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158 Cards in this Set
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What's the core definition of cirrhosis?
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scarring of liver
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What are four types of cirrhosis?
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1. Laennec's Portal Cirrhosis
2. Portnectrotic Cirrhosis 3. Biliary Cirrhosis 4. Chemically-Induced Cirrhosis |
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What type of cirrhosis comes from alcohol abuse?
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Laennec's Portal
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What does postnecrotic cirrhosis come from?
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hepatitis
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What does Laennec's Portal Cirrhosis come from?
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alcohol, possibly malnutrition
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What type of cirrhosis does hepatitis cause?
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postnecrotic
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What does biliary cirrhosis come from?
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chronic biliary obstruction or infection
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What's an example of a cause of chemical cirrhosis?
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arsenic
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What's the livers response to alcohol?
What's a name for it? |
Replaces glycogen stores with lipids.
Fatty infiltration |
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What two things can fatty infiltration cause?
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inflammation and scarring (cell death causes fibrosis)
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What kind of onset does cirrhosis have?
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insidious
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Early cirrhosis, what size is the liver?
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large (cells loaded with fat)
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Later cirrhosis, what size is the liver?
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small and hard (scar tissue contracted)
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What does the liver look like in later stages of cirrhosis?
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hobrail appearance,
rough w/ bumps |
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Initial symtoms of v liver function?
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GI: anorexia, fatigue, h/a
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What is a blood issue that develops with decreasing liver function?
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thrombcytopenia
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What happens as blood has trouble getting into the liver?
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Portal hypertension
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Where does blood back up into with portal htn?
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spleen and GI tract
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Waht can happen to speen with portal HTN?
What may that cause? |
Splenomegaly,
can cause anemia (from RBC destruction) |
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What GI issues occur if stagnant with blood?
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n/v, chronic indigestion, bloating, diarrhea/constipation, weight loss, anemia
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What % of hepatitis sufferers get jaundaice?
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50%
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What are the s/s of preicteric stage of hep?
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dull ache RUQ & fever (inflamed liver). h/a, fatigue, n/v, indigestion, dyspepsia, wt. loss, change in sensation of taste or smell, loss of desire for cigarette smoke. Hepatosplenomegaly.
Pounding h/a RUQ dull ache Enlarged spleen and liver Indigestion with n/v Cigarette smoke sucks Tired Elevated temp Reflux Inches off the waste (wt. loss) Changes in smell & taste |
Pounding h/a
RUQ dull ache Enlarged spleen and liver Indigestion with n/v Cigarette smoke sucks Tired Elevated temp Reflux Inches off the waste (wt. loss) Changes in smell & taste |
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How long does preicteric stage of hep last?
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1 week
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What's the highest priority with hep pt?
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promote rest
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What's the hep diet? x4
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Small frequent meals
high calorie and CHO mod-hi protein (unless r/o hep coma, then none) low fat |
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Hep pt is prone to what?
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infection
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A cirrhotic liver has difficulty metabolizing what 3 things?
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CHO, fat, and protein
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What liver condition makes it hard to metabolize CHO, fat, and protein?
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cirrhosis
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What vitamins are deficient in the cirrhotic pt?
6 kinds |
fat solubles: ADEK,
B complex Folic acid |
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What happens to glycogen stores in the cirrhotic liver?
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v glycogen stores
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What happens to protein in the cirrhotic pt.? (4 steps)
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1. v protein metabolism,
2. v serum protein, 3. v colloidal osmotic pressure, 4. fluid flows from vessels into abdominal cavity (ascites) |
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Why does cirrhotic liver cause ascites?
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v colloidal osmotic pressure from lack of serum albumin allow flow into belly
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What's the relationship of cirrhosis and aldosterone?
What's it cause? |
Aldosterone not metabolized and causes Na and water to be retained.
This causes ascites and edema |
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What are three causative factors of ascites in the pt w/ cirrhosis?
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1. Portal hypertension
2. v colloidal osmotic pressure r/t v serum albumin 3. INCREASED serum aldosterone |
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What happens to bilirubin w/ cirrhosis?
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impaired excretion from liver into intestines
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what s/s does v bilirubin excretion into intestines cause? x6
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^ serum and urine bilirubin, jaundice, pruritis, dark urine, clay-colored stools, fat intolerance
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How might cirrhosis progress prior to dx? Until what might happen?
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quietly until emergency develops, ex. bleeding varices
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What's normal range for SGOT?
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10-40 units/mL
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What's normal range for SGPT?
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5-35 units/mL
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In pt with cirrhosis, ^ or v:
Gamma-glutamyl transferase (GGT) |
^
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What other liver enzyme is elevated in cirrhosis besides SGOT/SGPT?
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Gamma-glutamyl transferase (GGT)
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What's normal range for direct bili?
indirect bili? total bili? |
0 - 0.3 bili ----------
0.8 - 1.0 indirect bili 0 - 0.9 total bili --- |
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Normal protime?
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11-15
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What's normal range for serum albumin?
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3.5 - 5 mg/100mL
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What's normal serum ammonia?
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20 - 120 ug/dL
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How much of the liver can be damaged before it tests abnormal?
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75%
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How do you get a definite dx for cirrhosis?
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liver biopsy
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What is particular about alcoholics electrolyte levels?
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hypomagnesemia
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What is the first action when pt doesn't understand a procedure like liver biopsy?
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Call MD to describe it again
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What position do you put liver biopsy pt in post-op? 3 steps
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1. lying on R side flat (for several hours)
2. Pillow under R costal margin 3. R arm over head |
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How often check VS for post liver biopsy pt?
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often, Q15 min x 4,
Q30 min x4, Q1 hr x 12 hours |
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How long post liver biopsy pt on bedrest?
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24 hrs
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What's the most important assessment after liver biopsy?
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bleeding
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What three things to you check for post liver biopsy?
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abdominal pain,
hemorrhage, bile drainage |
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What's the diet of cirrhosis pt w/o hep encheph? x5
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high protein,
high calories, high vitamins; well balanced diet, maybe low Na |
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What's the best way to evaluate fluid retention or loss?
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daily wt
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What position is best for ascites?
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High-fowler's
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If ascites severe, what is the nsg priority?
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promote adequate lung expansion
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What's the most important nursing action prior to PARACENTESIS?
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have pt. void
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What are the two major complications r/t cirrhosis?
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hepatic coma,
bleeding esophageal varices |
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What's priority if pt in ICU is NPO?
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frequent oral care
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After Sengstaken-Blakemore tube in place, what's best position?
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semi-fowler's
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What is the tube they put in for esophageal varices?
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Sengstaken-Blakemore tube (S-B tube)
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What condition is the Sengstaken-Blakemore tube used for?
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Bleeding esophageal varices
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What are two procedures to stop bleeding varices? (not SB tube)
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1. injection sclerotherapy
2. esophageal banding therapy |
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What do you give after injection sclerotherapy?
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antacids
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What is a purely palliative procedure for bleeding varices?
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shunts
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What do shunts decrease the risk of?
What do they increase the risk of? |
v risk of bleeding varices
^ risk of hepatica encephalopathy |
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What's the main immediately life-saving task of the liver?
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convert ammonia to urea
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Hepatic encephalopathy, initial s/s?
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mood changes, impaired memory and attention, v concentration, delayed response time, laughs easily, cries easily, confusion, slurred speech, change in speech or handwriting, lethargic
PRE LIVER COMA Poor response time Reduced concentration Easily cries Laughs easily Impaired memory Variations in speech or handwriting Enunciation issues (slurred speech) Real tired (lethargic) Confusion Obtuse (general slow reactions and attention) Mood changes Attention impaired |
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What's the onset of Hep A?
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acute
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What's the onset of Hep B and non-A-non-B?
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insidious
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In hepatic encephalopathy, what s/s are noted when coma is imminent? x3
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1. asterixis
2. Fetor hepaticus (liver breath, acetone breath); fruity odor to breath. 3. Maybe convulsions |
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What are three other names for ASTERIXIS?
How is it presented? |
muscle twitching, "flapping tremor" "liver flap": unable to hold hand extended when arm outstretched; involuntary clenching and re-clenching.
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Primary dietary Rx for hep encheph?
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decrease protein
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Why v intestinal bacteria?
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to prevent breakdown of protein to ammonia
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How do you v intestinal bacteria? x3
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1. give neomycin
2. give enemas 3. give lactulose (Cephulac) |
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How much and why do you give Neomycin to hep enceph pt.?
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4 gm/day
it destroys intestinal bacteria |
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What are 2 reasons to give enema to hep enceph pt?
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1. removal protein from GI before turned into ammonia
2. prevent constipation |
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What is teh enema solution for hep enceph pt?
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tap water and Neomycin
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When is it particularly important to remove protein from GI with enema?
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GI bleed
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How many stools do you want to see per day with Cephulac? And of what quality?
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2-3 soft stools
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What are four ways of diagnosing Hepatitis?
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1. Symptoms
2. Elevated liver enzymes 3. ^ urine & serum levels 4. antigens & antibodies |
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What is another name for liver enzymes?
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transaminases
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How elevated are SGOT/SGPT levels with hep?
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8x normal
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What stage sees a drop in GI symptoms with hepatitis?
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Icteric stage
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When are elevated SGOT/SGPT levels noted during hep cycle?
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before jaundice then peaks in icteric phase
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What is elevated in blood and urine during hep? x3
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bilirubin, alkaline phosphatase, and LDH
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What do you give post exposure to Hep A? How long?
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IG 2 wks before to 1 wk after symptoms
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How soon must you start post exposure prophylaxis to prevent acute Hep A?
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48 hours after exposure
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What can pt expect if they take IG 2 wks after exposure?
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v severity of infection
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If a pt had the vaccine, what do you give if exposed to Hep B?
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HBIG & booster
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If pt didn't have vaccine, what do you give if exposed to Hep B?
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HBIG & start Hep B vaccine series
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Primary adverse effect of suctioning trach?
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hypoxia
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How long do you suction trach?
How many minutes in between attempts? |
not > 15 seconds
3 min between |
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What two effects can suctioning cause r/t vagal stimulation?
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bradycardia followed by hypotension
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What is the best position for pt w/ trach?
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semi-folwer's
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What are two signs of rupture of cuff or tube on trach?
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1. ^ amount of air needed to inflate
2. withdrawing more air than was injected |
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How often to you change dressing after trach insertion?
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Q8 hours
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What's the expected drainage from trach wound?
For how long? |
serosanguineous drainge for 2-3 days post-op
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What drainage is abnormal for trach post-op?
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frank blood or persistent serosang.
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Nurse needs to check for what other than drainage for trach post-op?
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emphysema (air in tissues)
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How can you detect emphysema in the post-op trach?
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feeling gas bubbles in tissue around trach and
listening for crackling (crepitus) |
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What is particular with O2 given after trach insertion?
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must be humidified
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How do you prevent aspiration for trach pt eating?
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tilt head forward
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What's important to teach trach pt?
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trach self-care
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What's the name of the process of closing trach?
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decannulation
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Is closing a trach a sudden or gradual process?
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gradual
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What is most important in pre-op care for total laryngectomy?
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plan method of communication
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What is the highest priority post-op for total laryngectomy?
And how do you best do it? |
maintain respirations & circulation;
suction PRN |
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What position is best for post-op laryngectomy?
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semi-fowler's
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What exercises and activities do you encourage for post-op laryngectomy?
And when? |
T, C, DB, ambulate;
first day post-op |
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What resp. Tx do you provide for post-op laryngectomy?
Be careful of what? |
O2 PRN, but avoid high levels
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How do you prevent damage to suture line for post-op laryng.?
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support neck with hands when moving
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How long is pt NPO of total laryngectomy? Why?
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10-14 days, to prevent suture line contamination
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How does post-op total laryng'y get nutrition first?
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IVs
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How do you prevent contamination of suture line for post-op total laryng'y besides NPO?
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NG to intermittent suctioning
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After 10-14 NPO how do you feed total laryng'y pt?
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NG tube
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What's the process of tube feeding post-op total laryng'y pt if cuffed trach?
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inflate cuff before NG tube feeding and for 1 hour after
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When is it safe for post-op total laryng'y pt to take PO?
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When pt can swallow saliva
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What should 1st oral feedings be for post-op total laryng'y pt?
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thick fluids (ensure, jello)
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What happens r/t air not being passed thru nose for post-op total laryng'y pt?
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diminished sense of taste & smell
(body usu. accommodates in time) |
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What is pain like for post-op total laryng'y pt ?
What's pain Rx? |
minimal (just when swallowing b/c nerves severed);
pain meds PRN |
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What is the main complication to check for with a radical neck dissection?
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carotid rupture
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How do you identify a rupture of the carotid with a radical neck dissection?
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check skin flap for bleeding
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What do you do if you identify a rupture of the carotid with a radical neck dissection?
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1. Apply pressure directly over artery
2. Get help! 3. Do not remove dressing |
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What are three complications to check for after a radical neck dissection?
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1. rupture of carotid
2. facial paralysis or difficulty swallowing 3. Shoulder drop |
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What's the Rx for shoulder drop after radical neck dissection?
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exercise to replace function of lost muscles
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What do you teach pt after total laryngectomy? 5 things
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1. expect freq. coughing w/ lots of mucus
2. use humidification to v secretions 3. Cover stoma in shower 4. Cover stoma to warm air and keep stuff out 5. No swimming or water sports |
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What does treatment with radiation cause?
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thick scanty saliva, dry mouth, ulceration of the mucous membrane, pain, loss of taste, anorexia
Pain Ulcerations of the mucous membranes Delayed healing at surgical site Dry mouth Loss of taste Eat less (anorexia) Saliva is thick and scant |
PUDDLES
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What should a pt with radiation of the larynx do at meals to facilitate swallowing?
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drink large amounts of fluid
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What is the leading cause of acute pancreatitis
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gallbladder disease
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what is the second most common cause of acute pancreatitis?
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alcohol
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What are the symptoms of acute pancreatitis?
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PANCREATITIS HURTS
Peristalsis slows, Paralytic ileus, Peritonitis Abdomen tender Nausea/vomiting Confusion & agitation Respiratory distress or hypoxia Eating or drinking heavily may trigger symptoms Ascites Temp ^ (fever) Increased blood sugar (or other DM s/s) Tawny (jaundice) I gotta pee! (oliguria) Severe epigastric pain extending to back Hypovolemia s/s Umbilicus or flank bruising (Cullen's sign) Real bad bleeding may cause DIC Tetany Stools frequent, frothy, foul smelling |
PANCREATITIS HURTS
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What are three important diagnostic tests for pancreatitis?
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1. serum amylase ^
2. Blood lipase ^ 3. ERCP |
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What is the timing of the typical levels of positive serum amylase test for pancreatitis?
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peaks in 24 hrs,
fall to normal after 2-3 days |
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What is the timing of the bloods lipase levels in pancreatitis?
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^ longer than amylase,
often for 5-7 days |
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What does ERCP stand for?
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endoscopic retrograde choliangiopancreatography
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What do you have to assess before ERCP?
When can you do it? |
bilirubin levels,
only done if pt not acutely ill (i.e. has high bili levels) |
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What is the main focus of managing acute pancreatitis?
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rest GI tract (to v production of pancreatic enzymes)
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What are the five actions to help rest GI tract in acute pancreatitis?
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1. NPO
2. NG tube to suction 3. Bedrest 4. Give histamine antagonist (Zantac, Tagament, or Protonix) 5. Give antispasmodic/anticholinergic drugs (Pro-Banthine) |
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What do you do if pt w/ acute pancreatitis vomits after NG placement?
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check tube for patency
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What do you use to relieve pain r/t pancreatitis?
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morphine
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For pt w/ acute pancreatitis, what do you give besides GI drugs and pain killers?
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antibiotics
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What do you have to do r/t NPO status of acute panc. pt.?
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frequent oral & nasal care
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Why might you have severe epigastric pain that extends to back with acute panc.?
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due to edema and irritation
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What is unique about vomiting or eating with acute pancreatitis?
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^ pain (it usu. v upset)
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How can you determine if someone has decreased peristalsis?
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v bowel sounds
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How does paralytic leus present?
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distended abdomen
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What does a board-like abdomen signify (r/t acute pancreatitis)?
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ominous sign, means peritonitis
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Why does pt with acute panc. have frequent, frothy, foul stool?
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r/t fat content
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What is Cullen's sign?
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bluish discoloration of the periumbilical area from hemorrhage
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What is confusion or agitation r/t w/ acute panc.?
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pain
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What is a grave respiratory complication of acute pancreatitis?
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ARDS
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What do you do after acute attack of pancreatitis subsides and no longer NPO?
7x pos's 5x neg's |
positives:
.small meals .bland food .easily digested .^ CHO .give pancreatic enzymes .give bile salts .give vitamins negatives: .low fat .low protein .no caffeine .NO ALCOHOL .no meds that trigger attack |
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What are two pancreatic enzyme meds?
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pancreatin (Creon)
pancrelipase (Viokase) |
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When do you take pancreatic enzymes?
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ac and during meal
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What are three ex of meds than can cause pancreatitis attack?
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oral contraceptives,
thiazide diuretics, glucocorticoids |
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