Study your flashcards anywhere!

Download the official Cram app for free >

  • Shuffle
    Toggle On
    Toggle Off
  • Alphabetize
    Toggle On
    Toggle Off
  • Front First
    Toggle On
    Toggle Off
  • Both Sides
    Toggle On
    Toggle Off
  • Read
    Toggle On
    Toggle Off
Reading...
Front

How to study your flashcards.

Right/Left arrow keys: Navigate between flashcards.right arrow keyleft arrow key

Up/Down arrow keys: Flip the card between the front and back.down keyup key

H key: Show hint (3rd side).h key

A key: Read text to speech.a key

image

Play button

image

Play button

image

Progress

1/69

Click to flip

69 Cards in this Set

  • Front
  • Back
Alteration in GI Function
Cirrhosis
Hepatitis
Liver
Largest internal organ of the body
Consists of two lobes
Functional units of the liver are lobules
Contain hepatocytes
Lined with Kupffer's cells
-phagocytic activity (remove viruses)
Liver Functions
-Manufacture, storage, transformation and secretion of a number of substances involved in metabolism
-Waste Disposal Plant
*See handout*
Hepatic Disorders
Clinical Manifestations reflect alterations in normal liver function
Major Hepatic Disorders:
-Infectious and inflammatory conditions
-Structural abnormalities
-Trauma
-Neoplasms
Cirrhosis
Chronic progressive disease of extensive degeneration and destruction of liver cells
9th leading cause of death in U.S.
4th leading cause of death in 34-54 year olds
Two times more common in men
**Excessive alcohol intake is single most common cause**
Types of Cirrhosis: Alcoholic Cirrhosis
Alcoholic cirrhosis
-associated with alcohol abuse
-accumulation of fat in liver cells
-potentially reversible, if alcohol abuse continues, leads to widespread scar formation
-Protein malnutrition and alcohol are toxic to the hepatocytes
Types of Cirrhosis: Post necrotic cirrhosis
Post necrotic cirrhosis
-complication of viral, toxic or idiopathic (autoimmune)hepatitis
-broad bands of scar tissue form within the liver
Types of Cirrhosis: Biliary Cirrhosis
Biliary Cirrhosis
-associated with chronic biliary obstruction and infection
-diffuse fibrosis of liver with jaundice as a main feature
Types of Cirrhosis: Cardiac Cirrhosis
Cardiac Cirrhosis
-secondary to long-standing, severe right-sided heart failure in patients with cor pulmonale, constrictive pericarditis, and tricuspid insufficiency
**right-sided heart failure venous return impeded=portal hypertension
Etiology
*20-30% of people with chronic hep C and 10-20% of people with chronic hep B will develop cirrhosis
*Some have a predisposition to cirrhosis, regardless of dietary or alcohol intake
Clinical Manifestations/Early
(KNOW THIS SLIDE)
-fever
-spleenomegaly
-hepatomegaly
-slight weight loss
-GI disturbances: anorexia, dyspepsia (fullness), flatus, N/V, change in bowel habits
-abdominal pain or "heavy" feeling in RUQ
-liver responsible for CHO, Fat, & Protein metabolism = reason for a change in bowel habits
Clinical Manifestations/Late
*jaundice
*pruritis
*skin lesions-spider angiomas, Palmar erythema
*Hematologic Problems
-thrombocytopenia
-leukopenia
-anemia
-coagulation disorders: epitaxis, petechiae, easy bruising, gingival bleeding, heavy menstrual bleeding
Clinical Manifestations/Late
*Endocrine Disturbances
-Men-Gynecomastia, loss of axillary & pubic hair, testicular atrophy, impotence
-Younger women: amenorrhea
-Older women: vaginal bleeding
-Hyperaldosteronism
*Peripheral Neuropathy
-common alcoholic cirrhosis
-secondary to dietary deficiency of thiamine, folic acid, vitamin B12
-sensory symptoms dominate
**liver can't break down testosterone and estrogen**
Major Complications
**Portal Hypertension & Esophageal Varices**
*Peripheral Edema & Ascites
*Hepatic Encephalopathy
*Hepatorenal Syndrome
Portal Hypertension
*Normal blood flow through the liver becomes obstructed from scarring & compression on portal and hepatic veins and destruction of sinusoids (capillaries)
*Characterized by increased venous pressure in the portal circulation, spleenomegaly, large collateral veins, ascites, systemic HTN, and esophageal varices
**vascular congestion throughout the portal system. Blood settles in the esophagus
Esophageal Varices
*Tortuous, enlarged, swollen veins at lower end of esophagus
*Occurs in 2/3 to 3/4 patients with cirrhosis
*Bleeding varices are most life-threatening complication of cirrhosis
*30-50% die within 6 weeks of 1st esophageal bleed
Peripheral Edema & Ascites
*Edema is the result of decreased colloidal osmotic pressure due to decreased albumin and increased pressure from portal hypertension
*Ankle, presacral edema, anasarca (whole body edema)
*Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity
*Results from increase B/P in liver, decreased albumin, & hyperaldosteronism
*Client exhibits signs of intravascular dehydration
**decreased albumin = ascites, fluid waves and straie on abdomen**
-low u.o.
-low B/P
-fluid leaks out of vessels into spaces
Hepatic Encephalopathy
*Hepatic Encephalopathy occurs as a result of ammonia entering the systemic circulation without liver detoxification
*Liver unable to convert ammonia to urea for kidneys to excrete
*high mortality rate
Hepatic Encephalopathy
Main breakdown of protein metabolism = ammonia
Increased ammonia levels = mental status changes
Clinical Manifestations/Hepatic Encephalopathy
*Change in mental status/neuro status
-lethargy, deep coma, confusion, insomnia, slurred/slow speech, hyperactive reflexes, hiccups, agitation
-asterixis (liver flap)involuntary movements flapping tremors of arms/hands
-apraxia inability to construct simple figures (sequential things)
*Hyperventilation
*Hypothermia
*Fetor-hepaticus-musty, sweet odor of patients breath
Hepatorenal Syndrome (HRS)
*Portal HTN leads to splanchnic (internal organs)vasodilation and decreased arterial blood volume
*Renal vasoconstriction occurs and leads to renal failure
*Renal failure can be reversed by liver transplantation
*HRS frequently follows diuretic therapy (because of decreased circulating volume),GI hemorrhage, or paracentesis (remove fluid, no albumin fluid accumulates)
Diagnostic Studies (KNOW NORMAL VALUES)
Liver Function Tests: LFT's
-Elevated serum enzymes (ALT/SGPT, AST/SGOT)
-Elevated uncongugated bilirubin
-Elevated serum ammonia
-Prolonged prothrombin time
-Decreased total serum proteins and serum albumin
-Decreased cholesterol
Diagnostic Studies
*Liver biopsy
-definitive diagnosis
-identifies liver cell changes and alterations in lobular structure
**Post-bed rest for 24 hours, lay on right side (operative side for 6-8 hours, DSD**
Treatments: Medical
-Maximize liver function
-**Rest: decreases metabolic demand of liver**
-Prevent infection
-Control complications
-Pharmacological treatments
Treatments: Surgical
-No surgical treatment for cirrhosis
-Surgical treatment is aimed at treating complications
-liver transplant
Treatment Ascites
*Focus - NA restriction, diuretics, fluid removal
*SPA - Salt poor albumin
*Diruetics-aldactone:K sparing, loop diuretic (lasix: K wasting)
*Bedrest
*HOB elevated semi fowlers
*Paracentesis-needle puncture of abdominal cavity to remove ascitic fluid, temporary, done for symptom management
*Peritoneovenous Shunt - surgical procedure that provides continuous reinfusion of ascitic fluid into the venous system
Treatment/Esophageal Varices
**GOAL: Avoid bleeding and hemorrhage
-Avoid ETOH, ASA, irritating foods
-?NPO
-Control coughing
-B-blockers (Inderal)decrease cardiac output
-Octreotide (growth hormone)
-Vasopressin in conjunction with Nitroglycerin
-Vitamin K
-H2 receptor blockers decrease acidity
Management of Bleeding Varices
(Massive hemorrhage)
-Airway management/intubation
-Blood products-FFP, PRBS, PLTS
-Diagonosis by endoscopic exam ASAP
-Sclerotherapy or banding of varices
-Ligation of varices
-Shunt therapy
-Balloon tamponade
-Medications
Medication for Bleeding Varices
**Octreotide treatment of choice**
*Vasopressin in conjunction with Nitroglycerin
*Beta Blockers (Inderal)
*Vitamin K
*H2 receptor blockers decrease HCL
Balloon Tamponade for Bleeding Varices
*Used for esophageal, gastric variceal hemorrhage or both
*Minnesota or Sengstaken-Blakemore tube
*2 balloons - gastric and esophageal, 3rd port for gastric or esophageal aspiration
*When inflated, provides mechanical compression of the varices
*Gastric balloon anchors tube in position & applies pressure to any bleeding gastric varices
Shunting for Varices
*Tranjugular intrahepatic portosystemic shunt (TIPS) bypasses liver
*Non-surgical
*Shunt between systemic & portal venous system is created
*Catheter inserted thru jugular vein, threaded thru superior & inferior vena cava into hepatic vein into the portal vein
*Decreases portal venous pressure, decompresses varices, thus controlling bleeding
Treatment/Hepatic Encephalopathy
**GOAL: Reduce ammonia formation**
*Protein restricted diet (ammonia is a by-product of protein metabolism, liver unable to break protein down therefore ammonia forms)
*Decrease ammonia formation in intestines
-Lactulose
-Neomycin (PO decreases bacterial flora in intestine decreases ammonia
-Avoid constipation (straining)
-Remove blood from the GI tract
Nutritional Therapy
*Cirrhosis without complications - high cals, modified fat, protein depends on degree of liver damage & potential for encephalopathy
*Hepatic encephalopathy - very low or no protein diet
*Alcoholic cirrhosis - patients have protein-calorie malnutrition-Hepatic aid-contain AA metabolized by muscles
*Ascites/edema - low NA diet
Health Promotion/Acute Intervention
*Rest:decreases metabolic demand of liver, promotes liver regeneration
*Measures to prevent pneumonia, DVT, pressure ulcers
*Oral hygiene before meals
*Small frequent meals
*Assess for jaundice
*Assess for pruritis & treat
*Accurate I&O
*Prevent constipation (avoid straining)
*Daily weights
*Daily abdominal girths
*Semi fowlers/fowlers for dyspnea
*Monitor electrolytes and acid base
*Bleeding precautions
*Assess neuro/mental status
*Assess for S&S of altered body image
Health Promotion/Home Care
**GOAL: maintain highest level of wellness possible
*Teach:
-symptoms of complications
-importance of follow-up care
-avoid high risk activities for viral hep
-avoid hepatic toxins (ETOH, tylenol, ASA)
*Adequate rest
*Bleeding/Infection precautions
*Written explanations for fluid & diet restrictions
*Community support/AA
Liver Transplantation
*May be considered for recurring hepatic encephalopathy and end-stage disease
*Depends on the cause and other systemic medical problems
**Liver disease r/t chronic viral hepatitis is the leading indicator for liver transplantation** (dry for 1 year, eligible for liver transplant)
Major post-op complication -- rejection & infection, post transplant drugs can cause renal failure, work & financial issues
Post-op care/Liver transplant
*Monitor for hemorrhage
*Assess neuro status
*Prevent pulmonary complications and other complications from immobility
*Monitor fluid & electrolytes
*Monitor for S&S of infection
*Assess & measure drainage from JP, NGT, T tube
*Emotional support & teaching
Nursing Process: Nursing Dx/Cirrhosis
*Actual
-Altered nutrition...less
-Impaired skin integrity
-Ineffective breathing
-Ineffective airway clearance
-Activity intolerance
-Body image disturbance
*Risk and PC
-Risk for...
Injury
Ineffective management of therapeutic regime
Infection
*PC
Hemorrhage
Portal HTN & esophageal varices
Hepatic encephalopathy
Renal Failure
Hepatitis
*Inflammation of the liver and necrosis of the hepatic cells
*Non infectious causes
-Drugs & chemicals (table 38-6)
-Autoimmune
Infectious causes
-Bacteria & Viruses
Hepatitis
*HCV accounts for 45% of all chronic Hepatitis
*HCV most common liver disease in US
*40% of HIV clients have HCV (IV Drug Abuse)
*20-30% of pts with HCV progress to cirrhosis within 20 years
*Estimated 4 million infected with HCV-50% unaware of infection
*152,000 cases of HAV occur annually in US
*estimated 80,000 new cases of HBV annually in US
Pathophysiology
*Inflammation of hepatocytes (functional cells of liver)
*Damage
*Necrosis
*Liver damage is mediated by cytokines that cause lysis of infected hepatocytes
*Proliferation and enlargement of Kupffer cells
*Inflammation of periportan areas can interrupt bile flow and cause cholestasis (from liver to small intestine)
Clinical Manifestations
KNOW THIS SLIDE
*Preicteric Phase
*Icteric Phase
*Posticteric Phase
Preicteric Phase
(before jaundice)
KNOW THIS SLIDE
*Lasts 1-3 weeks
*Flu-like symptoms-arthritis, fever, malaise
*Smokers may have distaste for ciagarettes
*Hepto and spleenomegaly
*Elevated liver enzymes and urine bilirubin
*angioedema
*skin rashes
*lymphadenopathy
*GI symptoms N/V
*Weight loss
*RUQ discomfort
*Decreased sense of smell
Icteric Phase (jaundice phase)
KNOW THIS SLIDE
*Lasts 2-4 weeks
*Jaundice (sclera)
*Dark urine
*Light, clay colored stool
*Steatorrhea (fatty stools)
*Tenderness and fullness RUQ
*Pruritis (if bile stasis)
*Elevated LFT's including direct bilirubin (conjugated)
*GI symptoms remain
*Some fatique
**When jaundice occurs, fever usually subsides**
Posticteric Phase
(after jaundice)
*Lasts weeks to months (avg. 2-4 months)
*jaundice recedes
*stool and urine return to normal color
*CC: fatigue & malaise
*LFT's return to normal
*Serum antibodies rise
*Hepatomegaly remains for several weeks
*Spleenomegaly subsides
**Relapses may occur, and disappearance of jaundice does not mean the patient has fully recovered**
**Can take up to 1 year for full recovery**
**need follow-up for 1 year, need to avoid hepato toxins for 1 year or relapse may occur (tylenol, ASA, ETOH)
Variations in Manifestations
*Hepatitis A - onset more acute, symptoms usually mild, flu like
*Hepatitis B - onset is more insidious, symptoms more severe, fewer GI symptoms
*Hepatitis C - majority are asymptomatic & mild
**HCV and to a lesser extent HBV can persist and induce chronic liver disease
Diagnostic Tests
*LFT's
*Table 42-5
*Serologic Tests
-Specific antibody or antigen markers for HAV, HBV, HCV, and HDV
-Liver biopsy
*Handout page 6
Sequelae/Complications
*Chronic hepatitis
-75-85% of HCV
-10% of HBV
-Persistence of HBsAG for longer than 6 months = chronic HBV
-More likely to develop in infants born to infected moms, children <5 yrs., and patients with an altered immune response
*Fulminant Hepatitis
-Severe, massive necrosis leading to liver failure and death
-Most common cause HBV, particularly HBV accompanied by HDV
-Less frequently with HAV and HCV
-Drugs 2nd most common cause
-Tx may involve transplantation
Sequelae/Complications
*Cirrhosis (20%)
-HBV - 10%
-HCV -20-30% will develop cirrhosis
**prognosis of HCV has greatly increased the need for liver transplants**
-Risk factors for progression to cirrhosis: male, heavy ETOH, excess iron deposits in liver, steatorrhea, obesity, DM
Hepatitis A
*Transmitted through fecal to oral route
*Contaminated food and water
*Up to 50% of people in US are infected before adulthood
*Poor hygiene, crowds, poor sanitary conditions
*Transmitted between family members, day care centers, institutionalized clients
*Transmitted by persons who have undetectable, sub clinical infections
**you recover and then you are immune**
Hepatitis A
*Anti-HAV IgM indicates acute Hepatitis
*Anti-HAV IgG indicates past infection and provides lifelong immunity
*No chronic carrier state for HAV
*See Table 42-2 page 1106
*Handout page 6
Hepatitis B
*One of the most serious forms
*Transmitted through parenteral/permucosal exposure to blood or body fluids **Primarily sexual transmission**
*Healthcare workers are at high risk
*HBV can live on a dry surface for at least 7 days
**Much more infectious than HIV
Hepatitis B
*Three antigens -HBsAG & HBcAG-current or chronic infection
-HBeAG - acute, highly infectious
*2-10% become carriers and can transmit the disease
*10% chronic infection
**Persistence of HBsAG in the serum for 6-12 months after infection indicates carrier state
*Presence of HBsAB or anti-HBS indicates immunity from past infection or HBV vaccine
Hepatitis C
*Transmitted through parenteral/permucosal exposure to blood or body fluids
*Prevalent and underreported in US
*Progresses to chronic hepatitis(75-85%)-cirrhosis(20-30%)-death
*Most common indication for a liver transplant
Hepatitis C
*60% - IV drug use
*20% - sexual transmission
*10% - occupational exposure, hemodialysis, perinatal transmission
*10% cannot identify source
*Anti-HCV-acute or chronic infection
*Reliable antibody test for HCV was not widely available before 1992
*Unlike Hep A & B - antibodies to Hep C are not protective & may be indicator of chronic disease
Hepatitis D
CANNOT EXIST ALONE
*Appears only with HBV infection - delta virus can't survive on its own
*Chronic HBV carriers at risk
*High mortality rate - patients with HBV-HDV coinfection may have more acute disease & greater chance of Fulminant Hepatitis (2-20%)
*Transmitted percutaneously/parenterally like HBV
*Risk of transmission via sexual activity is less
*Anti-HDV IgM - current infection
*Anti-HDV IgG - past infection
Hepatitis E
*Transmitted through fecal to oral route
*Rare in US
*Seen primarily in developing countries
**Acute infection that does not progress to chronic hepatitis**
*10-20% mortality rate in pregnant women
*Most common drinking contaminated water*
*No serologic tests to dx HEV infection in US, only in research labs
*Travelers should avoid raw foods, use pure H2O supply (boil), and use effective hand hygiene
Hepatitis G
*Transmitted through parenteral/permucosal exposure to blood or body fluids
*Has been found as a co-infection in people with HCV
*Diagnosed by detection of hep G RNA in blood or liver tissue
*Some develop chronic hepatitis
*Recently recognized
*NO VACCINE*
Treatment
*Rest (promotes cell regeneration, decreases metabolic demand on the liver)
*Nutrition
*Antiemetics
*Comfort measures to relieve Pruritis, H/A, arthralgias
*Avoidance of hepatotoxins for 1 year during recovery
*Prevention of spread
Treatment/Chronic Hepatitis B
*Focus is to decrease the viral load and decrease the rate of disease progression
-Lamivudene (taken orally for a year)
*Lamivudene plus HBV immunoglobin for patients who have had a transplant for HBV
*Interferon - 4 month course - decreases cirrhosis and hepatocellular cancer
*Multiple side effects (table 42-7)Interferon can cause debilitating life-threatening depression
*Hepsera(2002) slow progression of Hep B inhibits the virus from replicating
Treatment/Chronic Hepatitis C
*Drug therapy to decrease the viral load & decrease the progression & promote seroconversion (no Anti-HCV detected in serum)
*Interferon (50% will relapse in 6 months)
**Interferon plus Ribavirin decrease rate of viral replication
Emotions Associated with Hepatitis C Treatment
*Frustration
*Anger
*Fear
*Sadness
Prevention/Hepatitis A
*Hepatitis A vaccine
*Immune globin (IG)
-used before or after exposure
**provides 6-8 weeks of passive immunity**
**can be given 1-2 weeks after exposure**
*Twinrix
-combined HAV & HBV vaccine
-requires 3 doses (0-1-6 months)
-given to high risk individuals
*Personal and environmental hygiene, good sanitation, **hand washing**
Prevention/Hepatitis B
*Hepatitis B vaccine
-3 doses (0-1-6 months)
-95% effective
*Post exposure - vaccine plus Hep B immunoglobin (HBIG)Need immunoglobin w/in 24 hrs. of needle stick
*Modify high risk behavior
*Gloves
*Use of disposable needles/syringes
*Condoms
*Hand washing
*Avoid sharing tooth brushes/razors
*Blood, tissue, and organ screening
Prevention/Hepatitis C
*No products available
*Several vaccines in development
*Screening blood, organ, tissue donors
*Modify high risk behavior
*Gloves
*Use of disposable needles/syringes
*Condoms
*Hand washing
*Avoid sharing toothbrushes/razors
Nursing Process: Role
*Assessment
-Physiological integrity
-Safe & effective care environment
-Psychosocial integrity
*Nursing Dx
-Activity intolerance
-Impaired Comfort: pruritis
-Impaired skin integrity
-Body image disturbance
-Risk for ineffective management of therapeutic regime (high risk behavior)
Nursing Interventions/Evaluation
*Nursing Intervention
-See Handout
*Expected Outcomes
-See Handout
Health Promotion/Home Care
**Rest
*Nutrition
**Regular follow-ups for a year
*Monitor for S&S of bleeding
*Monitor for S&S of encephalopathy
*Prevention measures
*Measures to prevent transmission
*Avoid ETOH 1 year
*Side effects of meds
*How to administer interferon (SC/IM)
Research
*Famvir & Cytovene investigational drugs for chronic HBV
*Telbivudine new, once-a-day, oral treatment for chronic HBV
*Research on effect of antiviral drugs or IG for chronic HCV
*Serology test for HEV