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278 Cards in this Set

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The various functions of the liver are caried out by?
hepatocytes
The liver produces & excretes?
bile
The liver produces and excretes bile (a greenish liquid) required for?
emulsifying fats
Some of the bile drains directly into the?
duodenum, and some is stored in the gallbladder
The liver also performs several roles in _____ & _______metabolism.
lipids & carbohydrates
The liver also performs several roles in lipid metabolism. Name them.
1- Cholesterol synthesis

2- The production of triglycerides (fats)
The liver performs several roles in carbohydrate metabolism. Name 3.
1- Gluconeogenesis (the synthesis of glucose from certain amino acids, lactate or glycerol)

2- Glycogenolysis (the breakdown of glycogen into glucose) (muscle tissues can also do this)
3- Glycogenesis (the formation of glycogen from glucose)
The synthesis of glucose from certain amino acids, lactate or glycerol?
Gluconeogenesis
The breakdown of glycogen into glucose) (muscle tissues can also do this?
Glycogenolysis:

The breakdown of glycogen into glucose. (muscle tissues can also do this)
The formation of glycogen from glucose?

a) Gluconeogenesis

b) Glycogenesis

c) Glycogenolysis
Glycogenesis

The formation of glycogen from glucose
The liver performs several roles in carbohydrate metabolism which include
Gluconeogenesis, Gycogenolysis, & Glycogenesis in addition to the breakdown of ______ & other _____.
insulin & other hormones
The liver is responsible for the mainstay of _____ metabolism.
protein
The liver produces what coagulation factors?
I (fibrinogen), II (prothrombin), V, VII, IX, X and XI, as well as protein C, protein S and antithrombin.
Creates metabolites that are added to bile as pigment (bilirubin and biliverdin).
haemoglobin

broken down by the liver
This sometimes results in toxication, when the metabolite is more toxic than its precursor
drug metabolism

The liver breaks down toxic substances and most medicinal products in a process called drug metabolism. This sometimes results in toxication, when the metabolite is more toxic than its precursor
The liver converts ammonia to ____?
urea
The liver stores glucose in the form of glycogen, ____, ____, and copper.
vitamin B12

iron
In the first trimester fetus, the main site of red blood cell production is?
liver
The liver is responsible for ______ effects.
immunological
The liver is responsible for immunological effects. The reticuloendothelial system of the liver contains many immunologically active cells, acting as a 'sieve' for ____ carried to it via the portal system.
antigens
Patients with liver dysfunction may exhibit . . .

Name 6.
1- Altered lipid & protein digestion

2- Altered Detoxification of blood

3- Altered Drug Metabolism

4- Altered Digestion as a whole (remember the bile)
= altered vitamin synthesis

5- Lack of energy (remember glycogen)

6- Irritation of other organs (think gallbladder/pancreas/brain)
Disorders of the liver.

NAME 6.
1- Viral Hepatitis (A,B,C,D,E,G)

2- Hepatitis 2nd to toxins (drugs, chemicals, alcohol

3- Autoimmune Hepatitis

4- Bacterial Hepatitis (steptococci, Ecoli, salmonella)

5- Jaundice Conditions

6- Cirrhosis Conditions
Complications from disorders of the liver.
Name 6.
1- Esophageal Varices

2- Portal Hypertension

3- Edema

4- Ascites

5- Encephalopathy

6- Hepatorenal syndrome
The primary manifestation from disorders of the liver is/are? jaundice
jaundice
Jaundice results from an alteration in normal _____ _____ or flow of bile into heptic or biliary duct systems.
bilirubin metabolism
Juandice is a symptom rather than disease.

true/false?
true
Bilirubin is formed by?
the breakdown of hemoglobin
Due to increased RBC breakdown 2nd to blood transfusion reaction, sickle cell crisis, hemolytic anemia?
Hemolytic jaundice
Altered ability of the liver to take up bilirubin or conjugate or excrete it. Causes include hepatitis, cirrhosis and carcinoma.
Hepaticellular hepatitis
Impeded or obstructed flow of bile, caused by stone obstructions, pancreas carcinomas, stool and urine changes noted with complete obstruction.
Obstructive jaundice
Hemolytic jaundice is due to _____ RBC breakdown 2nd to blood transfusion reaction, sickle cell crisis, hemolytic anemia.
increased
Hepaticellular hepatitis is the altered ability of the liver to take up bilirubin or conjugate or excrete it. Causes include _____, cirrhosis and carcinoma.
hepatitis
Obstructive jaundice is from impeded or obstructed flow of ____, caused by stone obstructions, pancreas carcinomas, stool and urine changes noted with complete obstruction.
bile
The only way to distinguish between what type of viral hepatitis is through ____ specific labs (table 42-4)
antigen
Infection by each type of hepatitis virus provides immunity to that virus only.

True/False
True
Vaccinations are available for Hep B but not Hep A.

True/False
False

Vaccinations are available for both Hep A & B
Available for Hep A exposure.
Immunoglobulin
Hepatic tenderness, hepatomegaly and splenomegaly may be revealed by?
Physical exam
Fecal-Oral hepatitis:

a) Hep A
b) Hep B
c) Hep C
d) Hep D
e) Hep E
f) Hep G
a) Hep A
Infection only with Hep B/Same routes:

a) Hep A
b) Hep B
c) Hep C
d) Hep D
e) Hep E
f) Hep G
d) Hep D
Parental/Per-mucosal/Sexual/Perinatal

a) Hep A
b) Hep B
c) Hep C
d) Hep D
e) Hep E
f) Hep G
b) Hep B
and . . .
Hep C
Fecal – Oral/contaminated water

a) Hep A
b) Hep B
c) Hep C
d) Hep D
e) Hep E
f) Hep G
e) Hep E
Parental/Sexual

a) Hep A
b) Hep B
c) Hep C
d) Hep D
e) Hep E
f) Hep G
f) Hep G
Hep A, B, C, D, E, & G all have similar pathophysiologic effects which are widespread _____ of liver tissue
inflammation
Acute damage from hepatitis causes cell _____ & ____
necrosis & cholestasis
Systemic damage from hepatitis includes angioedema, arthritis, fever and malaise, ____ & ____ damage
kidney and vascular
Damage from hepatitis occurs in _____ phases.
Three
Name the 3 phases of damge caused by hepatitis.
1- Preicteric/prodromal phase

2- Icteric phase

3- Posticteric/convalescent phase
Complications from hepatitis are are most recover completely unless comorbidities exist. 10% of HBV will have ____ ____chronic infection & 75% of HCV
chronic infection
A syndrome with severe impairment or necrosis with potential liver failure
Fulminant
Precedes jaundice & lasts from 1-21 days.
preicteric phase of viral hepatitis
Period of maximal infectivity for Hep A.
preiteric phase
Hep B positive & hep c patients can be infective for?
years
GI symptoms in patients w/hepatitis include anorexia, nausea, abdominal discomfort (r-upper quadrant) & sometimes vomiting, constipation, or diarrhea. The anorexia is often severe & may be due to _____ or other chemicals produced by the infectied liver.
cytokines
Phase of hepatitis characterized by jaundice.
icteric phase
The icteric phase of hepatitis is characterized by jaundice which generally last from ____ weeks.
2-4
Phase of hepatitis in which the urine may darken because of excess bilirubin excreted by the kidneys.
icteric phase
During the icteric phase of hepatitis, the urine may darken because of excess bilirubin excreted by the kidneys & if conjugated bilirubin cannot flow out of the liver because of an abstruction or inflammation of the bile ducts the stools will be?
light or clay colored
Pruritus sometimes accompanies jaundice especialaly if ____ is present.
cholestasis
Pruritus with jaundice occurs as a result of?
accumulation of bile salts beneath the skin
When jaundice occurs the fever usually rises.

true/false
false

once jaundice appears the fever usually subsides.

Gi symptoms generally remain & fatigue continues. Liver is usually enlarged & tender.
The posticteric phase of of hepatitis begins when?
jaundice is disappearing
How long will the posticteric phase last?
weeks to months with an average of 2-4 months
The patients jaundice has begun to disappear & the major complaint is malaise & easy fatigability. What phase is this?
posticteric phase
Phase when splenomegally subsides but hepatomegaly remains for several weeks.
posticteric phase
The disappearance of jaundice indicates that the patient is totally recovered.

true/false
false


does not mean patient has yet fully recovered & relapses may occur
All patients with viral hepatitis experience jaundice.

true/false
false
Anicteric hepatitis means?
hepatitis infection without occurance of jaundice & common in Hep A
You are caring for a patient who is in the preicteric phase of acute viral hepatitis. Your patient asks “am I going to turn yellow”? Which response is most appropriate?
“As your liver copes with the viral infection it can’t get rid of bilirubin which may cause your skin, urine or stool to turn yellow”
“Jaundice is scary, everything gets yellow”
“No, very few people turn yellow”
I am in question about this hypothetical presented.

The first response listed by instructor is a true response & "may" indeed cause skin to turn yellow.

However, the book states that "a high % of persons" w/HAV are anicteric & w/out symptoms in addition to stating 30% of all patients w/acute HBV & 80% with acute HCV are asymptomatic.
Hepatitis from an unknown cause which often includes systemic problems, s/s mimic viral hepatitis, elevated LFT without + viral lab & of which 70-80% of cases are female.
Autoimmune (Idiopathic) Hepatitis
Autoimmune (Idiopathic) Hepatitis is more common in men or women?
70-80% of cases are female
Autoimmune (Idiopathic) Hepatitis is of an unknown cause & often includes systemic problems. S/S mimic viral hepatitis, elevated LFT without + viral lab. This form of hepatitis is TX with?
corticosteroids and immunosuppressants
Unlike viral hepatitis, with Autoimmune (Idiopathic) Hepatitis there is evidence of ____ & ____.
cirrhosis and tissue necrosis
RX for Autoimmune (Idiopathic) Hepatitis is corticosteroids and immunosuppressant meds. Daily TX is with methylprednisone alone or in combination with ______ which will induce remission in apx 80% of patients.
azathioprine (Imuran)
RX for Autoimmune (Idiopathic) Hepatitis is corticosteroids and immunosuppressant meds. Daily TX with methylprednisone alone or in combination with Imuran which will induce remission in apx 80% of patients. If these RX & other immunosuppresive therapies do not work?
Liver transplant may be indicated for liver failure
Associated Lab Tests including the liver profile
almost are all abnormally ______due to destruction of hepatocytes and loss of all liver enzymes into the systemic circulation.

a) decreased
b) elevated
b) elevated
Peripheral edema sometimes precedes ascites but in some patients its development coincides with or occurs after ascites. Edema results from ____ colloidal oncotic pressure from impaired liver synthesis of albumin & increased portocaval pressure from portal hypertension.


a) decreased
b) increased
a) decreased
The accumulation of serous fluid in the peritoneal or abdominal cavity.
Ascites
A diagnostic procedure that can pick up on levels of protein/infection.
paracentesis
A therapeutic procedure that relieves pressure to aide breathing/comfort caused from ascites.
paracentesis
A chronic progressive disease of the liver with extensive destruction of parenchymal cells.
Cirrhosis of the Liver
In cirrhosis, cells attempt to regenerate but are disorganized and abnormal cell regeneration damages ___ ___ and bile ducts
blood vessels
Cirrhosis is a chronic progressive disease of the liver with extensive destruction of _____ _____
parenchymal cells
Cirrhosis equally affects men & women.

true/false
false

2X more common in men
There are 4 types of cirrhosis.

Name them.
1 - Alcoholic
2- Post necrotic
3- Biliary cirrhosis
4- Cardiac
A type of cirrhosis which is a complication of viral, toxic, or idiopathic hepatitis from which broad bands of scar tissue form.
Post necrotic cirrhosis of the of the liver
A type of cirrhosis that is associated with biliary obstruction and infection causing diffuse liver fibrosis and jaundice.
Biliary cirrhosis
Cardiac cirrhosis is caused from long standing ___ heart failure that causes congestion & scarring.
right
There are 4 major complications of cirrhosis which include
portal hypertension & esophageal varices, Peripheral edema & ascites, hepatic encephelopathy, & ____.
Hepatorenal syndrome
Incfreased venous pressure in the portal circulation, splenomegaly, large collateral veins, ascites, systemic hypertension & esophageal varices are charateristic of?
portal hypertension
Portal hypertension is caused by compression & destruction of the ____ & sinusoids due to structural changes in the liver from the cirrhotic process. These changes result in the obstruction of blood flow through the ____ ____.
portal veins

portal system
Portal hypertension results in ____ ____ in an attempt to reduce high portal pressure & reduce increased plasma volume & lymphatic flow.
collateral circulation
In portal hypertension, common sites for collateral circulation are?
lower esophagus

(left gastric vein & azygos veins)
Variscosities resulting from collateral circulation due to portal hypertension develop in the lower esophagus, the anteior abdominal wall, the parietal peritoneum and the rectum. Variscosities may develop in areas where the collateral & systemic circulations communicate resulting in esophageal & gastric varices and ____.
hemmorhoids
Esophageal varices are a complex of tortuous veins at the lower end of the esophagus which become _____ & ____ as a result of portal hypertension.
emlarged & swollen
The most life threatening complication of cirrhosis is?
bleeding esophageal varices
Approximately 30-50% of patients w/bleeding esophageal varices die within?
6 weeks of their 1st esophageal bleed
Varices that develop as a result of collateral circulation due to portal hypertension, are fragile & do not tolerate high pressure causing distention, ruptures thus bleeding. Ruptures & bleeds occur in response to ulcerations & irritation usually caused from numerous factors. Name some of these factors.
1- ingesting alcohol

2- not chewing food wll
course foods

3- acid reguritation from stomach

4- increased abd pressure
caused by:

a-nausea
b-vomiting
c-straining at stool
d-coughing
e-sneezing
f-heavy lifting
A medical emergency as a result of esophageal carices is:
massive hemmorrhage
Thi scondition results from decreased colloidal oncotic pressure from impaired liver synthesis of albumin & increased portocaval pressure from portal hypertension.
edema
Edema as a result of portal hypertension occurs as ankle & ____ edema.
presacral
The accumulation of serous fluid in the peritoneal or abdominal cavity which is a common manifestation of cirrhosis.
ascites
Ascites occurs when blood pressure is elevated in the liver causing ____ to move from the blood vessels via the larger pores of the sinusoids into the ____ space.
proteins

lymph
Occurs when the lymphatic system is unable to carry off the excess proteins & water & begin to leak through the liver capsule into the peritoneal cavity, thus osmotic pressure of the proteins pulls additional fluid into the peritoneal cavity.
ascites
A second mechanism of ascites formation is hypoalbuminemia that results from the inability of the liver to synthezize _____.
albumin
Secondary to ascites, this condition results from the inability of the liver to synthezize albumin.
hypoalbuminemia
Hypoalbuminemia, secondary to ascites results from the inability of the liver to synthesize albumin which causes _____colloidal oncotic pressure.
decreased
A 3rd mechanism of ascites is hyperaldosteronism. Hyperaldosteronism occurs when aldosterone is not metabolized by damaged hepatocytes causing increased levels of ____ which in turn increases ____ reabsorption by the renal tubules.
aldosterone

sodium
A 3rd mechanism of ascites is hyperaldosteronism which occurs when aldosterone is not metabolized by damaged hepatocytes causing increased levels of aldosterone which in turn increases sodium reabsorption by the renal tubules. This retention of sodium & increase on antidiuretic hormone causes?
additional water retention in patients with ascites
Due to edema formation as a result of hyperaldosteronism, there is decreased intravascular volume & subsequently decreased ____ ____ ____ & glomerular filtration.
renal blood flow
Decreased colloidal pressure from impaired liver synthesis of albumin and increased pressure secondary to portal HTN is?
Peripheral Edema
Secondary to or in addition to Peripheral Edema may be the development of ____?
Ascites
Accumulation of serous fluid in the peritoneal or abdominal cavity is?
Ascites
Manifestations of ascites are weight gain, & if severe, the umbilicus may be inverted, & abdominal striae with distended abd wall veins can be observed. What are some other manifestations?
Can you name 3?
1- dehydration

2- dry tongue, dry skin, sunken eyeballs, & muscle weakness

3- decreased urinary output

4- hypokalemia due to excessive loss of K+ because of affects of aldsterone & also resultant from diuretic therapy used to treat ascites
With ascites, this e;ectolyte imbalance is likely to occur?
hypokalemia
Hypokalemia in association with ascites is common & due to an excessive loss of K+ because of the affects of ____?
aldosterone
Hypokalemia can result in ascites because of the effects of aldosterone but can also occur due to?
diuretic therapy used to TX the ascites
Too much aldosterone, too much water in the wrong place, decreased renal vascular flow triggers excessive levels of ADH hormone causing what?
More water retention!
In association with ascites, ___ ___ can occur r/t vasoconstriction due to ?
renal failure

decreased reanl blood flow & glomerular filtration
A neuropsychiatric manifestation of liver damage that is a terminal complication.
Hepatic Encephalopathy

COMA !!!
The manifestation which is characteristic of hepatic encephalopathy is?
A coma !!!
Hepatic encephalopathy is a coma that can occur in any condition in which the liver damage causes ____ to enter the sytemic circulation without liver detoxification.
amonia
Hepatic Encephalopathy is a terminal complication that can occur in any condition where liver damage causes ammonia to enter the ____ ____ without liver detoxification. The ammonia comes from the ____ then routed through hepatic circulation where it is converted to urea in the kidneys & excreted.
systemic circulation

intestines
Hepatic Encephalopathy is a terminal complication that can occur in any condition where liver damage causes ammonia to enter the systemic circulation without liver detoxification. Normally, ammonia goes to the ___ via portal circulation. However, due to collateral circulation blood is shunted past the liver & the ammonia is not converted to ____ which is normally excrested by the kidneys but instead remains in the systemic circulation.
liver

urea
Ammonia doesn’t belong in the systemic circulation & values of ammonia greater than ___ causes neurological changes ranging from lethargy to ___
30

coma
In association with hepatic encephalopathy, ammonia crosses the ___ ___ ___ which produces neurotoxic manifestations.
blood brain barrier
A risk associated with the TX of reducing portal hypertension using surgical shunt precedures is?
hepatic encephalopathy
In the early stages of hepatic encephalopathy, manifestions are?
euphoria & depression

apathy & irritability

memory loss & confusion

yawning & drowsiness

slow & slurred speech

emotional lability & impaired judgment

hiccups & slow deep respirations

hyperactive reflexes

POSITVE BABINSKI reflex
With hepatic encephelopathy, disorientation to time, place, or person, & flapping tremors (asterixis)are?
signs of impending coma
Asterixis is?
flapping tremors

most commonly rapid flexion & extension movements in hands & arms when stretched out; unable to hold hands & arms in position when stretched out
Apraxia is?
the inability to construct simple figures as with using a pen or pencil from left to right
In addition to disorientation & asterixis, other signs of impending coma (hepatic encephalopathy) are?
apraxia, hyperventilation, hypothermia, grimacing, & grasping reflexes.
Term used to describe a musty, sweet, odor of the breath caused from an accumulation of digestive by products that the liver cannot degrade.
fetor hepaticus
Nmae 3 characteristics of hepatic encephelopathy.
1- asterixis (flapping tremors)

2- apraxia (difficulty using pen from left to right)

3- fector hepaticus (musty, sweet breath odor)
A serious complication of cirrhosis characterized by functional renal failure w/advancing azotemia, oliguria, & intractable ascites.
Hapatorenal syndrome
In cirrhosis there are abnormalities in most of the liver function studies.

enzyme levels are decreased or elevated?
elevated

AST, ALT, SGOT, SGPT, GGT
In cirrhosis there are abnormalities in most of the liver function studies of which enzyme levels are elevated in addition to increased ____ levels. Protein metabolism tests are _____.
globulin

decreased
Early manifestations of cirrhosis may include GI disturbances, anorexia, dypepsia, flatulence, N&V, & change in bowel habits. These symptoms occur as a result of?
livers altered metabolism of carbs, fats, proteins
Early manifestations of cirrhosis may include GI disturbances, anorexia, dypepsia, flatulence, N&V, & change in bowel habits as a result of result of livers altered metabolism of carbs, fats & proteins. The patient may also complain of?
abd pain described as dull, heavy feeling in the R-upper quadrant or epigastrium

may be due to swelling & stretching of liver capsule, spasm of bilary ducts, or intermittant vascular spasm
Early manifestations of cirrhosis may include GI disturbances, anorexia, dypepsia, flatulence, N&V, & change in bowel habits as a result of result of livers altered metabolism of carbs, fats & proteins. Patient may also complain of dull, heavy pain in the R-upper quadrant & other manifestations may include?
fever, lassitude, slight weight loss, & enlargement of the liver & spleen
Later manifestations of cirrhosis are?

Name 5.
1-jaundice
2-skin lesions
3-hematologic problems
4-endocrine disturbances
5-peripheral neuropathy
attributed to an increase in circulating estrogen as a result of the damaged liver's inability to metabolize steroid hormones:

a) jaundice
b) skin lesions
c) hematologic problems
d) endocrine disturbances
e) peripheral neuropathy
b) skin lesions

spider angioma's
due to an accumulation of bile salts underneath the skin

a) jaundice
b) skin lesions
c) hematologic problems
d) endocrine disturbances
e) peripheral neuropathy
a) jaundice
Throbocytopenia, leukopenia, & anemia probably caused by splenomegaly in patients with cirrhosis:

a) jaundice
b) skin lesions
c) hematologic problems
d) endocrine disturbances
e) peripheral neuropathy
c) hematologic problems
In patients with cirrhosis hemmorrhagic phenomina or bleeding tendencies such as epitaxis, purpura, petechiae, easy bruising, gingival belleding, & heavy menstrual bleeding are characteristics associated with:

a) jaundice
b) skin lesions
c) hematologic problems
d) endocrine disturbances
e) peripheral neuropathy
c) hematologic problems
Signs & symptoms relating to the metabolism & inactivation of adrenocortical hormones such as estrogen, & testosterone in patients wth cirrhosis are associated with:

a) jaundice
b) skin lesions
c) hematologic problems
d) endocrine disturbances
e) peripheral neuropathy
d) endocrine disturbances
In patients with cirrhosis, gymecomastia, loss of axillary & pubic hair, testicular atrophy, & impotence with a loss in libido occur as a result of:

a) jaundice
b) skin lesions
c) hematologic problems
d) endocrine disturbances
e) peripheral neuropathy
d) endocrine disturbances
In patients with cirrhosis, gymecomastia, loss of axillary & pubic hair, testicular atrophy, & impotence with a loss in libido occur as a result of:
estrogen accumulation
With cirrhosis, amennorrhea may occur in younger women & in older women there may be?

a) jaundice
b) skin lesions
c) hematologic problems
d) endocrine disturbances
e) peripheral neuropathy
vaginal bleeding
In cirrhosis, the liver fails to metabolize ______ adequately resulting in hyperaldosteronism with subsequent sodium & water retention & ____ loss.

a) jaundice
b) skin lesions
c) hematologic problems
d) endocrine disturbances
e) peripheral neuropathy
aldosterone

K+
In cirrhosis, the liver fails to metabolize aldosterone adequately resulting in hyperaldosteronism with subsequent sodium & water retention & K+ loss whic is associated with later manifestations of ?


a) jaundice
b) skin lesions
c) hematologic problems
d) endocrine disturbances
e) peripheral neuropathy
d) endocrine disturbances
A common finding in alcoholics with cirrhosis due to a dietary deficiency of thiamine, folic acid, & cobalamin which are associated with later manifestations associated with:

a) jaundice
b) skin lesions
c) hematologic problems
d) endocrine disturbances
e) peripheral neuropathy
e) peripheral neuropathy
A red area that blanches with pressure & located on the palms of the hands is termed ______ ______ & associated with an increase in circulating estrogen due to the inability of the damaged liver to metabolize ___ ___.
Palmar erythema

steroid hormones
Disorder of the liver most commonly caused by viral hepatitis secondary to drugs such as tylenol + ETOH, Isoniazid, sulfa drugs & NSAIDS).
Fulminant Hepatic failure
A clinical syndrome of which there is severe impairment associated with development of hepatic encephalopathy. Lab studies will reveal increased LFT, prolonged PT, increased bilirubin. This condition may require liver transplant.
Fulminant Hepatic failure
Primary Liver Cancer originates in the liver, is rare & most common in?
males
In Fulminant Hepatic failure, hepatic encephelopathy usually occurs with the 1st ___ of the 1st symptoms.
8 weeks
The most common cause of Fulminant Hepatic failure is?
viral hepatitis

in particular with HBV

may also manifest with HAV

less frequent in HCV
With viral hepatitis being the most common cause of Fulminant Hepatic failure, the second leading cause is?
drugs
In considering the second most common cause of Fulminant Hepatic failure, the most common offending agent is?
acetaminophen in combination w/alcohol
Though the combination of acetaminophen in combination w/alcohol is the most common offending agent in causing Fulminant Hepatic failure other drugs would include?
isonizid, fluothane, sulfa containing drugs & NSAIDS
Symptoms of Fulminant Hepatic failure are?
jaundice & S/S of hepatic encephalopathy
TX for Fulminant Hepatic failure may be?
liver transplantation
Approxinmately 20% of these patients will develop cirrhosis?
Chronic Hep C
Approxinmately 10-20% of these patients will develop cirrhosis?
Chronic Hep B
ALthought there is no specific therapy for cirrhosis, certain measures can be taken to promote liver cell regeneration & prevent complications. A significant measure is?
rest

reduces metabolic demands of the liver & allows for recovery of liver cells.
At various times during the progress of cirrhosis, rest may have to take on the form of complete bed rest.

true/false
true
Management of ascites is focused on what 3 things?
1- sodium restriction
2- diuretics
3- fluid removal
Restriction of sodium in TX of patients w/ascites can result in?
reduced nutritional intake & subsequent problems associated with malnutrition
In patients undergoing TX for ascites, the patient is not on restricted fluids unless severe ascites develops. Accurate assessment of ____ & ____ balance is necessary.
fluid & electrolyte
In patients with ascites, this is a potassium sparing & effective diuretic even in patients with severe sodium retention.
aldactone

(antagonist of aldosterone)
In patients with ascites, this is a high-potency loop diuretic that is fequently used in combination with a potassium sparing drug.
Lasix
A needle puncture of the abdominal cavity that nmay be performed to remove ascitic fluid.
paracentesis
Paracentesis is a TX for ascites that is reserved for the patient with ____ ____ or abdominal pain caused by severe ascites.
impaired respirations
A surgical procedure that provides continuous reinfusion of ascitic fluid into the venous system.
Paeritonovenous shunt
The main goal of patients with esophageal varices is?
avoidance of bleeding & hemmorrhage
The patient w/esophageal varices should avoid what 3 things?
alcohol
aspirin
irritating foods
When variceal bleeding occurs, the 1st step is to?
stabilize the patient & manage the airway

IV therapy is initiated & may involve administration of blood products
DX of esophageal varices is made by?
endoscopic examination ASAP
The goal of TX for hepatic encephalopathy is?
reduction of ammonia formation

protien reduction
The diet for patients with cirrhosis without complications is?
high calories (3000kcal/day)

high carb, low fat & prorein determined by degree of liver damage
Diets for patients w/hepatic encephalopathy are low in ?
protein to NO protein
The common etiologies for cirrhosis are alcohol, malnutrition, hepatitis, biliary obstruction & ___ ___ ___ ___.
R-sided heart failure
Acute hepatitis must be identified & TX early so that it does not progress to?
chronic hepatitis
Biliary disease must be TX early so that the stones do not cause ___ & ___.
obstruction & infection
The focus of NRSG care for patients w/cirrhosis is on?
conserving the patients strength; promoting rest
The focus on patients w/cirrhosis who are on complete bed rest are what 3 things?
1- measures to prevent pneumonia

2- prevent thromboembolic problems

3- prevent pressure ulcers
Anorexia, N&V, pressure from ascites & poor eating habits all create problems in maintaining adequate nutrition. NRSG measures would include?
1- oral hygiene

2- between meal nourishments

3- provide food preferences when possible

4- explain any necessary dietary restrictions to pt & family
NRSG assessment of pts w/ cirrhosis include pt's physiologic response to cirrhosis which include: is jaundice present?; where is it observed?; what is the progression. What observations will you be making?
1-presence of pruritus
2- relieve itching (Questran)
3- color of urine
4-color of stools
5- is urine foamy?
6-presence of edema or ascites
7- intake & output
8-daily weights
9-measurements of extremities
10-measurements of abd girth
When pts have paracentesis done tghe NRS should have the patient ___ ___ before the procedure to revent puncture of the _____.
void immediately

bladder
The proper position for a patient undergoing paracentesis is sitting on the side of the bed or in ____ ___.
high Fowler's
After a pt has paracentesis done, the NRS should do what 3 things?
1- monitor for hypovolemia

2- monitor electrolyte imbalances

3- check the dressing for bleeding & leakage
A common problem for patients with ascites is___ & should be placed in what position?
dyspnea

semi-Fowlers or Fowlers position to allow for maximal respiratory efficiency
In caring for patients with ascites, meticulous skin vcare is essential because of?
edematous tissue is subject to breakdown

air mattress, turning schedule, pillows, ,ROM, TCDB, elevation of lower extremities
In caring for patients with ascites & the patient is taking diuretics, what serum levels should be monitored?
K+, CL-, & Bicarbonate
In patients with ascites & taking diuretics the patient should be observed for fluid & electrolyte imbalance especially?
K+
Hypokalemia is manifested by what 4 signs?
1-cardiac arrhythmias
2- hypotension
3- tachycardia
4-generalized muscle weakness
Excess water retention is manifested by 4 signs?
1-muscle cramping
2-weakness
3-lethargy
4-confusion
If a patient has esophageal varices in addition to cirrhosis the nurse must observe for any signs of?
any signs of bleeding

hematemesis & melena
If hematemesis occurs the nurse should assess the patient for _____, call the physician, & be ready to assist with whatever TX is used to control the bleeding.
hemmorrhage
If hematemesis occurs, the nurse will assess the patient for hemmorrhage, call the physician, & ready to assist with whatever TX is used to control the bleeding. The NRS will anticipate what 2 things will happen next?
1- patient will be admitted to ICU

2-patients airway must be maintained
The focus of nursing care of patients w/ hepatic encephalopathy is?
sustaining life & assisting w/measures to reduce formation of amonia
In assessing the patient w/hepatic encephalopathy the NRS will do what 5 things?
1- assess level of responsivness (reflexes, pupils, orientation)

2- sensory & motor abnormalities (hypereflexia, asterixis, motor coordination)

3-fluid & electrolyte imbalance

4- acid base imbalance

5- effectiveness of TX measures
When Balloon tamponade is is used for esophageal varices the initial nursing task related to insertion of the tube will be to?
explain the use of this tube & how it will be inserted

balloons shoul dbe checked for patency

secure tube with a piece of sponge or foam rubber at the nostrils (nasal cuff)
Sometimes a saline lavage is used to remove blood from the stomach to prevent degradation to amonia which leads to encephalopathy. The balloon used in this procedure should be deflated every ___-___ to avoid necrosis.
8-12 hours

Each lumen must also be labeled to avoid confusion
The most common complication of of balloon tamponade is?
aspiration pneumonia
Nursing care for patients with a balloon tamponade includes monitoring for complications of rupture or erosion of the esophagus, regurgitation & aspiration of gastric contents, &?
occulsion of the airway by the balloon
WHat should be kept at the bedside of a patient with a balloon tamponade?
scissors

if the ballon breaks or is deflated, the esophageal balloon will will slip upward obstruct airway & cause asphyxiation. In this event:

cut the tube or deflate the esophageal balloon

Reguritation is minimized by oral & pharengeal suctioning& keeping patient in semi-Fowlers position
NRSG assessments of a patient w/hepatic encephalopathy will include neurologic checks q2h. Measures to prevent constipation are important because?
need to decrease ammonia production

drugs, laxatives & enemas should be administered as prescribed

encourage fluids if not contraindicated

Patient should not strain at stool to prevent bleeding of hemmorroidal varices
The most common primary liver cancer is?
hepatocellular carcinoma
A high % of patients w/primary cell carcinoma have?
cirrhosis of the liver
Hepatocellular carcinoma is often associated with chronic liver diseases including?
chronic Hep B & C
More common than primary liver carcinoma?
metastatic carcinoma of the liver
In liver cancer, malignant cells cause the liver to be enlarged & _____, hemmorrhage & necrosis is common.
misshapened
Primary liver tumors commonly metastasisize to the?
lung
Test used to assist in diagnosis of liver cancer are?
CT

hepatic arteriography

ERCP endoscopic retrograde cholangiopancreatography

liver biopsy

AFP alphafetoprotein (+)
Lab study in patients with hepatocellular carcinoma (70%) that helps to distinguish primary cancer from metastatic cancer?
AFP alphafetoprotein (+)
An effective immunosuppressant used in patients with liver transplants that does not impair healing or suppress bone marrow.
Cyclosporine
Type of jaundice assoc. w/ gallstone is?
obstructive
With obstructive jaundice, the type of serum bilirubin that is most likely elevated is?
conjugated
Hemolytic jaundice is caused by?
an increased breakdown of RBC's.
Hemolytic jaundice caused by an increased breakdown of RBC's will reflect what type of elevated bilirubin?
unconjugated
Jaundice that occurs from failure of the liver to conjugate & excrete bilirubin is known as?
hepatocellular
Jaundice that occurs from failure of the liver to conjugate & excrete bilirubin is Hepatocellular jaundice & causes elevations in conjugated & unconjugated ____?
bilirubin
IV drug use is method of greatest transmission

a) Hep A
b) Hep B
c) Hep C
d) Hep D
e) Hep E
c) Hep C
Type that is uncommon in the U.S.

a) Hep A
b) Hep B
c) Hep C
d) Hep D
e) Hep E
e) Hep E
Exists only with Hep B

a) Hep A
b) Hep B
c) Hep C
d) Hep D
e) Hep E
d) Hep D
Caused by a DNA Virus

a) Hep A
b) Hep B
c) Hep C
d) Hep D
e) Hep E
b) Hep B
Most common cause of chronic hepatitis

a) Hep A
b) Hep B
c) Hep C
d) Hep D
e) Hep E
c) Hep C
Often causes asymptomatic anicteric hepatitis

a) Hep A
b) Hep B
c) Hep C
d) Hep D
e) Hep E
a) Hep A
Chronic carriers have increased risk for hepatocellular cancer

a) Hep A
b) Hep B
c) Hep C
d) Hep D
e) Hep E
b) Hep B
Has no chronic carrier state

a) Hep A
b) Hep B
c) Hep C
d) Hep D
e) Hep E
a) Hep A
No readilay available serology tests

a) Hep A
b) Hep B
c) Hep C
d) Hep D
e) Hep E
e) Hep E
Usual cause of hepatitis epidemics

a) Hep A
b) Hep B
c) Hep C
d) Hep D
e) Hep E
a) Hep A
The systemic effects of viral hepatitis are caused primarily by:

a) cholestasis
b) impaired portal circulation
c) toxins produced by the infected liver
d) activation of the compliment system by antigen-antibody complexes
d) activation of the compliment system by antigen-antibody complexes
During the preicteric phase of viral hepatitis, the nurse would expect to report

a) pruritus & malaise
b) dark urine & easy fatigability
c) anorexia & r-upper quadrant discomfort
d) constipation or diarrhea w/light colored stools
c) anorexia & r-upper quadrant discomfort
Fulimant hepatic failure as a complication of viral hepatitis is highest in those individuals with

a) hep a
b) hep c
c) hep B accompanied w/hep c
d) hep b accompanied w/hep d
d) hep b accompanied w/hep d
The family members of a patient w/hep A asks if there is anything that will prevent them from developing the disease. The best response is

a) No immunization is available for hep A, nor are you likely to get the disease

b) only people who have had sexual contact w/the patient should receive immunizations

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 w/the patient should receive immune globulin
d) those who have had household or close contact w/the patient should receive immune globulin
A patient newly diagnosed w/ acute hep B asks if there is drug therapy to TX the disease. The appropriate response by the nurse is informing the patient that

a) there are no specific drug therapies that are effective for TX viral hepatitis

b) only chronic hep C is treatable w/antiviral agents or interferon

c) no drugs can be used for TX of viral hep C because of risks assoc w/additional damage to liver

d) interferon combined w/epivir will decrease viral load & liver damage if taken for 1 yr
a) there are no specific drug therapies that are effective for TX viral hepatitis
The nurse identifies a need for further teaching when the patient with hep B states

a) i should avoid alcohol completely for as long as a year
b) i must avoid all physical contact w/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 can tolerate it
b) i must avoid all physical contact w/my family until the jaundice is gone
One of the most cjhalenging nursing interventions to promote healing in the patient w/viral hep is

a) providing adequate nutritional intake
b) promting strict bed rest
c) providing pain relief w/out using liver metabolized drugs
d) providing quiet diversional activities during periods of fatigue
a) providing adequate nutritional intake
When caring for a patient with autoimmune hep, the nurse recognizes that unlike viral hep, the patient

a) does not manifest hepatomegaly or jaundice
b) experiences less liver inflammation or damage
c) is TX w/corticosteroids or other immunosuppresant agents
d) is usually an older adult who has used a variety of prescription & over-the-counter drugs
c) is TX w/corticosteroids or other immunosuppresant agents
Diffuse liver fibrosis

a) alcoholic
b) postnecrotic
c) biliary
d) cardiac
c) biliary
Vascular congestion of liver

a) alcoholic
b) postnecrotic
c) biliary
d) cardiac
d) cardiac
related to malnutrition

a) alcoholic
b) postnecrotic
c) biliary
d) cardiac
a) alcoholic
associated with chemical toxicity

a) alcoholic
b) postnecrotic
c) biliary
d) cardiac
b) postnecrotic
Early fatty infiltration

a) alcoholic
b) postnecrotic
c) biliary
d) cardiac
a) alcoholic
Viral induced

a) alcoholic
b) postnecrotic
c) biliary
d) cardiac
b) postnecrotic
Chronic biliary obstruction

a) alcoholic
b) postnecrotic
c) biliary
d) cardiac
c) biliary
Testicular atrophy

a) decreased prothrombin production
b) vascular congestion of spleen
c) decreased estrogen metabolism
d) stretching over liver capsule
c) decreased estrogen metabolism
Anemia, leukopenia, thrombocytopenia

a) decreased prothrombin production
b) vascular congestion of spleen
c) decreased estrogen metabolism
d) stretching over liver capsule
b) vascular congestion of spleen
Dull, heavy, RUQ pain

a) decreased prothrombin production
b) vascular congestion of spleen
c) decreased estrogen metabolism
d) stretching over liver capsule
d) stretching over liver capsule
Petechia & pupura

a) decreased prothrombin production
b) vascular congestion of spleen
c) decreased estrogen metabolism
d) stretching over liver capsule
a) decreased prothrombin production
Jaundice

a) decreased bilirubin conjugation & excretion
b) altered carbohydrtate, protein, & fat metabolism
c) decreased testosterone metabolism
d) vitamin B deficiencies
a) decreased bilirubin conjugation & excretion
anorexia & dyspepsia

a) decreased bilirubin conjugation & excretion
b) altered carbohydrtate, protein, & fat metabolism
c) decreased testosterone metabolism
d) vitamin B deficiencies
b) altered carbohydrtate, protein, & fat metabolism
amennorrhea

a) decreased bilirubin conjugation & excretion
b) altered carbohydrtate, protein, & fat metabolism
c) decreased testosterone metabolism
d) vitamin B deficiencies
c) decreased testosterone metabolism
Peripheral neuropathy

a) decreased bilirubin conjugation & excretion
b) altered carbohydrtate, protein, & fat metabolism
c) decreased testosterone metabolism
d) vitamin B deficiencies
d) vitamin B deficiencies
spider angiomas

a) decreased prothrombin production
b) vascular congestion of spleen
c) decreased estrogen metabolism
d) stretching over liver capsule
c) decreased estrogen metabolism
male gynocomastia

a) decreased prothrombin production
b) vascular congestion of spleen
c) decreased estrogen metabolism
d) stretching over liver capsule
c) decreased estrogen metabolism
Portal hypertension & the resulting increased hydrostatic pressure cause leakage of plasma into the abd cavity from 3 major sources.

Nmae them.
1- liver lympatics

2- liver tissue

3- intestinal vasculature
In addition to the liver lympatics, liver tissue, & the intestinal vasculature, fluid also moves into the abd cavity & produces ascites because of decreased serum oncotic colloidal pressure. The decreased serum colloidal pressure is caused by?
decreasing liver production of albumin
Fluid sequestering in the peritoneal cavity results in (increased/decreased) vascular volume, (increased/decreased) blood return to the heart, & (increased/decreased) cardiac output.
decreased
decreased
decreased
The change in cardiac output results in (increased/decreased) kidney perfusion & secretion of ____ & ____, both of which increase fluid retention.
decreased

aldosterone

ADH
The retained fluid has low oncotic colloidal pressure, & it escapes into the interstitial spaces causing _______.
peripheral edema
Excessive fluid cntinues to be reabsorbed from the kidney because of the altered kidney perfusion & because ____ is not metabolized by the impaired liver.
aldosterone
The changes in lab test results that relate to this process are ____ & ____.
hypoalbuminemia

hypokalemia
Lab tests results that the nurse would expect to find in a patient with cirrhosis include

a) serum albumin: 7.0 g/dl (70g/L)
b) bilirubin: total 3.2 mg/dl (54.7 umol/L)
c) serum cholesterol: 260 mg/dl (6.7 mmol/L)
d) asparate aminotransferase (AST): 6U/L (0.1 ukat/L)
b) bilirubin: total 3.2 mg/dl (54.7 umol/L)
The nurse recognizes early signs of hepatic encephalopathy in the patient who

a) menifests asterixis
b) becomes unconscious
c) has increasing oliguria
d) is irritable & letahrgic
d) is irritable & letahrgic
A patient w/cirrhosis has a nursing diagnosis of disturbed body image. Common etiologic factors for this diagnosis include:

a) jaundice & ascites
b) dyspnea & pruritus
c) alopecia & skin lesions
d) periorbital edema & decreased sensory perception
a) jaundice & ascites
A patient w/advanced cirrhosis has a nursing diagnosis of imbalanced nutrition, less than body requirements related to anorexia & inadequate food intake. An appropriate midday snack for the patient would be

a) peanut butter & salt free crackers
b) popcorn w/salt free butter & herbal seasoning
c) canned chicken noodle soup w/low protein bread
d) a tomato sandwhich w/low protein bread & salt free butter
d) a tomato sandwhich w/low protein bread & salt free butter
A [patient w/ascites is short of breath & has an increased respiratory rate. The nurse should

a) notify the physician so a paracentesis can be performed
b) initiate 02 therapy at 2L/min to increase gas exchange
c) ask the patient to cough & deep breath to clear respiratory secretions
d) place the patient in Fowlers position to relieve pressure on the diaphragm
d) place the patient in Fowlers position to relieve pressure on the diaphragm
During the TX of the patient w/bleeding esophageal varices, it is most important that the nurse

a) prepares the patient for immediate portal shunting surgery
b) performs guaiac testing on all stools to detect occult blood
c) maintains the patients airway & prevents aspiration of blood
d) monitiors for the cardiac stimulant effects of IV vasopressin & nitroglycerin
d) monitiors for the cardiac stimulant effects of IV
A patient w/cirrhosis that is refractory to other TX for esophageal varices undergoes a peritoneovenous shunt. As a result of this procedure, the nurse would expect the patient to experience:

a) an improved survival time
b) decreased serum ammonia levels
c) improved metabolism of nutrients
d) improved hemodynamic fxn & renal perfusion
d) improved hemodynamic fxn & renal perfusion
In discussing the patient w/alcoholic cirrhosis, the nurse advises the patient that

a) a daily exercise regimen is important to increase the blood flow through the liver
b) cirrhosis can be reversed if the patient follows a regimen of proper rest & nutrition
c) abstinence from alcohol is the most important factor in improvement of the patients condition
d) the only O-T-C analgesic that should be used for minor aches & pains is aceaminophen
c) abstinence from alcohol is the most important factor in improvement of the patients condition
A patient is hospitalized w/metastatic cancer of the iver. The nurse plans care for the patient based on the knowledge that

a) chemotherapy is highly successful in the TX of liver cancer
b) the patient will undergo surgery to remove the involved portions of the liver
c) supportive care that is appropriate for all patients w/severe liver damage is indicated
d) metastatic cancer of the liver is more responsive to TX than primary carcinoma of the liver
c) supportive care that is appropriate for all patients w/severe liver damage is indicated
A patient w/cirrhosis asks the nurse about the possibility of a liver transplant. The best response by the nurse is

a) liver transplants are only indicated in children w/irreversible liver disease
b) if you are interested in a transplant you really should talk to your doctor about it
c) rejection is such a problem in liver transplants that it is seldom attempted in patients w/cirrhosis
d) cirrhosis is an indication for transplantation in some cases. Have you talked to your DR about this?
d) cirrhosis is an indication for transplantation in some cases. Have you talked to your DR about this?-
An estimated 136,000 cases of hep occurr annually in the U.S. & _____ of these are in children

a) 1/8th
b) 1/4th
c) 1/3rd
d) over 1/2
c) 1/3rd
The most common form of hep is acute, highly contagious, & traditionally called infectious hepatitis

a) hep A
b) hep B
c) hep C
d) hep D
a) hep A

fecal-oral