Ms Unit 7 Liver And Pancreas

Front 1

functions of the liver

Back 1

stores excess glucose as glycogen. Synthesizes 12/20 amino acids. also breaks down amino acids, where the remaining carbon chain can be used for energy or stored as fat. Synthesizes/excretes cholesterol into bile. Synthesizes plasma proteins such as albumin. Synthesizes bilirubin. Stores vitamins such as A, D, E, K and B12. Phagocytosis. Detoxifies, such as converting ammonia from protein metabolism into urea

Front 2

functions of the gallbladder

Back 2

located on the undersurface of the liver. Stores bile received from the cystic and hepatic ducts. When the gallbladder contracts, it forces bile through the cystic and common bile duct and into the duodenum.

Front 3

pancreas

Back 3

the pancreatic duct joins the common bile duct at the Ampule of Vater, where pancreatic juices (that contain pancreatic enzymes such as amylase) enter the duodenum.

Front 4

amylase

Back 4

an enzyme made in the pancreas. Increases in acute pancreatitis

Front 5

bilirubin

Back 5

Used to evaluate liver function. Increases in chronic liver failure, hepatitis, and biliary obstruction.

Front 6

urobilinogen

Back 6

increases with the destruction of RBCs, hepatitis, chronic liver failure, and obstructive jaundice

Front 7

blood alanine aminotransferase (ALT)

Back 7

an enzyme found mainly in the liver. Increases in chronic liver failure and hepatitis, and liver injury/disease in general.

Front 8

albumin

Back 8

made in the liver. Decreases in liver disease.

Front 9

ammonia

Back 9

a by-product of protein catabolism. Increases in chronic liver failure and hepatitis.

Front 10

cholesterol

Back 10

manufactured in liver. Increases in pancreatitis and gallbladder disease, and decreases in severe liver disease.

Front 11

lactic dehydrogenase (LDH)

Back 11

an enzyme present in all cells that increases in liver disease or injury.

Front 12

lipase

Back 12

made in pancreas. It's function is to break down fats. Increases in acute pancreatitis and cholecystitis.

Front 13

prothrombin time (PTT)

Back 13

determines adequacy of clotting mechanism. Increases in liver disease.

Front 14

endoscopic retrograde choloangiopancreatography (ERCP)

Back 14

endoscope is passed through the esophagus to the duodenum, where dye is injected to outline the pancreatic and bile ducts. This helps visualize liver, pancreas, and gallbladder. Check PTT before procedure! Contrast medium may be used. NPO after 8 pm to prevent aspiration. Dentures must be off. Atropine may be given to dry secretions. An anesthetic is sprayed to inhibit gag reflex and pt lays on left side before the scope is inserted into the Ampule of Vater. After procedure: pt lays on one side to prevent aspiration, NPO until gag reflex returns. Monitor for signs of perforation or infection.

Front 15

signs of perforation after ERCP

Back 15

bleeding, fever, dysphagia, RUQ pain, hematoma, n/v, and even cyanosis.

VS: hypotension, tachycardia, tachypnea

Front 16

signs of infection after ERCP

Back 16

increased right upper quadrant pain, fever, or chills.

Front 17

liver biopsy

Back 17

Pt must be NPO for 6-8 hours before procedure, Check CBC and coagulation ability. Pt lays on back w/ right arm behind head, or lays on the left side. Pt exhales and holds breathe during needle insertion. Pt is on bedrest for 24 hrs after procedure. Pt lays on right side for 2 hrs after procedure as a way of applying pressure and preventing bleeding. Avoid coughing or straining. Greatest risk is hemorrhage because the liver is highly vascular AND liver disease pts have reduced clotting abilities. Pt is advised to avoid coughing or straining

Front 18

HIDA scan

Back 18

pt is injected with a small amount of radioactive isotope, which goes into the gallbladder and is secreted into the bile. It goes wherever the bile goes, and can therefore be used to check for gallbladder disorders such as obstruction. Pt must be NPO for 2-6 hrs

Front 19

Hepatitis

Back 19

caused by bacteria, viruses (Hep A, B, C, etc.), drugs, alcohol, or toxic chemicals. These cause inflammation of the liver, damage of liver cells, and loss of liver function. If no complications, liver regenerates itself. Must be compliant with meds though

s/s: flu-like symptoms, anorexia (and weight loss), RUQ pain, diarrhea, enlarged liver, elevated liver enzymes, pruritis, easy bleeding, lack of appetite, ascites, liver enzymes increase, and there are low levels of albumin and clotting factors

Front 20

Hepatitis A, B, and C

Back 20

ABC are most common in US, although there are more. Hep A is most common but has low mortality rate, whereas B is more serious. Hep A and B have vaccines, there is no vaccine for hep C. Hep A is transmitted via the oral-fecal route, which is "when pathogens in fecal particles pass from one host and introduced into the oral cavity of another host." Hep B is transmitted via blood and body fluids. Hep C is transmitted via blood.

Front 21

Complications & Diagnostic tests

Back 21

Hepatitis may lead to fulminant (sudden, severe) acute liver failure. 5% will develop chronic liver failure.

LFTs will show elevated liver enzymes. Abdominal x-ray will show enlarged liver (hepatomegaly)

Front 22

treatment

Back 22

currently, there are no specific drugs for hepatitis. the only treatment is rest and adequate nutrition. No alcohol or hepatotoxic drugs such as motrin, tylenol, valium, (and dilantin?). Tylenol should not exceeds more than 4 grams.

Front 23

3 stages of hepatitis

Back 23

1) prodromal/preicteric phase = flu-like symptoms of anorexia, malaise, h/a, fever, n/v, diarrhea, or constripation, RUQ pain. Lasts one week

2) icteric stage = all the prodromal symptoms, plus jaundice, dark amber urine from the bilirubin, and clay colored stools from the fat that exists from the bile not breaking it down d/t liver cells not making bile. Liver is enlarged and tender. Lasts 2-6 weeks

3) posticteric = begins when the pt starts feeling better and after jaundice has gone away. This stage lasts 2-6 weeks with full recovery (normal LFTs) within 6mo-1yr.

Front 24

nursing process

Back 24

a low-grade fever, any abnormal bruising or bleeding is reported immediately. Encourage nondrug pain relief such as alternative methods. Acetaminophen is usually avoided d/t risk of liver toxicity.

Front 25

nutrition for hepatitis

Back 25

high protein (healing), high carb, and high calorie diet (so protein is not broken down for energy). Avoid fats. Provide frequent, smaller meals for better tolerance. Vitamin supplements are usually avoided bc they are metabolized by the liver. Bilirubin pigment deposits in skin can cause itching, so antihistamines can be given for that. Hands should be washed after toileting.

Front 26

triple therapy for prevention of chronic Hep C infection

Back 26

treatment to prevent chronic Hep C infection: interferon therapy is combined with an antiviral medication such as Ribavirin. Proteas inhibitors (antiviral meds) such as boceprevir (victrelis) and telaprevir (incivek) are also used.

to manage chronic hep B:

Front 27

Acute liver failure

Back 27

a serious condition that can develop as rapidly as 2 days. Liver is severely damage and functions are impaired. The best case scenario is liver recovery, worst is death. A common cause is tylenol overdose. Other causes are Hepatitis and Cirrhosis.

Front 28

S/S of acute liver failure

Back 28

S/S: fatigue, upset stomach, and diarrhea. As severity increases, we see jaundice, hepatic encephalopathy, bleeding, ascites, confusion, and even coma. A typical sign of ALF is a rapid reduction of liver size on x-ray. Liver enzymes increase, low levels of albumin and clotting factors, and K+ and glucose also drop.

Front 29

treatment for ALF

Back 29

Pt is put on bedrest in an attempt to put the liver completely at rest. All drugs are discontinued since they are metabolized by the liver. Dialysis may be done if the liver damage results from an overdose of a hepatotoxic substance. Lactulose, neomycin, magnesium citrate, or sobitol may be given to decrease ammonia levels. Liver transplant may or may not be an option

Front 30

nutrition for ALF

Back 30

high-calorie so that protein is not broken down for energy)

low sodium to prevent further water retention

low protein because liver is no longer able to convert the ammonia from protein breakdown into urea

Front 31

nursing process for ALF

Back 31

look out for early signs of liver failure, which are abdominal pain, anorexia, nausea, severe itching, and dull aching RUQ pain.

look out for late signs of liver failure, which are jaundice, clay colored stools, ascites, ecchymosis, GI bleeding, and confusion.

both weight and girth should be measured daily to assess fluid retention/ascites. Report any increases of these immediately. Check vitals q4hrs

Follow proper diet, administer diuretics, and monitor IV rate to prevent fluid overload. Small, frequent, and calorie-rich meals to reduce feeling of fullness. Assess neuromuscular function by asking the pt to hold arms straight out steadily in front- asterixis aka liver flap happens when pts hand dips down and then back up again d/t the ammonia. IS and GENTLE coughing should be done q2-4h. Any and all secretions/outputs should be monitored q8h to assess for bleeding. Pt should use soft brush and electric razor.

Front 32

Cirrhosis aka CHRONIC liver failure

Back 32

progressive and irreversible replacement of healthy liver tissue with scar tissue. Chronic alcohol use is the most common cause. All the scar tissue results in portal venous hypertension. The liver shrinks and is covered with gray connective tissue, afterwhich liver function becomes impaired. Eventually, many years of cirrhosis leads to chronic liver failure. It also causes biliary obstruction. Chronic alcohol use the most common cause of cirrhosis.

Front 33

prevention of cirrhosis

Back 33

avoid alcohol, balance diet with protein, avoid infections, avoid hepatotoxic chemicals

Front 34

S/S of Chirrhosis

Back 34

malaise, anorexia, n/v, fatigue, indigestion, weight loss, change in bowel patterns, RUQ pain, bruising, bleeding gums, anemia, jaundice, pruritis, enlarged and tender liver, LFTs indicative of liver dysfunction, hepatic encephalopathy, portal hypertension which can cause hemorrhoids, ascites, esophageal varices, the kidneys retain urine, clay-colored stools, splenomegaly (enlarged spleen), asterixis, hemmorhoids, confusion, and gradual progression to coma

Front 35

complications of cirrhosis (C)

Back 35

Cheap
Clotting defects: impaired PT and fibrinogen production in liver and also malabsorption of vitamin K in liver, which is essential for some blood clotting factors.

Front 36

complications of cirrhosis (H)

Back 36

cHeap
Hepatorenal syndrome: failure of the kidneys in some pts. Oliguria happens, as well as reduced glomerular filtration rate. No urine output or <200 mL/day because nearly all of the sodium is retained as a rxn to decreased blood volume d/t ascites.

Front 37

complications of cirrhosis (E)

Back 37

chEap
Encephalopathy: ammonia, the by-product of protein metabolism, which the liver cannot do anymore, leads to altered mental status. Signs of this is confusion, asterixis caused by ammonia (a toxin) at the peripheral nerves. Fetor hepaticus happens too, which is foul breath caused by metabolic end products related to sulfur

Front 38

complications of cirrhosis (A)

Back 38

cheAp
Ascites: accumulation of serous fluid in the abdominal cavity. The fluid accumulates bc of portal hypertension, low production of albumin bc of failing liver, and aldosterone accumulation. This causes decreased circulating blood volume, which causes the kidneys to retain urine. Treated with diuretics such as Lasix. Sodium and fluid is restricted. Albumin infusions for severe ascites. Paracentesis done to remove fluid from the peritoneal cavity. If large amounts r

Front 39

complications of cirrhosis (P)

Back 39

cheaP
Portal hypertension: HTN in the portal circulation of the abdomen. This causes visible visible abdominal veins, rectal hemorrhoids, splenomegaly, and esophageal varices (dilated veins in the esophagus). The esophageal varices can bleed, which is the most serious complication. The walls are thin and tear easily. This would cause severe bleeding, which is why pts are advised not to cough, lift, or strain.

Front 40

esophageal varices

Back 40

goal for bleeding esophageal varices is to stop the bleeding, maintain normal clotting, and treat infection. Vomiting blood, either frank or melena, can be indicative of this.

Treatment = sengstaken-blakemore tube. It's a 3-lumen tube that has a balloon at the end that gets inflated. One lumen is used to inflate the tube, another is used to inflate the balloon so that it stays in place, and the third lumen is used to connect suction to wall to prevent aspiration. Complications of this include aspiration, mucosal erosion, perforation, and suffocation, so it's not often used.

Sclerotherapy is also used. Post procedure the patient me experience chest pain for up to 72 hours. Vitamin k is also injected to promote clotting.

Front 41

in the case of complications with the sengstaken-blakemore tube...

Back 41

a pair of scissors must ALWAYS be kept by the client's bedside to cut (will deflate balloon) and remove the whole tubing in case the gastric balloon ruptures and the tube moves up the esophagus and causes suffocation.

Front 42

hepatic encephalopathy

Back 42

lactulose is given, either PO or via NG tube or enema, to acidify colon contents which would make ammonia insoluble and cause it to be excreted in the stool. Neomycin is an antibiotic given to bacteria in the colon that change ammonium to ammonia. MgSO4 (contains magnesium = diarrhea) is an enema given to cause diarrhea and flush ammonia out that way. Dialysis is done to clean out the blood in severe cases. Protein consumption is restricted. High protein consumption should be consumed if hepatic encephalopathy has not yet developed - once developed though, you must cut it from diet.

Front 43

Liver Transplantation

Back 43

pts in end-stage liver failure who don't respond to treatments can be evaluated for a liver transplant. Cancer pts are not candidates bc anti-tissue rejection drugs used for transplant can make the cancer worse. Pt will be on daily medications for life. Pts w/HTN, esophageal varices, infection, or severe cardiac disease (bc CHF can cause liver disease) are not candidates for a liver transplant.

Front 44

complication of liver transplantation

Back 44

pt must be closely observed for evidence of organ rejection:
PP >100
temp >101
RUQ pain
increased jaundice
decrease or color change of bile
labs may show increased enzymes

symptoms usually develop between 4-10 days postop.

Front 45

Cancer of the Liver

Back 45

usually results from cancer at another location. Prognosis is poor, usually 6 months. Pts with a history of hep B or C, alcohol or smoking, have increased risk of liver cancer.

Front 46

symptoms of liver cancer

Back 46

encephalopathy, abnormal bleeding, jaundice, and ascites. Alkaline phosphatase level in blood will be elevated. Diagnosed by a liver biopsy. Rarely, liver cancer can be surgically removed. Chemo may be done by injection directly into liver or hepatic artery.

Front 47

acute pancreatitis

Back 47

caused by a process called autodigestion, which is when the enzymes inside the pancreas that are meant to be excreted into the body actually for some reason activate while still inside the pancreas and digest the pancreas and cause INFLAMMATION. Autodigestion happens from excessive alcohol consumption and biliary diseases (higher mortality rate) such as cholelithiasis (gallstones - excessive fluid pressure & bile is irritating) or cholangitis (inflammation of the bile ducts). Opioids can cause acute pancreatitis too, as well as blunt trauma or infection.

Front 48

S/S of acute pancreatitis

Back 48

Patient feels like he is having a heart attack. trypsin destroys pancreatic tissue and causes vasodilation, which increases capillary permeability, which causes fluid to seep out into retroperitoneal space, causing SHOCK. Prothrombin is converted to thrombin, so clots form (dangerous!). Elevated serum amylase (a pancreatic enzyme), accumulation of fluid in bowel and around pancreas, decreased urine output, fever, flushing, severe vomiting, abdominal pain, guarding, rigid abdomen, hypotension or shock. Shock will cause renal failure bc of lack of renal perfusion. Respiratory distress from fluid accumulating in the retroperitoneal space. Respirations will be shallow d/t pain. Pt will have tachypnea. Mid epigastric pain w/ radiation to the spine, back, and flank. Eating makes pain worse. Pt will have tachycardia. If the cause is biliary, pt will definitely have n/v and jaundice.

Front 49

complications of acute pancreatitis

Back 49

death is most likely to occur from the secondary causes of AP. These are cardiovascular, pulmonary (ARDs), and renal failures. X-ray shows pleural effusion. Hemorrhage into third spacing can cause shock, and infection is also a concern.

Front 50

labs will show

Back 50

decrease in albumin, sodium, calcium, and magnesium.

Everything else, including the enzymes (especially amylase), glucose, cholesterol, and potassium, are all elevated.

Front 51

treatment of acute pancreatitis

Back 51

resting the pancreas is essential to reducing autodigestion. NPO and NGT to rest and decompress the GI tract. TPN to provide nutrition during this resting time. Something will be given to treat the acid caused by pancreatic enzymes. As pt recovers, NPO diet is advanced to a clear liquid diet, which is then advanced to a low fat diet. Pain is treated bc pain and anxiety stimulate the ANS and increase pancreatic secretions. Strict I&O. Electrolytes to replace calcium and magnesium. Insulin to combat hyperglycemia. Antibiotics for infection/sepsis. Antiemetic for nausea.

Front 52

pancreatic cancer

Back 52

70% of cancers occur in the head of the pancreas. 30% are located in the body or tail. Spreads rapidly, as it directly extends to the stomach, gallbladder, and duodenum. Cancers of the body/tail worse than cancers located in the head of the pancreas.

Front 53

causes of pancreatic cancer

Back 53

pancreatic cancer has been associated with chemical carcinogens such as high-fat diet, smoking, drinking, chemical exposure, diabetes, and chronic pancreatitis. It can also occur from metastasis of a cancer at another location.

Front 54

S/S of pancreatic cancer

Back 54

weight loss, pain, n/v, anorexia, and weakness are among the early symptoms. Abdominal pain worse at night. Pain radiates to the back. Pain may be relieved by a side-lying position with knees drawn up to chest or bending over when walking. Pain gets worse as cancer worsens. Pt feels full/bloated after eating.

Front 55

complications of pancreatic cancer

Back 55

malnutrition, gastric or duodenal obstruction, and metastasis. After surgery, fistulas and thrombophlebitis may occur. Thrombophlebitis occurs because as the tumor grows, by-products increase thromboplastic factors in the blood, which makes clotting easier.

Front 56

diagnostic tests

Back 56

alkaline phosphatase , glucose, and bilirubin levels are elevated. Carcinoembryonic antigen (CEA) ordered to confirm the presence of cancer. ERCP used to visualize common ducts and take samples. Biopsy needed for official and definitive diagnosis.

Front 57

treatment for pancreatic cancer

Back 57

depends on stage. early diagnosis may potentially be cured. If metastasized, the aim is to reduce symptoms and make pt more comfortable. If tumor is at the head of the pancreas, the Whipple procedure is done to remove the head of the pancreas, the lower portion of the common bile duct, sometimes the whole gallbladder, most of the duodenum, and possible the lower part of the stomach. A total pancreatectomy can be done, or partial for tumors in the body or tail. Radiation and chemo are done after surgery to prevent metastasis.

Front 58

Disorders of the gallbladder - cholecystitis

Back 58

inflammation of the gallbladder. Most often caused from obstruction of the common bile duct d/t cholelithiasis. Bacteria can invade and add to the inflammation. The gallbladder becomes thickened and fibrotic and doesn't empty easily/completely.

Front 59

Disorders of the gallbladder - cholelithiasis

Back 59

gallstones in the gallbladder caused by pooled bile. Can be caused by partial obstruction in the common bile duct. Can also be caused by anything that decreases the gallbladder emptying rate, such as pregnancy, high cholesterol (super saturates bile and then crystallizes and forms stones), and sedentary lifestyle.

Front 60

Disorders of the gallbladder - choledocholithiasis

Back 60

gallstones in the common bile duct

Front 61

symptoms of gallbladder disorders

Back 61

symptoms for cholecystitis and cholelithiasis are similar. epigastric pain, RUQ tenderness, nausea, and indigestion, especially after eating foods high in fat. Signs of inflammation are symptoms too, such as fever, elevated pulse and respirations, as well as vomiting and jaundice. a positive murphys sign happens when the pt is unable to breath when below the liver is pressed. Biliary colic may be present, which is severe epigastric and RUQ pain that radiates to the back behind the right scapula or right shoulder that is caused by cholelithiasis. Usually begins after a fatty meal. The pain is worse if it is caused from a stone in the common bile duct.

Front 62

complications of gallbladder disorders

Back 62

fsf