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MedSurg II - Unit 3 (liver&pancreas narratives)

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olanjones's version from 2017-04-17 17:43

Pancreatitis

Question Answer
Inflammation that occurs as a result ofthe enzymes of the pancreas eating (breaking down) the tissue of the pancreas
Common causes#1 cause gallbladder disease, #2 cause alcoholism
Main symptomAbd pain usu in LUQ that can radiate to the back (pancreas is retroperitoneal); pain is sudden, severe, deep, & continuous or steady, aggravated by eating & not relieved by vomiting
What may release of enzymes (esp trypsin) causeintravascular damage; the abdomen may be greenish to yellow brown color
Grey Turner’s signbluish flank discolorations which may look like ecchymosis
Cullen’s signbluish pre-umbilical discoloration from seepage of blood-stained exudate from the pancreas
When may shock occurwith hemorrhage into the pancreas, hypovolemia d/t fluid shift into the retroperitoneal space; toxemia may occur d/t the activated enzymes
Complicationspseudocyst (accumulation of fluid, enzymes, tissue, exudate surrounded by a wall); abscess (a collection of pus from necrosis in pancreas which can become infected or perforate)
PseudocystS/S: abd pain, may have palpable epigastric mass, N&V & anorexia
Dx: ultrasound (usu resolve on their own in a few weeks but may perforate & cause peritonitis)
Tx: surgical drainage; percutaneous cath placement & drainage; endoscopic drainage
AbscessS/S: abd pain, abd mass, high fever, leukocytosis
Tx: surgery to drain (to prevent sepsis)
Systemic issuesPleural effusion, pneumonia, ARDS, & cardiovascular hypotension; Hypocalcemia may cause tetany (sign of severe disease); Trypsin can activate prothrombin & plasminogen which ↑pt's risk of intravascular thrombi, PE, & DIC
Conservative tx Hydration, pain management (morphine & anti-spasmodics), may need O2 & glucose monitoring
How to ↓ pancreatic stimulationNPO status (may need NG tube to suction or for enteral feedings)
Tx for shockVolume expanders (albumin or dextran); may also receive LR for fluid imbalance; If hypotension doesn't respond to volume, may need Intropin (dopamine)
Why may pt need a cholecystectomyif they have gallstones & if the gallbladder disease is causing the pancreatitis (and they are not responding to conservative tx or drainage)
Why is challenging to diagnoseSymptoms are similar to many other abd issues (jaundice, low-grade fever, abdominal distention/tenderness); Pancreatitis pts may also have discoloration of the abdomen/flank, flushing, diaphoresis, basilar crackles, hypotension, & tachycardia
Assessments-Monitor VS, respiratory function, IV fluids & watch for electrolyte changes(esp for hypocalcemia & hypomagnesemia)
-Pain control (morphine, frequent positioning); Wound care (be checking glucose levels)
-PPIs, position in semi-Fowler’s, monitor for paralytic ileus
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Hepatitis

Question Answer
Inflammation of liver caused bya virus (A, B, C, D, & E)
Hep AContact w/ contaminated food or drinking water; are contagious BEFORE symptomatic (present in feces for up to 2 wks before)
–Acute, not chronic *Vaccination available (HeptaVax)
-Usually requires treatment
Hep BContaminated needles, syringes, blood products, sex w/ infected partner (carriers are infectious for life)
-Acute and/or Chronic *Vaccination available (HeptaVax)
-Only needs tx if the hepatitis is severe & pt goes into liver failure (may receive interferon)
Hep CBlood/blood products, needles, sex w/ infected partner (Epogen has ↓risk for dialysis pts b/c they need fewer blood products)
Causes chronic liver damage (there is also an acute type)
-Will receive interferon to prevent chronic infection
Hep DCannot survive on its own (needs Hep B to replicate) -Vaccine does not cover Hep D
S/S all typesAcute & Chronic phases: malaise, fatigue, poss enlarged liver (but can be asymptomatic)
Acute S/S1-4 mos; anorexia, wt loss, N&V, abd discomfort; may have skin rashes, low-grade fever, arthralgia; Exam may reveal hepatomegaly, lymphedema, splenomegaly, jaundice (dark urine, light/clay-colored stools, pruritus)
Convalescent S/Slasts wks-mos: Jaundice begins to disappear (hepatomegaly persists), spleen returns to normal size; most pts will recover w/ no complaints (may be re-infected w/ other types of hepatitis)
Complications (these are pts you will see in hospital)Acute liver failure, Chronic hepatitis (common w/ Hep C), Cirrhosis, Liver cancer (may also see pt w/ other conditions or surgery who also have hepatitis)
Nursing careAdequate nutrition/rest for liver regeneration (↓metabolic demands); Avoid ETOH
Interferon txPrevents viral replication; requires sub-q admin at least 3x a week d/t its short half-life (peglyated interferon is a long acting preparation & can be given once a week)
nucleoside & nucleotide analogue txInhibit DNA synthesis ↓viral replication (don't prevent all viral reproduction but so ↓the amount of virus in the body)
Other meds for Hep CProtease inhibitors & ribavirin - is teratogenic & should not be taken by anyone who is pregnant; pregnancy should also be avoided if the woman's partner is taking it
Assessment*Subjective questions: IV drug or alcohol abuse, high risk sexual behavior, exposure to an infected person, eating contaminated food or water, abdominal discomfort, & urine/stool color
*Objective data: low-grade fever, jaundice, a possible rash, hepatomegaly, splenomegaly, & abnormal lab values
Nutritionmay be challenging due to anorexia and the distaste of food; small, frequent meals will help; anorexia may be less in the morning (poss to eat a bigger breakfast)
What may help stimulate appetitemouth care, anti-emetics; avoid very hot or cold liquids, carbonated beverages may also help
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Cirrhosis Basics

Question Answer
What is itprogressive liver disease that causes extensive degeneration & destruction of the liver cells: cells → try to regenerate but are disorganized → abnormal growth of connective tissue which can impede blood flow → to ↓functioning & liver failure
What floors will you see these pts onMedSurg, CCU, Psych, Peds (older kids) – Especially in AK d/t ↑ETOH consumption
What are other causesChronic Hep C, Right heart failure (d/t ↓perfusion to the liver)
S/SEarly- may be none (pts w/ compensated cirrhosis may not know they have it)
Gradual: Jaundice, peripheral edema, ascites, liver failure, portal hypertension
Late: Skin lesions, endocrine disturbances, neurologic disorder
Jaundice caused by↓ ability of the liver to conjugate and excrete bilirubin (yellow skin, conjunctiva)
Skin lesions caused by↑in circulating estrogen d/t the liver's inability to metabolize steroids
Spider angiomassmall, dilated blood vessels with a bright red center & spiderlike branches which appear on the nose, cheeks, upper truck, neck, shoulders
Palmar erythemared areas that blanch with pressure on the palms
Hematologic disordersthrombocytopenia, leukopenia, anemia (secondary to spleen/portal HTN); coagulation disorders (liver's inability to produce prothrombin & other coagulation factors)
Dietary deficienciesthiamine, folic acid, & vitamin B12 causes peripheral neuropathy
Portal HTN caused byblockage/destruction of the portal & hepatic veins → shunts blood to low pressure areas → esophageal varices, ascites, splenomegaly, hepatic encephalopathy, hepatorenal syndrome
Complications of varicestolerate ↑pressure poorly/bleed easily; responsible for 80% variceal hemorrhages or can also slowly bleed which may result in melena or hematemesis; massive hemorrhage is a medical emergency - DUH
Ascites & peripheral edema caused byimpaired liver synthesis of albumin which ↓oncotic pressure allowing fluid to leak into the interstitium
Renal failure caused byrenal vasoconstriction reacting to the portal hypertension (if cirrhosis reversed, as in a liver transplant, the renal failure will reverse)
End result of liver failureliver is unable to convert ↑ammonia → hepatic encephalopathy d/t ammonia crossing the BBB (ammonia is very toxic to the brain & cannot be reversed)
S/S: changes in neurologic/mental responsiveness, impaired consciousness, sleep disturbances to coma, asterixis (flapping tremors involving arms & hands)
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Cirrhosis Nursing

Question Answer
If caused by ETOHmay need CIWA protocol
Tx for ascitesreceive albumin, diuretics (used for the edema), and sodium restriction; poss paracentesis (but the fluid will come back if pt’s albumin isn’t ↑enough); poss intrahepatic shunt
Tx for varicesvasopressin w/ nitroglycerin or Octreotide; Banding of the varices along w/sclerotherapy (an ablation therapy)
If bleeding occursstabilize the pt, manage airway, provide IV therapy & blood transfusions; balloon tamponade (acute esophageal hemorrhage that cannot be controlled with endoscopic banding/ablation)
Blakemore tube (type of balloon tamponade)-Has two balloons (for the gastric & esophageal varices) with lumens for aspiration; To avoid confusion you should label each lumen
-Proper use: deflate the balloons for 5 mins every 8-12 hrs per policy to prevent tissue necrosis; make sure pt is kept in semi-Fowler’s, gets good oral/nasal care
*Keep scissors at bedside in case you need to cut the balloon; *Balloons not used as frequently as banding/sclerotherapy
Tx for encephalopathy↓ ammonia levels w/ lactulose & rifaxim (an antibiotic) which cause you to poop it out (encourage fluids); Maintain a safe environment (neuro checks q 2 hrs)
Nutritionhigh calorie, high carbohydrates, low fat diet with protein supplements. If pt has ascites & edema may have low sodium diet
What might you see during objective assessmentwasting of extremities, jaundice, angiomas or erythema, ascites & peripheral edema (ask about bloody stools)
Monitor-Labs: for anemia, thrombocytopenia, leukopenia, ↓albumin & potassium, abnormal liver function studies, ammonia, & bilirubin levels & ↑INR
-Physical: I&Os, daily wts, abd girth (per shift), urine/stool for blood
Interventions-Rest: prevent complications, modify sched
-Nutrition: oral hygiene, snacks, food preferences, explain dietary restrictions
-Dyspnea: semi or high Fowler’s; cough/deep breathing for prevention
-Skin care: special mattress (alt-air pressure), turn q 2 hrs; ROM exercises; Elevate extremities, scrotal support
-Monitor for F&E, bleeding; Assess body image
Paracentesis: done whenpt is experiencing respiratory difficulty or having severe pain from the ascites
Paracentesis: prephave pt void, place in high Fowler position or sitting on the edge of the bed
Paracentesis: monitoringfluid electrolyte balance, the dressing for bleeding or drainage
Cirrhosis & liver cancerCan be difficult to differentiate because they have similar manis: dull abdominal pain in the epigastric/RUQ, anorexia, N&V, ↑abd girth; HCC can have pulmonary emboli & portal vein thrombosis
Tests used to screen and diagnose liver cancer are ultrasound, CT, MRI
*Usually liver cancer is a metastatic cancer meaning that it's not the primary site
Why are older adults vulnerable to drug induced liver injury↑ use of Rx & OTC drugs (can lead to drug interactions & potential toxicity); ↓liver function d/t aging process; may have Hep C and a resulting cirrhosis
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