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378 Cards in this Set
- Front
- Back
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What is the function of the gallbladder?
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Store bile and concentrate water
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Where is the gallbladder located in relation to the liver?
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inferior surface
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How much bile does the liver produce each day?
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500-600 mL
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Is the gallbladder essential to life?
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No
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Bile leaves the liver through the:
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Hepatic duct
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Once the bile goes through the hepatic duct, it goes into the:
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gallbladder
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What triggers the gallbladder to release bile?
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Fat in the diet
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Where does bile go once it leaves the gallbladder? Through which structure?
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Into the small intestine via the common bile duct
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What chemical controls the release of bile salts?
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Cholecystokinin (CCK)
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What happens to bile once it aids in fat absorption in the intestine?
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It is recycled and travels back to the gallbladder
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What is the normal level of total bilirubin in lab testing?
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0.3-1 mg/dL
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What is the normal level of conjugated/direct bilirubin in lab testing?
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0.1-0.4 mg/dL
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What is conjugated bilirubin?
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Bilirubin that has been turned into a liquid.
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Should there be bilirubin in the urine?
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No
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If total bilirubin is increased, what may be the cause?
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Obstruction
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What is urobilinogen?
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Bilirubin that has been used and processed and is being removed in the urine.
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What is the normal lab value for urobilinogen?
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0.5-4 mg/24 hours
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What organ secretes alkaline phosphatase?
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Liver
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What is the normal lab value for alkaline phosphatase?
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35-150 units/liter
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What is the most frequent radiological test used to test gallbladder function?
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Ultrasound
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What pre-test procedures must be followed before an ultrasound of the gallbladder?
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Low fat supper night before
NPO 8-12h before procedure |
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Why is a low-fat supper important before a GB ultrasound?
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Increased fat increases the release of bile. Bile in the GB helps us visualize problems if present
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What is an important thing to assess before any test involving contrast dye?
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Allergies to shellfish or iodine
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Before a CT scan of the GB, how long should the client be NPO?
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8-12 hours
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What does a cholangiography look at?
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Ducts of the GB
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How is a cholangiography performed?
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Thin needle inserted in skin to liver to inject contrast dye. X-ray images taken to follow route through ducts.
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Before a cholangiography what does a client need to do?
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Bowel Prep
NPO |
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After a cholangiography, what should the nurse monitor? (Why?)
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Signs of bleeding-liver very vascular (direct or indirect)
Signs of sepsis Tachycardia Hypotension |
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What position should the client be placed in after a choleangiography? Why?
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Right side to provide pressure and decrease incidence of bleeding
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What is an endoscopic retrograde cholangiopancreatography?
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Like EGD but proceeds to where pancreas meets small bowel. Mouth to small bowel to pancreas
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What is special about the laparoscopic camera used in the ECRP?
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Side-angle camera
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Where is the dye injected during an ECRP?
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Where small bowel meets pancreatic duct
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What other task can be completed during an ECRP?
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Removal of very small stones
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Pre ECRP instructions:
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NPO 6-8 hours before
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Post ECRP nursing responsibilities:
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NPO until gag reflex returns, monitor for perforation, pain, leeding, fever, may have sore throat
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What is a hepatobiliary scan?
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HIDA scan: very slow injection of radiographic dye to examine biliary ducts
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What must a patient do during a HIDA scan?
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Stay very still. If they can't they may need some type of sedative.
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Why can't a pregnant nurse care for someone who has had a HIDA scan?
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Radionucleotide excreted in urine and feces; teratogenic
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What are two important things to consider regarding patient safety and HIDA scans?
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Can't be pregnant or have been on morphine
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What is morphine thought to do that may give inaccurate results to a HIDA scan?
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Morphine is thought to interfere with the function of teh Sphincter of Oddi, causing inaccurate test results.
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What percentage of gallstones are composed of cholesterol? What percentage of gallstones are pigmented stones?
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Cholesterol 80%
Pigmented stones 20% |
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What are the two types of pigmented stones?
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Black and Brown
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What are black stones composed of?
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increased bilirubin and calcium, decreased bile salts
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What usually occurs before brown stones are present?
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Infection
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What is cholelithiasis?
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Having gallstones
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What is cholecystitis?
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Inflammation caused by presence of stones moving
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What are the two types of cholecystitis?
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Acute and chronic
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What is choledocholithiasis?
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Gallstone in the common bile duct. More symptomatic than cholecystitis.
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What are the 3 main risk factors for gallstone problems? *Remember "Fair, Fat and Forty"
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Females over males
Obesity Middle Age |
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What other factors can put one at higher risk for gallstone problems?
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Rapid weight loss
Caucasian, Hispanic, Native American Hormonal influence Hypercholterolemia Disease of ileum |
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What is meant by hormonal influence affecting risk for GB problems?
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Women with more than 1 child
Those taking oral contraceptives Pregnant females |
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What is hypercholesterolemia?
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Increased cholesterol levels and/or medications used to treat high cholesterol
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What happens to cholesterol when it combines with bile?
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it turns to liquid
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What does excessive cholesterol do to bile composition?
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Changes it
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What causes cholesterol stones?
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Alteration in bile composition
Cholesterol precipitation Supersaturation Stasis |
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What is stasis?
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A low fat diet means that less bile is secreted so what is in there accumulates
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Do cholesterol stones usually occur singly or in multiples?
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Multiples
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Are cholesterol stones or pigmented stones more symtomatic?
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Pigmented stones
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What is acute cholecystitis?
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Inflammation related to a stone obstruction
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Where do stones usually lodge in relation to the GB?
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Edge of GB or in duct
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What does stone obstruction cause?
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Inflammation and tissue damage
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What happens to the GB if there is an obstruction?
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Becomes full, swollen and firm. Possible necrosis.
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What causes chronic cholecystitis?
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Repeated attacks of acute cholecystitis causing GB wall scarring.
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What is cholangitis and where does it occur?
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Inflammation of biliary tree in the bile ducts or around obstruction
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What 3 factors decrease the risk for gallstones?
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Exercise
Caffeine Nicotine |
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What are some manifestations of acute cholecystitis?
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Biliary colic
Anorexia N/V/D Fever Abnormal bowel sounds Murphy's sign positive Possible jaundice |
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What is biliary colic?
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Intense pain increasing after fatty meals that is sharp. Can last 15 min to hours. Normally found in RUQ but can refer
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What type of fever is common with acute cholecystitis?
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mid-grade--100-101
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Describe bowel sounds found in acute cholecystitis?
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Decreased or absent
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What is Murphy's sign?
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When you push on abdomen it hurts so bad there is a temporary respiratory arrest
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What may cause jaundice in acute cholecystitis?
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Obstruction in biliary tree
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How long does an episode of acute cholecystitis last?
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1-4 days
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How is acute cholecystitis diagnosed?
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US primary--visualize stones in GB
ERCP--visualize stones in duct Possible removal of small stones Liver function tests Serum amylase test WBC |
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What happens to liver enzyme levels during acute cholecystitis?
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Increase
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Why do physicians perform serum amylase tests to diagnose acute cholecystitis?
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To determine if the pancreas is involved
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Why does WBC increase during acute cholecystitis?
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To fight infection
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What medications are used to treat acute cholecystitis?
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Actigall
Opiates Antispasmodics |
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What does Actigall do?
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Used to prevent stone formation
Used when surgery impossible Dissolves stones in 1-3 years |
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Why are opiates used to treat acute cholecystitis?
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Morphine contraindicated because of Sphincter of Oddi-condition very painful
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What are the 3 other treatments used for acute cholecystitis?
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Endoscopic stone removal using ERCP
Lithotripsy Cholecystectomy |
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What is the definitive treatment for acute cholecystitis?
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Cholecystectomy
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What is lithrotripsy? How helpful is it?
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Breaking up of stones so they can pass. Not very helpful
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What 2 ways can cholecystectomy be performed?
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Open or laparoscopic
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What should be monitored after cholecystectomy?
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VS, bleeding, infection
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What type of pain is associated with laparoscopic surgery not related to incision or removal of organs?
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Gas inflation of CO2, sometimes referring to the shoulder
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How long does it take for gas inflation to be reabsorbed into the body for removal?
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About 1 week
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What does the nurse need to teach the client after the cholecystectomy?
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How to monitor for infection
NVD should be reported to physician after 1-3 days Limit fat in diet Activity as tolerated No lifting |
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What supplement should a person take after a cholecystectomy?
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Fat-soluble vitamins--no bile
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What is primary sclerosing cholangitis?
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Scar tissue causes blockage of ducts, causing bile to back up into the GB and liver, damaging liver cells. Eventually can cause liver failure
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What may be a cause of primary sclerosing cholangitis?
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Immunologic component
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What other disorder is associated with primary sclerosing cholangitis?
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Ulcerative colitis
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What causes the ducts to close in primary sclerosing cholangitis?
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Scar tissue and strictures
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Why can't the biliary ducts be resected to allow bile to pass through in primary sclerosing cholangitis?
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Because there are multiple strictures that won't allow this
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Does primary sclerosing cholangitis involve the GB?
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No
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When symptoms of primary sclerosing cholangitis occur, what happens?
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Recurrent attacks
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Why is primary sclerosing cholangitis hard to diagnose?
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Symptoms vague and often asymptomatic until severe liver damage occurs. Also usually present with other liver problems
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What are some of these common non-specific symptoms?
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fatigue
weight loss low-grade fever |
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What are symptoms specific to primary sclerosing cholangitis?
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jaundice
pruritis |
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What is the best way to diagnose primary sclerosing cholangitis?
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liver biopsy
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How can an ERCP be useful when diagnosing primary sclerosing cholangitis?
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Reveal structural problems
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With primary sclerosing cholangitis, which liver enzymes are you looking for?
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Alkaline phosphatase
Bilirubin |
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What drug is used to treat primary sclerosing cholangitis? What does it do?
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Ursodeoxycholic acid-improves biochemical abnormalities
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What is the name of the procedure used in management of primary sclerosing cholangitis that can remove stones and possibly dilate the strictures?
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Endoscopic palliation
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What may help ease the severity of pruritis found with primary sclerosing cholangitis?
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massage
antihistamine-cholestrain? cool wash cloth |
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What type of diet should someone with primary sclerosing cholangitis eat?
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Low fat
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What is the prognosis for primary sclerosing cholangitis withoug liver transplant?
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10 years
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How prevalent is carcinomas of the biliary system?
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Rare
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What is the usual cause of carcinomas found in the GB or bile ducts?
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Usually metastasis from another site
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What condition increases the risk of cancer of the bile ducts?
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primary sclerosing cholangitis
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Doescancer of the biliary system normally occur in younger adults or older adults?
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Older adults
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Are women or men more likely to develop cancer of the GB?
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women twice as likely
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First symptoms of biliary system cancer usually mimick:
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GI problems
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What is the likelihood of metastasis of this type of cancer?
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Fairly likely
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How does this type of cancer spread? (3 ways)
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adjacent tissue
through blood through lymph |
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When do symptoms usually occur with cancer of the biliary tract?
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after metastasis
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When symptoms do develop, what is the primary symptom?
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Severe pain
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Symptoms of cancer of the biliary tract usually mimick symptoms of ___ and ___.
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Cholelithiasis
Cystitis |
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If cancer has spread beyond the gallbladder into the liver or biliary tree, which condition is prevalent?
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Jaundice
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What is the most common way that cancer of the biliary system is found?
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Accidentally while looking for gallstones
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What three techniques are used to diagnose cancer of the biliary system?
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US
CT MRI |
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What 2 treatments are used to manage GB cancer?
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Cholecystectomy with wedge resection liver and lymph node dissection
Chemo/radiation |
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When is a cholecystectomy with wedge resection liver and lymph node dissection effective?
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If caught early before metastasis or with localized metastasis
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What is the normal prognosis for someone with GB cancer that has metastasized?
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1 year
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What is cholangiocarcinoma?
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Cancer of the bile ducts
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How is cholangiocarcinoma managed?
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Maintain patency of bile flow
surgical diversion stents |
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Where is the pancreas located?
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in posterior abdomen behind the stomach
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What is another dame for the pancreatic duct?
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Duct of Wirsung
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What does the pancreatic duct empty into?
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Ampula of Vater
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What does the the Ampula of Vater empty into?
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Common bile duct
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What does the common bile duct empty into?
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Sphincter of Oddi
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What does the Sphincter of Oddi empty into?
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Duodenum
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What does the pancreatic secretions control?
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Parasympathetic nervous system
Gastrin Duodenal hormones |
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What are the three enzymes associated with the pancreas?
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Trypsin/chymotrypsin
pancreatic amylase Lipase |
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What does trypsin/chymotrypsin do?
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Digest proteins
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What does pancreatic amylase do?
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digest carbs
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What does lipase do?
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digest fats
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When do these enzymes become activated?
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When they hit the small bowel
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What is the normal level of serum amylase?
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25-125 u/L
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What happens to serum amylase and lipase when there is a pancreatic problem?
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Increases
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What is the normal level of serum lipase?
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10-140 u/L
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What is the normal serum calcium level?
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8.4-10.6 mg/dL
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What happens to calcium levels when there is a pancreas problem?
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Decreases because the pancreas holds on to the calcium
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What is the normal level of urine amylase?
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<17 U/h
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Which stays elevated longer: urine amylase or serum amylase?
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Urine amylase
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What are the two major risk factors for acute pancreatitis?
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Alcohol use
Biliary stones |
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What are some other factors that increase the risk for acute pancreatitis?
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Trauma
Infectious disease Cancer Chronic illness Drug toxicities |
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What are the 2 types of acute pancreatitis?
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Acute interstitial pancreatitis
Acute hemorrhagic pancreatitis |
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Which is more prevalent: acute interstitial pancreatitis or acute hemorrhagic pancreatitis?
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acute interstitial pancreatitis
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What is the mortality rate for acute interstitial pancreatitis?
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10%
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What is the mortality rate for acute hemorrhagic pancreatitis?
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50%
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What are the physical manifestations of acute interstitial pancreatitis?
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swollen with normal anatomic features with absence of hemorrhage and necrosis
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What are the physical manifestations of acute hemorrhagic pancreatitis?
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Acute inflammation
Hemorrhage Vast necrosis Abscess formation Systemic complications |
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What systemic complications are common with acute hemorrhagic pancreatitis?
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Fat emboli
Hypotension Hypovolemia Shock |
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What happens to pancreatic enzymes during acute pancreatitis?
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Become activated early, inside pancreas, causing autodigestion
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Outline the cycle of acute pancreatitis physical manifestations:
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Insult
Activation of enzymes Autodigestion Edema/hemorrhage/necrosis Cell death Release of hist./bradykinin Inc. vasc. permeability and digestion Worsening of edema/damage Further cell death |
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What are 2 systemic effects of acute pancreatitis?
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Increased vascular permeability and dilation
Microvasculature emboli |
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Describe increased vascular permeability:
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Fluid shifts to ECF; ICF dehydration
Circulatory insufficiency Renin-Angiotensin activation |
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Another systemic effect of acute hemorrhagic pancreatitis is microvasculature emboli. Describe this.
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Clumping and blocking of small vessels causing them to back up and ooze blood
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A complication of acute hemorrhagic pancreatitis is emboli. Where might you look for this?
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In small vessels of the fingers and kidneys. When this occurs in the kidney it leads to acute kidney failure.
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Name the 10 complications of acute hemorrhagic pancreatitis.
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emboli
circulatory collapse acute tubular necrosis adult resp distress syndrome hypocalcemia hyperlipidemia GI bleed pancreatic infection pseudocysts chronic pancreatitis |
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What occurs during acute respiratory distress syndrome (ARDS)?
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Fluid shift to pulmonary beds
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What happens to calcium stored in the body when a person suffers from acute hemorrhagic pancreatitis?
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It moves to the necrotic fat and leaves circulation
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What are the two main manifestations of acute hemorrhagic pancreatitis?
|
Intense pain
N/V |
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Where is this pain located?
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epigastric but can radiate
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What are 4 other common manifestations of acute hemorrhagic pancreatitis?
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Abdominal distention
Hypoactive bowel sounds Mid-grade fever Dehydration |
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What 3 signature signs of acute hemorrhagic pancreatitis may help with a diagnosis?
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Jaundice (if CB obstruction)
Cullen's sign Turner's sign |
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What is Cullen's sign and what causes it?
|
Umbilical area discoloration caused by blood and/or pancreatic juices oozing out
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WHat is Turner's sign and what causes it?
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Flank discoloration caused by blood and/or pancreatic juices oozing out
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What 3 ways is acute hemorrhagic pancreatitis diagnosed?
|
Lab values
Manifestations x-ray, US, CT |
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What makes testing of amylase (amylase P) not be the best test to use for diagnosis of acute hemorrhagic pancreatitis?
|
It is expensive
Most labs don't have right equipment |
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What happens to serum amylase initially? After body begins to heal?
|
First to increase, first to decrease
|
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Which 2 enzymes allow for retrospective diagnosis?
|
amylase
Lipase |
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Another systemic effect of acute hemorrhagic pancreatitis is microvasculature emboli. Describe this.
|
Clumping and blocking of small vessels causing them to back up and ooze blood
|
|
|
A complication of acute hemorrhagic pancreatitis is emboli. Where might you look for this?
|
In small vessels of the fingers and kidneys. When this occurs in the kidney it leads to acute kidney failure.
|
|
|
Name the 10 complications of acute hemorrhagic pancreatitis.
|
emboli
circulatory collapse acute tubular necrosis adult resp distress syndrome hypocalcemia hyperlipidemia GI bleed pancreatic infection pseudocysts chronic pancreatitis |
|
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What occurs during acute respiratory distress syndrome (ARDS)?
|
Fluid shift to pulmonary beds
|
|
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What happens to calcium stored in the body when a person suffers from acute hemorrhagic pancreatitis?
|
It moves to the necrotic fat and leaves circulation
|
|
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What are the two main manifestations of acute hemorrhagic pancreatitis?
|
Intense pain
N/V |
|
|
Where is this pain located?
|
epigastric but can radiate
|
|
|
What are 4 other common manifestations of acute hemorrhagic pancreatitis?
|
Abdominal distention
Hypoactive bowel sounds Mid-grade fever Dehydration |
|
|
What 3 signature signs of acute hemorrhagic pancreatitis may help with a diagnosis?
|
Jaundice (if CB obstruction)
Cullen's sign Turner's sign |
|
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What is Cullen's sign and what causes it?
|
Umbilical area discoloration caused by blood and/or pancreatic juices oozing out
|
|
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WHat is Turner's sign and what causes it?
|
Flank discoloration caused by blood and/or pancreatic juices oozing out
|
|
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What 3 ways is acute hemorrhagic pancreatitis diagnosed?
|
Lab values
Manifestations x-ray, US, CT |
|
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What makes testing of amylase (amylase P) not be the best test to use for diagnosis of acute hemorrhagic pancreatitis?
|
It is expensive
Most labs don't have right equipment |
|
|
What happens to serum amylase initially? After body begins to heal?
|
First to increase, first to decrease
|
|
|
Which 2 enzymes allow for retrospective diagnosis?
|
amylase
Lipase |
|
|
How long does serum lipase stay elevated after a case of acute hemorrhagic pancreatitis?
|
about 2 weeks
|
|
|
What happens to WBC levels during acute hemorrhagic pancreatitis?
|
increase
|
|
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What happens to glucose levels during acute hemorrhagic pancreatitis?
|
increase
|
|
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What happens to calcium levels during acute hemorrhagic pancreatitis?
|
decrease
|
|
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To diagnose acute hemorrhagic pancreatitis, which test is best?
X-ray CT scan Ultrasound |
CT scan
|
|
|
Is dehydration a problem during acute hemorrhagic pancreatitis?
|
Yes, it is severe.
|
|
|
How is dehydration treated when a person suffers from acute hemorrhagic pancreatitis?
|
Very aggressively
IV fluids Monitor F/E Supplement as necessary |
|
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What is the opiate of choice for pain in cases of acute hemorrhagic pancreatitis?
|
Demerol
|
|
|
What is important to remember about phenergin when administering IV?
|
Must be diluted
Must be injected slowly Can irritate veins and be fatal |
|
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When would surgery be indicated for a case of acute hemorrhagic pancreatitis?
|
If there is an obstruction
|
|
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Fat emulsions are normally given with TPN to supplement. Are these given with acute hemorrhagic pancreatitis? Why?
|
No, because the pancreas cannot secrete lipase to break it down
|
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What is the purpose of NG tube placement in cases of acute hemorrhagic pancreatitis?
|
Bowel decompression
|
|
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What two aspects of education should be covered in regards to treatment of acute hemorrhagic pancreatitis?
|
Alcohol
Recognizing GB problems |
|
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What is the biggest cause of chronic pancreatitis in the US?
|
Alcohol
|
|
|
What is the biggest cause of chronic pancreatitis in developing countries?
|
Malnutrition
|
|
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Other than alcohol, what can cause chronic pancreatitis?
|
Obstruction
Trauma (surgical or ECRP) Autoimmune system Metabolic disturbances |
|
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What medical disturbances can cause chronic pancreatitis?
|
Hyperlipidemia
Hyperparathyroidism Malnutriton |
|
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Scar tissue on the pancreas causes chronic pancreatitis. Where does this scar tissue develop first?
|
Exocrine cells
|
|
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What happens to pancreatic ducts in chronic pancreatitis?
|
Become dilated due to scar tissue
|
|
|
After scar tissue damages exocrine cells of the pancreas, which cells do they damage?
|
Islets of Langerhans
|
|
|
What percentage of pancreatic function can you lose and still have a functional pancreas?
|
80%
|
|
|
What causes pain caused from chronic pancreatitis?
|
Autodigestion of pancreas
|
|
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Does pain in chronic pancreatitis increase, decrease or stay at the same level as time passes?
|
Decreases
|
|
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What will happen to diarrhea and steatorrhea as chronic pancreatitis progresses?
|
Worsen because of no fat digestion
|
|
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Hyperglycemia is a manifestation of chronic pancreatitis. How is it treated?
|
Insulin. Oral meds cannot proceed down to the pancreas because of blockage.
|
|
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What type of supplements may a person with chronic pancreatitis need?
|
Fat soluble vitamins A, D, E, K
|
|
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What 5 factors are considered when diagnosing chronic pancreatitis?
|
History
Symptoms x-ray and ultrasound CT scan Labs |
|
|
What may an x-ray or ultrasound detect when looking for chronic pancreatitis?
|
Calcification or hardening
|
|
|
What may a CT scan detect when looking for chronic pancreatitis?
|
Abnormal duct dilation
|
|
|
What 3 enzymes may detect chronic pancreatitis?
|
Increased amylase
Increased lipase Decreased trypsin |
|
|
When collecting fecal matter to test for fecal fat, how long might a nurse expect to obtain samples?
|
24, 48, or 72 hours
|
|
|
When administering medications for pain related to chronic pancreatitis, what must a nurse look for?
|
Opiate dependence
Increased opiate tolerance |
|
|
When treating a person with chronic pancreatitis, enzymes are required. When are these enzymes to be ingested?
|
Before each meal or snack
|
|
|
Which ethnic group is at an increased risk for pancreatic cancer?
|
African Americans
|
|
|
Are males or females more at risk for pancreatic cancer? At what age?
|
Males at middle age
|
|
|
85% of pancreatic cancer is found in which structurs?
|
Pancreatic duct
|
|
|
Is pancreatic cancer more or less likely to metastasize?
|
More-does not limit itself
|
|
|
What are the 2 major indicators of pancreatic cancer?
|
Pain
Jaundice |
|
|
With jaundice, what changes do you see in feces and ?
|
Tea-colored, dark
Tan, chalky stools |
|
|
What are other manifestations of pancreatic cancer?
|
Fatigue
Ascites GI bleed Weight loss Anorexia, N/V |
|
|
There are three ways to diagnose pancreatic cancer. What are they and how do they work?
|
Based on symptoms
CT to see mass Biopsy to determine type of cell (usually adenocarcinoma) |
|
|
What percentage of pancreatic cancer patients make it to the 5-year mark?
|
4%
|
|
|
Is addiction to opiates a concern with pancreatic cancer?
|
No, very painful.
They are going to die, make it comfortable |
|
|
Is a pancreatectomy a common procedure?
|
No--very viscious surgery
|
|
|
What does the Whipple procedure remove?
|
proximal head of pancreas
duodenum Portion of jejunum Stomach (total or partial) gallbladder |
|
|
What are the long-term consequences of the Whipple procedure?
|
Diabetic for life
Lost area for F/E absorption Malnutrition common |
|
|
What is endoscopic palliation?
|
Dilation of ducts in case of obstruction
|
|
|
Are chemotherapy and radiation curative procedures for pancreatic cancer?
|
No, may help shrink tumor but it is still there
|
|
|
Which quadrant of the abdomen is the liver in?
|
RUQ
|
|
|
What is the internal pressure inside the liver?
|
3 mmHg
|
|
|
If internal pressure of liver is over 10 mmHG, what is it called?
|
Portal hypertension
|
|
|
What are the functional units of the liver?
|
Venus sinusoids--small cove of liver cells lined with hepatocytes
|
|
|
What is the function of Kupffer cells in the liver?
|
To remove damaged RBCs and bacteria
|
|
|
The liver functions to metabolize three types of food. What are they?
|
Carbs
Fat Protein |
|
|
What does the liver do with carbohydrates?
|
Extract the carbs and metabolize into glycogen for energy. Extra stored as fat
|
|
|
The liver creates clotting factors that are dependent on which vitamin?
|
K
|
|
|
The liver makes bilirubin that is _______ and then changes it to _________ bile.
|
Unconjugated
Conjugated |
|
|
The liver functions to detoxify three main components. What are these?
|
Drugs
Alcohol Ammonia |
|
|
What does the liver change ammonia into for excretion?
|
Urea
|
|
|
The liver functions to store two things. What are they?
|
Vitamins/minerals
Blood |
|
|
What situation may cause the liver to release its stored blood?
|
Hemorrhage
|
|
|
Liver lab tests:
Normal range of albumin |
3.5-5.0 g/dL
|
|
|
Liver lab tests:
Normal range of ALT (alanine aminotransferase) |
3-35 international units/L or
8-20 units/L |
|
|
Liver lab tests:
Normal range of AST (aspartate aminotransferase) |
5-40 units/L
|
|
|
Liver lab tests:
Normal range of LDH (lactate dehydrogenase) |
115-225 international units/L
|
|
|
Liver lab tests:
Normal range of alkaline phosphatase |
30-85 international units/L or 42-128 units/L
|
|
|
Liver lab tests:
Normal range of serum bilirubin |
0.1-1.0 mg/dL
|
|
|
Liver lab tests:
Normal range of conjugated (direct) bilirubin |
0.1-0.3 mg/dL
|
|
|
Liver lab tests:
Normal range of unconjugated (indirect) bilirubin |
0.2-0.8 mg/dL
|
|
|
What is another name for ALT and AST?
|
Serum transferase
|
|
|
What tests are used to diagnose pancreatic cancer?
|
Percutaneous transhepatic cholangiography
HIDA scan Ultrasound CT/MRI |
|
|
What is a percutaneous transhepatic cholangiography?
|
Needle through skin, through liver to biliary tree to insert contrast dye--watch through x-ray
|
|
|
What is hepatic angiography?
|
Contrast dye in blood to see if tumor is blocking blood flow and if abnormal blood vessels are present
|
|
|
Because a contrast dye is used, what do we assess before the procedure?
|
Allergies to iodine or shellfish
|
|
|
What do we monitor after the angiography?
|
Insertion site for swelling and inflammation
VS very frequently |
|
|
What does a liver biopsy identify?
|
If there is cellular damage
|
|
|
What are two complications of a liver biopsy?
|
Bleeding-Liver very vascular
Peritonitis-bile can leak to peritoneal space |
|
|
What is paracentesis?
|
Aspiration of peritoneal fluid for labs
|
|
|
Before paracentesis is performed, what do you ask the patient to do?
|
Void so there is less chance of hitting the bladder
|
|
|
What should the fluid drawn in a paracentesis look like?
|
Clear with no blood
Cloudy indicates peritonitis |
|
|
Where is paracentesis performed?
|
bedside
|
|
|
What do we measure after a liver biopsy?
|
Diameter of abdomen every day to look for shrinking
|
|
|
What dictates how often we check vital signs after paracentesis?
|
How much fluid is removed
|
|
|
Who is at risk for biliary atresia?
|
Infants
|
|
|
What is biliary atresia?
|
A disorder of the ducts outside of the liver
|
|
|
Biliay atresia is the most common cause of:
|
infant jaundice
|
|
|
How long does it take after the child is born to develop biliary atresia?
|
2 weeks
|
|
|
What is the cause of biliary atresia?
|
Unknown
|
|
|
If biliary atresia is present and the hepatic ducts are blocked or absent, what happens to fat in the body?
|
Not digested--results in steatorrhea
|
|
|
If biliary atresia is not treated, what happens to the liver?
|
It gets backed up with fluids and becomes fatal
|
|
|
What are manifestations of biiary attresia?
|
Jaundice
Splenomegaly/hepatomegaly Bleeding Pruritis Stool and urine discoloration Malnutrition |
|
|
What is the nursing diagnosis for a child with biliary atresia?
|
Failure to thrive--not gaining weight or losing weight
|
|
|
How is biliary atresia diagnosed?
|
H&P
Labs Ultrasound to rule out other causes Liver biopsy |
|
|
What do labs reveal in an infant with biliary atresia?
|
Increase in:
Bilirubin Aminotransferase Alkaline phosphatase Prothrombin time Ammonia |
|
|
What is a temporary way to manage biliary atresia until a liver transplant is available?
|
Surgical correction using bypass to either dilate or bypass the area(s) of obstruction
|
|
|
What supportive care may be necessary with an infant suffereing from biliary atresia?
|
Vitamin K and D supplements to help clotting
Antihhistamines (Questran) |
|
|
What does Questran do?
|
Absorbs the bile so that it can be excreted in the feces
|
|
|
How common is acute liver failure?
|
Not very--usally chronic
|
|
|
What are some physical things in the body that happen during acute liver failure?
|
Loss of liver function
Encephalopathy Bleeding |
|
|
What is encephalopathy?
|
Deteriorating neuro status related to increased ammonia levels
|
|
|
What is the prognosis for acute liver failure?
|
75% will die within a few days
|
|
|
What are some causes of acute liver failure?
|
Hepatitis (B/D combo)
Drug OD (acetaminophen) Preg. complications (eclampsia) Unknown |
|
|
What happens to the liver tissue in acute liver failure?
|
Necrosis
|
|
|
MODS is a complication of acute liver failure. What is this?
|
Multiple organ dysfunction syndrome: failure of other organs because of liver failure--usually renal, circulatory or neurologic
|
|
|
What are the classic manifestations of acute liver failure?
|
Encephalopathy
Coagulopathy MODS |
|
|
How often is acute liver failure cured with a transplant?
|
Rare--only have a few days to work with and MODS cause other serious problems
|
|
|
What is the difference between focal hepatocellular disorders and diffuse hepatocellular disorders?
|
Focal are localized to one part of the liver. Diffuse affects the entire liver
|
|
|
What are the 3 types of focal hepatocellular disorders?
|
Liver abscess
Liver trauma Liver tumors |
|
|
In liver abscess, what kinds of abscesses are you looking at? (Size and number)
|
1 large or multiple small
|
|
|
What organisms can cause liver abscess?
|
E. Coli
Klebsellia pneumonaie Polymicrobial |
|
|
In developing countries, what is the major cause of liver abscess?
|
Protozans from contaminated food and water
|
|
|
What are two complications if a liver abscess walls off?
|
Perforation
Fistula |
|
|
If a fistula developse, where may it connect to?
|
Respiratory cavity
Abdominal cavity external |
|
|
What is the mortality rate for liver abscesses?
|
High
|
|
|
Liver abscesses show the signs of infection. What are these?
|
Fever, chills, diaphoresis
Dyspnea/abn. breath sounds Abdominal pain GI distress Peritonitis sx |
|
|
If a person has a liver abscess and presents with dyspnea or abnormal breath sounds, what may be going on?
|
Fistula to respiratory system
|
|
|
If a person has a liver abscess and shows shoulder pain, what may be going on?
|
Diaphragmic involvement
|
|
|
What three signs may you see that directs you to believe that a liver abscess is the cause?
|
Hepatosplenomegaly
Jaundice Abdominal distention and ascites |
|
|
What happens to the following when you have a liver abscess:
WBC ESR AST ALT Bilirubin Albumin |
WBC increase
ESR increase AST increase ALT increase Bilirubin increase Albumin decrease |
|
|
When a liver abscess is walled off, why is it harder to treat?
|
Because the tissue is necrotic and medications in the vascular system don't get near it because the tissue is dead and not receiving blood supply
|
|
|
What are some options for treating a liver abscess?
|
Drainage through aspiration
Surgical drainage Supportive |
|
|
How painful is a liver abscess? How is pain treated?
|
Very painful--often large doses of opiates
|
|
|
What nursing interventions are important with liver abscess?
|
Fever
Pruritis F/E balance |
|
|
What are 2 ways liver trauma could occur?
|
Penetrating--knife or gun shot wound
Blunt-car accident, crushed |
|
|
Which type of liver trauma usually causes more damage?
|
Blunt
|
|
|
If there is an accident, how would a doctor determine if the client is suffering from liver trauma?
|
Abdominal/shoulder pain
Shock/Hypovolemia Visible (if penetrating) |
|
|
How is liver trauma diagnosed?
|
Look for increased WBC levels, decreased hemoglobin or hematocrit levels, perform peritoneal lavage to look for blood
|
|
|
When may surgery be indicated for liver trauma?
|
If it is penetrating or blunt and unstable
|
|
|
If liver trauma is blunt an stable, what does the nurse do?
|
Monitor
|
|
|
What are complications related to liver trauma?
|
hemorrhage
Peritonitis Abscess Fistula formation Permanent damage |
|
|
What does the nurse monitor when a client has suffered from liver trauma?
|
Resp status
VS until stable Mean arterial pressure I&O F/E balance Perfusion and bleeding Neuro status Signs of peritonitis |
|
|
How can we monitor for perfusion or bleeding?
|
Monitor capillary refill
Circulation to extremites Extremity sensation |
|
|
How common are liver tumors?
|
Common--second on transplant list after cirrhosis
|
|
|
Are liver tumors primary or secondary (normally)?
|
Secondary related to metastasis of another cancerous site
|
|
|
What are the 2 main risk factors for development of liver tumors?
|
Cirrhosis
Hepatitis |
|
|
What are early manifestations of liver tumors?
|
General--abd pain, fatigue, weight loss, anorexia, sometimes palpable mass in RUQ
|
|
|
What is the main indicator of liver tumors in early studies?
|
Liver function tests--levels rise
|
|
|
In later stages of liver tumors, what are the manifestations?
|
Severe fatigue
Severe anorexia Ascites Liver failure Jaundice |
|
|
How are tumors of the liver diagnosed?
|
Labs
CT/MRI/US Biopsy best |
|
|
What labs indicate liver tumor?
|
ESR increase
Anemia HGB decrease HCT decrease LFT results increase Albumin decrease Alpha-Fetoprotein abnormally present |
|
|
What 3 things can be done to help treat the tumor but not cure it?
|
Chemotherapy
Radiation Hepatic artery ligation |
|
|
Preop for a resection for a liver tumor, what do we look at?
|
Coagulation study
Help blood volume Nutrition |
|
|
Postop for a resection for a liver tumor, what do we look at?
|
NG tube
NPO with TPN initially Bleeding/hypovolemia Neuro Cardiopulmonary |
|
|
What are the 3 types of hepatitis?
|
Toxic
Viral Autoimmune |
|
|
How might one suffer from toxic hepatitis?
|
Liver trying to metabolize a toxic substance
|
|
|
What is an example of a predictable form of toxic hepatitis?
|
OD on acetaminophen--know how to treat it
|
|
|
Most hepatotoxic substances are: predictable or nonpredictable
|
Nonpredictable
|
|
|
What are early manifestations of toxic hepatitis? When do they start and how long do they last?
|
12 hours to 2 days after exposure
Anorexia, N/V Lethargy Elevated aminotransferases |
|
|
What are late manifestations of toxic hepatitis? When do they start and how long do they last?
|
Hepatomegaly
Tenderness Elevated bilirubin |
|
|
What is the best management for toxic hepatitis?
|
the antidote
|
|
|
With toxic hepatitis, how ill the person is relates to:
|
how damaged the liver is
|
|
|
In a case of autoimmune hepatitis, what happens to the liver?
|
becomes inflammed and leads to fibrosis and/or cirrhosis
|
|
|
How is autoimmune hepatitis diagnosed?
|
Antibody serology and rule out other causes
|
|
|
How is autoimmine hepatitis treated if caught early?
|
Corticosteroids and immunosuppressants
|
|
|
For all types of viral hepatitis, what happens to the liver?
|
Cellular edema, necrosis
Bile channels obstructed |
|
|
Viral hepatitis puts you at risk for:
|
Cirrhosis and/or cancer of liver
|
|
|
Hepatitis has 3 stages:
|
Preicteric (prodromal)
Icteric Posticteric |
|
|
During the preicteric stage, what symptoms are observed?
|
Fatigue
Anorexia N/V Low grade fever cough |
|
|
During the icteric stage, what symptoms are observed?
|
Possible jaundice
Stool/urine changes RUQ pain Pruritis |
|
|
During the posticteric stage, what symptoms are observed?
|
All symptoms return to normal
|
|
|
What lab abnormalities are present in the preicteric stage of hepatitis?
|
Viral confirmation
Acute liver enzyme elevation Increased serum aminotransferrin Increased bilirubin |
|
|
What lab abnormalities are present in the icteric stage of hepatitis?
|
Elevated bilirubin
|
|
|
How long does the preicteric stage of hepatitis normally last?
|
About 1 week
|
|
|
How long does the icteric stage of hepatitis normally last?
|
About 4 weeks
|
|
|
How long does the preicteric stage of hepatitis normally last?
|
About 3 months
|
|
|
During viral hepatitis it is important to limit all medications to the essentials because:
|
the liver is not functioning correctly and can not metabolize the drug. Look for toxicity
|
|
|
What type of diet is appropriate for someone suffering from viral hepatitis?
|
Low fat
High carb No alcohol Possible protein and sodium restrictions |
|
|
What is compensated cirrhosis?
Uncompensated? |
When person looks outwardly normal.
When person looks really sick. |
|
|
Alcoholic cirrhosis is also called:
|
Laennec's cirrhosis
|
|
|
In cirrhosis related to alcohol, what percent of liver damage can be reversed if the person stops drinking?
|
1/5 to 1/3
|
|
|
Other than alcohol and nutrition, what other things can cause cirrhosis?
|
Primary sclerosing cholangitis
Abscesses Right heart failure |
|
|
In general, what happens during cirrhosis?
|
Inflammation occurs leaving scar tissue and fibrosis. Eventually this causes function to suffer
|
|
|
In early cirrhosis, what does palpation feel like?
|
enlarged and firm
|
|
|
In late cirrhosis, what does palpation feel like?
|
shrunk but still firm
|
|
|
What nonspecific manifestations are present with cirrhosis?
|
N/V
Constipation Weight loss Anorexia Malnutrition |
|
|
What are some signs of liver failure?
|
ascites
edema asterixis jaundice pruritis steatorrhea |
|
|
What is the best way to diagnose cirrhosis?
|
Biopsy and CT scan
|
|
|
If the supply of blood is compromised, what test may be performed?
|
angiography
|
|
|
With cirrhosis, is a person more likely to get hyperglycemia or hypoglycemia?
|
Hypoglycemia--can't make glycogen
|
|
|
A CBC of a patient with cirrhosis may show:
|
Increased prothrombin time Decreased RBC
Decreased hemoglobin Decreased hematocrit Decreased platelet count |
|
|
Initial liver function tests may show ___________ then later liver function tests may show __________ or ___________.
|
Increases
Increases Decreases |
|
|
Because transplant is normally not an option, what supportive measures does the nurse begin?
|
VS
Daily weight Abdominal girth measurement F/E management Low protein diet |
|
|
What position is best for a person laying in bed who has ascites?
|
Semi-Fowlers
|
|
|
Why is Aldactone a good diuretic for people with ascites?
|
It does not waste potassium
|
|
|
What supplements may a person with cirrhosis need?
|
Fat soluble vitamins, especially K
Albumin |
|
|
When fluid from the liver backs up into the spleen, what happens to it?
|
Spleen begins to dissolve the blood and excrete it
|
|
|
Portal hypertension has a portal pressure of:
|
10mmHg or higher
|
|
|
In portal hypertension, the blood flows slower causing congestion. What is this called?
|
hepatosplenomegaly
|
|
|
What two areas are most commonly affected when blood vessels stretch or redirect?
|
Periumbilical and hemorrhoidal areas
Cardia of stomach and esophagus |
|
|
Consequences of portal hypertension are usually:
|
ascites
esophageal varices |
|
|
What procedure is sometimes used to manage portal hypertension?
|
Surgical shunt that diverts portal venous flow
|
