasodilation - hypotension * Increase capillary permeability - hypotension that decreased blood flow to other organs * DIC * Hemorrhaging around pancreas

Medications for ACUTE pancreatitis

* Narcotics for pain: Morphine, hydromorphone for acute pain dilaudid, fentynl Ketorolac, an NSAID for mild pain * ABTS: Imipenem generally only used in clients who have acute necrotizing pancreatitis NO MEPERIDINE (DEMEROL) CAN CAUSE SEIZURES

Types of cirrhosis

-Postnecrotic --Viral hepatitis --Medications --Toxins -Laennec's --Chronic ETOH use -Biliary --Chronic biliary obstruction --Autoimmune disease

How do you take pancreatic enzymes

1 hr to immediately before eating

Three major hepatic themes and issues PROTEIN

1. Protein Comes from liver and food Amino acids break down food and release nitrogen Normally liver converts nitrogen into urea and the kidneys excrete it When liver fails, it does not convert nitrogen to urea and nitrogen accumulates Remember, protein ( albumin) creates colloid osmotic pressure to keep fluid in the blood vessels. So if protein is decreased, fluid will leak out of the vessels into cavities and tissues causing things like ascites, pleural effusions, and third spacing

Pain starts how long after eating during pancreatitis

24-48 hrs

A nurse is admitting a patient with cirrhosis. Which of the following prescriptions should the nurse anticipate? A. Obtain the clients PT and INR measurements B. Administer lactulose 30 ml PO 4 times daily C. Obtain daily weight and abdominal girth measurements D. Administer a daily multivitamin E. Place the client on a low-protein diet

A,B,C,D

A nurse is assisting a provider with performing a paracentesis on a client. Which of the following actions should the nurse take? A. Ask the client to empty his bladder before the procedure. B. Place the client leaning forward over the bedside table for the procedure. C. Inform the client he will be sedated during the procedure. D. Instruct the client to fast for 6 hr prior to procedure.

A. Ask the client to empty his bladder before the procedure to prevent injury to the bladder.

A nurse is teaching a group of clients about the functions of the liver and gallbladder. Which of the following should the nurse include in the teaching as the purpose of bile? A. Digesting fats B. Producing Chyme C. Stimulating gastric acid secretion D. Providing energy

A. Digesting fats

A nurse is caring for a client with a history of cirrhosis who has been admitted with manifestations of hepatic encephalopathy. The nurse should anticipate a prescription for which of the following lab tests to determine the possibility of recent excessive alcohol use? A. Gamma-glutamyl transferase ( GGT) B. Alkaline phosphatase (ALP) C. Serum bilirubin D. Alanine aminotransferase (ALT)

A. Gamma-glutamyl transferase (GGT) The GGT lab test is specific to the hepatobiliary system in which levels can be raised by alcohol and hepatotoxic drugs. Therefore, it is useful for monitoring drug toxicity and excessive alcohol use.

A nurse is teaching dietary-modification strategies to a client who has been newly diagnosed with cirrhosis. Which of the following foods should the nurse recommend? A. Grilled chicken B. Potato soup C. Fish sticks D. Baked ham

A. Grilled chicken The nurse should identify that a client who has cirrhosis requires protein to compensate for disease related weight loss. Increased protein intake from animal or plant source will also provide the client with more energy.

A nurse is caring for a client who is scheduled to undergo a liver biopsy for suspected malignancy. Which of the following laboratory findings should the nurse monitor prior to the procedure? A. Prothrombin time B. Serum lipase C. Bilirubin D. Calcium

A. Prothrombin time A major complication following liver biopsy is hemorrhage. Many clients who have liver disease have clotting defects and are at risk of bleeding.

A nurse is teaching a newly licensed nurse about caring for a client who is scheduled for an esophagogastric balloon tamponade tube to treat bleeding esophageal varices. Which of the following pieces of information should the nurse include in the teaching? A. The client will be placed on mechanical ventilation prior to this procedure. B. The tube will be inserted into the clients trachea. C. The client will receive a bowel prep with cathartics prior to this procedure. D. The tube allows the application of a ligation band to the bleeding varices.

A. The client will be placed on mechanical ventilation prior to this procedure.

Chemical and medication causes of hepatitis

Alcohol, ephedra, acetaminophen

A nurse is assessing a client who is in the early stages of hepatitis A. Which of the following manifestations should the nurse expect? A. Jaundice B. Anorexia C. Dark urine D. Pale stools

B. Anorexia Anorexia is an early manifestation of hepatitis A and is often severe.

A nurse is providing discharge teaching to the partner of a client who has a new diagnosis of hepatitis A. Which of the following instructions should the nurse include in the teaching? A. During this illness, she may take acetaminophen for fevers or discomfort. B. Encourage her to eat foods that are high in carbohydrates. C. The provider will prescribe a medication for her liver to heal faster. D. Have her perform moderate exercise to restore her strength more quickly

B. Encourage her to eat foods that are high in carbs. The clients diet should be high in carbs and calories with only moderate amounts of protein and fats especially if nausea is present.

Liver biopsy

Best test to determine extent of infection and degree of liver damage -Educate patient regarding procedure, obtain consent, NPO after midnight -Patient supine position with RUQ of abdomen exposed -Patient should exhale and hold for 10 seconds while needle inserted -Apply pressure after biopsy -Client to right side lying position for several hours

Hepatic Functions

Bile formation CHO, Fat, protein metabolism Protein formation Detoxification RBC formation and maturation Stores: iron, copper, vitamins A, D, E, K, B12 Deactivation of steroids and estrogen Converts ammonia to urea

Hepatitis C route of transmission

Blood IV drug use Blood, blood products, organ transplant Unprotected sex Contaminated needles Needle stick Dirty tattoo needles

Hepatitis B route of transmission

Blood Unprotected sex Infants born to infected mothers Contact with infected blood IV drug use

Diagnosis of pancreatitis LABS Serum amylase

Blood amylase increases within 24hr, and remains increased for 2-3 days

Diagnosis of pancreatitis LABS Serum Lipase

Blood lipase increases slowly and remains increased for days longer than amylase

Cullens sign

Bluish-gray periumbilical discoloration

A nurse is caring for a client who has acute pancreatitis. Which of the following serum laboratory values should return to the expected reference range within 72 hours of treatment beginning? A. Aldolase B. Lipase C. Amylase D. Lactic dehydrogenase

C. Amylase Pancreatitis is the most common diagnosis for marked elevations in serum amylase.

A nurse caring for a client who has abdominal pain and possible pancreatitis. Which of the following laboratory results the nurse identify as an indication of pancreatitis? A. Decreased wbc count B. Increased albumin level C. Increased serum lipase level D. Decreased blood glucose level

C. Increased serum lipase level Due to the release of lipase into the pancreas and auto-digestion, pancreatitis causes an increase serum lipase level.

A nurse is caring for a client who has fulminant hepatic failure. Which of the following procedures should the nurse anticipate for this client? A. Endoscopic sclerotherapy B. Liver lobectomy C. Liver transplant D. Trans-jugular intra-hepatic portal-systemic placement

C. Liver transplant Fulminant hepatic failure, most often caused by viral hepatitis, is characterized by the development of hepatic encephalopathy within weeks of the onset of disease in a client without prior evidence of hepatic dysfunction. Mortality remains high, even with treatment modalities such as blood or plasma exchanges, charcoal hemo-perfusion, corticosteroids. Consequently liver transplantation has become the treatment of choice in these clients.

A nurse in the emergency department is caring for a client who has bleeding esophageal varices. The nurse should anticipate a prescription for which of the following medications? A. Famotidine B. Esomeprazole C. Vasopressin D. Omeprazole

C. Vasopressin Vasopressin constricts the splanchnic bed and decreases portal pressure.

Hepatitis complications

Chronic hepatitis Fulminating hepatitis - Severe and deadly Cirrhosis Liver failure Liver cancer

Hepatitis D route of transmission

Co-infection with Hepatitis B IV drug use Unprotected sex with infected individual

Physical assessment findings in Liver failure

Cognitive changes altered sleep pattern gastroesophageal bleed splenomegaly ascites jaundice petechiae, ecchymosis, epistaxis, hematemesis palmar erythema spider angiomas extremity and sacral edema asterixis Fetor hepaticus

Hepatitis Nursing Care

Contact precautions if in hospital High carb, high calorie, low fat, low protein diet Small frequent meals Promote nutritional healing Promote liver rest -Only necessary medications -Avoid OTC and herbal supplements NO ETOH -Limited physical activity - want patient to rest Educate patient to prevent transmission of disease in their home -No sexual activity until Hep B surface antigen is negative Proper hand hygiene

A nurse is completing a history and physical assessment for a client who has chronic pancreatitis. Which of the following findings should the nurse identify as a likely cause of the clients condition? A. High calorie diet B. Gastrointestinal illness C. Tobacco use D. Alcohol use

D. Alcohol use

A nurse is monitoring the laboratory results of a client who has end-stage liver failure. Which of the following results should the nurse expect? A. Decreased lactate dehydrogenase B. Increased serum albumin C. Decreased serum ammonia D. Increased prothrombin time

D. Increased prothrombin time. Clients who have end-stage liver failure have an inadequate supply of clotting factors and an increased (prolonged) prothrombin time.

A nurse is performing a gastrointestinal assessment of a client who has liver cirrhosis with abdominal distention. Which of the following actions should the nurse take to assess for changes in the clients abdominal distention? A. Percuss the abdomen for tympanic sounds B. Inspect the contour of the abdominal wall C. Instruct the client to report increased abdominal discomfort D. Take serial measurements of the abdomen with a tape measure.

D. Take serial measurements of the abdomen with a tape measure.

Pancreatic LABS Platelets

Decreased

Pancreatic LABS Blood calcium and magnesium

Decreased due to fat necrosis with pancreatitis

Pancreas Exocrine functions 1 Amylase:

Digests carbs

Pancreas exocrine function 2 Lipase

Digests fats

Hepatic encephalopathy

Due to ammonia accumulation -Sources of ammonia --Protein in diet --GI bleed Pick answer with protein with least amount of fat

Risk for Liver failure

ETOH use ( Lennecs) Chronic viral infections Hep B,C,D Autoimmune hepatitis Steatohepatitis (fatty liver disease from chronic inlammation Meds/toxins/infection Chronic biliary issues ( bile duct obstruction, fibrosis) Cardiac cirrhosis (due to decreased perfusion)

Grey turners sign

Ecchymoses on flanks

Pancreatic LABS Erythrocyte sedimentation rate

Elevated

Gastroesophageal bleeding

Enlarged esophageal vessels develop from increased portal HTN Varices burst causing hematemesis and GI bleed Blood vessels become fragile due to ammonia and this makes blood vessels burst more easily Small bleeds may be able to be controlled but larger bleeds could be lethal

Patho of cirrhosis

Extensive scarring of liver from injury or chronic condition Normal tissue replaced with fibrotic tissue which does not function Portal areas affected most and decreased blood flow through liver occurs Liver enlarges and jaundice results

Signs and symptoms of liver failure

Fatigue weight loss abdominal pain and distention pruritus confusion or problems thinking due to toxin and ammonia buildup Personality and mental status changes

Hepatitis E route of transmission

Fecal-oral Ingestion of food or water contaminated with fecal waste Unscreened blood transfusions before 1992 Hemodialysis Contaminated needle use or needlestick Sharing utensils or toothbrushes Unprotected sex with an infected person Travel to an underdeveloped country Eating or living in crowded environments Jails Dormitories Universities long-term care military base housing

Hepatitis A route of transmission

Fecal-oral Ingestion of contaminated food, water, or shellfish Close personal contact with an infected person Sharing utensils or toothbrush

Hepatitis signs and symptoms

Flu like symptoms -Fatigue -Decreased appetite with nausea -Abdominal pain -Joint pain Fever Vomiting Dark colored urine Clay-colored stools Jaundice

Pancreas endocrine function 1 Apha cells

Glucagon

Labs for Hepatitis B

Hepatitis B surface antigen HBsAg Educate patient to refrain from sexual activity until Hep B surface antigen is negative

Hematologic complications of pancreatitis

Hyper-coagulable state, bleeding/hemorrhage

Metabolic complications of pancreatitis

Hyperglycemia, acidosis, hypocalcemia

Pulmonary complications of pancreatitis

Hypoxemia, atelectasis, pleural effusion, ARDS

Pancreatic LABS Serum Glucose

Increased due to a decrease in insulin production

Pancreatic LABS WBC

Increased due to infection

Three major hepatic themes and issues AMMONIA

Increased nitrogen in blood combines with hydrogen to form ammonia Ammonia causes neurological changes such as agitation, confusion, lethargy, and eventually coma and death if not treated Ammonia also causes blood vessel walls to become fragile and brittle and can break easily with increased pressure (portal HTN) coughing, sneezing, dry heaving, and bending at the waist Treatment for elevated ammonia levels is lactulose --can be administered orally, via NGT, or by retention enema which. needs to be 30-60 minutes 2-3 BMS a day and increased mental status and decreased ammonia level is what you want to achieve

Pancreatic LABS Blood liver enzymes and bilirubin

Increased with associated biliary dysfunction

Pancreatitis

Inflammation, edema, and autodigestion

Pancreas endocrine function 2 Beta cells

Insulin

Laboratory studies for Cirrhosis

Liver enzymes -AST asparatate amino transferase -ALT alanine aminotransferase -LDH lactic acid dehydrogenase -ALP alkaline phosphatase - also in bone, kidneys, and intestinal mucosa Cholesterol and phospholipids

Liver failure: Nursing interventions

Monitor respiratory status Monitor skin integrity Monitor fluid balance Monitor VS labs and pain level Monitor neurological status -Hepatic encephalopathy - lethargy and mild confusion can lead to coma and death Monitor nutrition GI assessment daily abd girth limit protein and fat

Management of hypovolemia in pancreatitis

Monitor urine output, monitor electrolytes, monitor for hypotension, and tachycardia.o. Provide IV fluid and electrolyte replacement

Management of pancreatitis Inhibition of pancreatic secretions by

NPO (PRIORITY INTERVENTION) NG tube

Chronic pancreatitis management

No narcotics- positioning and PPI's and H2 blockers Pancreatic enzymes Chronic pancreatic enzyme replacement

Biggest cause of pancreatitis

Obstruction of duct - Acute- biliary pancreatitis

Chronic pancreatitis

Occurrences of acute pancreatitis leads to chronic

Liver failure procedures

Paracentesis for ascites (causes hypotension and dehydration) Endoscopic variceal ligation/ sclerotherapy Transjugular intraheptic portosystemic shunt Surgical bypass shunt Liver transplant

Liver failure complications

Portal systemic hepatic encephalopathy - decrease protein and get rid of old blood Esophageal varices Graft rejection post liver transplant

Signs of hypocalcemia tetany

Trousseaus sign: Hand spasm when blood pressure cuff is inflated Chvosteks sign: facial twitching when facial nerve is trapped

Pancreas exocrine 3 Typsin

Protein

More Labs for liver failure

Protein/albumin - decreased RBC, Hgb/Hct - decreased Platelets - decreased PT/INR - increased Ammonia - increased ALT/AST/ALP - increased Bilirubin - increased

Management of pancreatitis Decrease hydrochloric acid by

Proton pump inhibitor Omeprozole (monitor for hypomagnesemia) Histamine receptor antagonists Cimetidine Pancreatic enzymes Pancrelipase

Labs: Liver failure

Serum liver enzymes (LDH, ALT, AST) -Increased initially due to inflammation -ALT and AST will return to normal once the liver cells can no longer be inflammed ALP -Increased due to intrahepatic biliary obstruction Total bilirubin -Increased

How do you know if they arent getting enough pancreatic enzymes?

Steatorrhea and signs of T2DM

Late sign of pancreatitis

Tetany caused by hypocalcemia Calcium deposits in pancreatic tissues

Liver failure diagnostic tests

US - detects ascites, hepatomegaly, splenomegaly, biliary obstruction Abdominal x-ray and CT scan - detects ascites, hepatomegaly and splenomegaly MRI - detects masses Liver biopsy - fibrosis EGD - Detects esophageal varices, gastric and duodenal ulcers ERCP - view biliary tract, remove stones, and place stents if needed

Liver failure medications

Use opioids, sedatives, barbiturates with CAUTION and Sparingly best to avoid completely Beta blockers - help decrease esophageal bleeding by decreasing BP and vessel pressure Lactulose - binds to ammonia and it is excreted via stool - Dose to 2-3 stools per day - Check mental status for effectiveness Its working when mental status is improved and decreased or normal ammonia levels are obtained

Viral causes of Hepatitis

Varicella zoster, cytomegalovirus, herpes simplex

Three major hepatic themes and issues BLEEDING

When the liver fails, it does not produce Vitamin K and that leads to an increased PT/INR and thin blood You can get Vit K from green vegetables or you can administer it as a medication Old blood breaks down and released Nitrogen - so which can increase ammonia levels ---Administer saline enemas or perform gastric lavage to remove this old blood if the patient is internally bleeding

If you open a capsule of pancreatic enzymes for a patient to take what do you teach them

Wipe lips and swish water in mouth

Number one cause of chronic pancreatitis

alcoholism

Cardiovascular complications of pancreatitis

angina, hypotension

Autodigestion

caused by pancreatic digestive enzymes that activate prematurely before reaching intestines