Nursing 4Th Liver, Gi, Gb, Endocrine

Front 1

The______ is essential for life. It functions in the manufacture, storage, transformation, and excretion of a number of substances involved in metabolism.

Back 1

The liver is essential for life. It functions in the manufacture, storage, transformation, and excretion of a number of substances involved in metabolism.
Review page 903-904 for details about the liver and its many functions

Front 2

Jaundice, the yellowish discoloration of body tissues, results from an alteration in normal _____ metabolism or flow of ____ into the hepatic or biliary duct systems.
True or False: Jaundice is a disease not a symptom

Back 2

Jaundice, the yellowish discoloration of body tissues, results from an alteration in normal bilirubin metabolism or flow of bile into the hepatic or biliary duct systems.
False, it's a symptom

Front 3

Review page 903 anatomy of liver... especially the different ducts

Back 3

If somewhere in duct system is fibrosed, constricted, etc. the whole system can be effected. When looking at US and other imaging studies looking at biliary tree etc. think about what ducts are involved, then you can figure out what organ(s) are in trouble

Front 4

When does jaundice start to occur? where will you see it first?

Back 4

when concentration of bilirubin in blood becomes abnormally increased, has to be 3x ormal level (2 - 3 mg/dl)
First detected in sclera and skin.

Front 5

Most of the body's bilirubin is formed from the breakdown of ______ by macrophages. Some types of bilirubin are returned to portal circulation, excreted in stool (and gives it its color), or secreted into bile, which flows through the hepatic and biliary duct system of the small intestine.

Back 5

Most of the body's bilirubin is formed from the breakdown of hemoglobin (erythrocytes) by macrophages.

Front 6

Where can you first notice jaundice on a dark-skinned person?

Back 6

upper palate of mouth, inner canthus of eyes

Front 7

What are the 3 types or classifications of jaundice ?

Back 7

hemolytic, hepatocellular, obstructive

Front 8

Hemolytic jaundice, also called ______ jaundice is due to an decreased/increased breakdown of RBC's. The liver is unable to handle the increased load of unconjugated bilirubin in the blood. What are some causes? Labs will show increased/decreased bili and increased/decreased H & H.

Back 8

Some causes of hemolytic jaundice include: blood transfusion reactions, sickle cell crisis, and hemolytic anemia (RBC's are being broken down in all of these, causing increased bili levels)

Labs will show increased bili and decreased H & H.

Front 9

Hepatocellular jaundice, also called _________ jaundice. This is due to ________ hepatocytes. What are 3 main causes? Labs will show increased/decreased bili, and increased/decreased urine bilirubin.



(In hepatocellular disease, the hepatocytes are damaged and leak bilirubin, thus increasing levels of conjugated (direct) bilrubin. In severe disease, both kinds of bilirubin, conjugated and unconjugated (indirect) are increased as a result of both the inability of hepatocytes to conjugate bilirubin and continued hepatocyte leaking of conjugated bilirubin. As the number of unhealthy hepatocytes increases, the ability to conjugate bilirubin will eventually decrease.)

Back 9

Hepatocellular jaundice, also called _________ jaundice. This is due to damaged or injured hepatocytes. 3 main causes: hepa***is, cirrhosis, and hepatocellular carcinoma. Labs will show increased OR decreased bili, and increased urine bilirubin. (Conjugated bili is water soluble therefore excreted by kidneys into urine).

Front 10

Obstructive or ____hepatic jaundice is due to disrupted or obstructed flow of ___ through the liver or biliary duct system. Obstruction may occur in both intrahepatic and extrahepatic bile ducts. Describe each type including causes.
What will labs show (bili)?
What is an additional finding for this kind of jaundice?

Back 10

Obstructive or hepatic jaundice is due to disrupted or obstructed flow of bile through the liver or biliary duct system.

Intrahepatic obstructions include swelling or fibrosis of the liver's canaliculi and bile ducts due to damage from liver tumors, hepa***is, or cirrhosis.

Extrahepatic obstruction can be caused by common bile duct obstruction from a stone, biliary strictures, sclerosing cholangitis, and pancreatic cancer.

Labs: inreased bili, decreased bili in urine , little to none in stool

Stool will be pale or clay colored

Front 11

Review *****sment and age-related considerations.

Back 11

table 44-8

Front 12

Describe liver palpation..

Back 12

Review how to palpate a liver...
910

Front 13

What labs do you look at to determine a patient's nutritional status?

Back 13

prealbumin- short term (best indicator of nutrition, not easily influenced by hydration etc)
albumin- long term protein status

Front 14

What lab is an indication of hepatocellular cancer?

Back 14

alpha a-Fetoprotein

Front 15

What are the 4 liver function tests?

Back 15

ALP
AST
ALT
GGT

Front 16

Conversion of _____ to urea normally occurs in the liver. Elevation can result in ____ ____ secondary to liver ____.

Back 16

Conversion of ammonia (NH3) to urea normally occurs in the liver. Elevation can result in hepatic encephalopathy secondary to liver cirrhosis. (In cirrhosis, the patient has difficulty getting rid of bacteria/protein etc reach toxic levels of bad stuff)

Front 17

Patients with liver problems might have problems with bleeding because liver is involved with clotting factors etc. What should someone do to prevent bleeding after biopsy?

Back 17

What should someone do to prevent bleeding after biopsy?
lay on right side or use sandbag
(prevent other complications like peritonitis, PNA, shock, etc)

Front 18

A ______ or fibroscan is specific to the liver.

Review diagnostic tests... 914-18

Back 18

sonogram (fibroscan)

Front 19

review chart on page 905 and difference between conjugated and unconjugated bili

Back 19

..
also... according to Tania dark skinned-people jaundice shows up on hands/soles of feet... this is more obvious than eyes/mouth, probably later signs

Front 20

Review cultural and ethnic health disparities for hepa***is.

Back 20

P. 1060 chart
More Hep C in African American and Mexican populations, also have harder time getting effective tx, higher death rates

Front 21

Hepaitis is defined as inflammation of the liver. Viral hepa***is is the most common kind, and includes Hep A,B,C,D,E, and G. (Don't worry about Hep F, focus on ABC). What are some other causes of hepa***is? (

Back 21

Other causes of hepa***is:
Hepatotoxic Drugs/chemicals (including alcohol, see table 39-6 p. 906)
Autoimmune disease
metabolic abnormalities
Bacteria (very rare)

Front 22

True or False:There is a 15-20 y delay between and clinical appearance of liver damage from Hep C

Back 22

True- There is a 15-20 y delay between and clinical appearance of liver damage from Hep C and long-term effects may pose important health care challenges for the next 20 y.

Front 23

What is the only definitive way to distinguish among the various forms of viral hepa***is?

Back 23

The only definitive way to distinguish among the various forms of viral hepa***is is by the presence of the viral antigens and the subsequent development of antibodies to them.

Front 24

True or False: An individual with Hep C can be reinfected with another strain of hepa***is C.

Back 24

True

Front 25

What are some examples of percutaneous transmission of a virus?

Back 25

IV Drug use- sharing needles
accidental needle stick
tattoos from contaminated needles

Front 26

how is Hep A spread?

Back 26

fecal-oral

(food handlers)

Front 27

how is Hep B spread?

Back 27

percutaneous
permucosal -mucosal exposure to infectious blood, blood products, or other body fluids (semen, vaginal secretions, saliva)
body fluid exposure
blood transfusions,
perinatal exposure (at birth)

Front 28

True or False: Infected semen and saliva contain much lower concentrations of HBV than blood, but the virus can be transmitted via these secretions.

Back 28

true

Front 29

How is hep C spread?

Back 29

primarily percutaneous
also permucosal, blood transfusion, body fluid exposure, perinatal

Front 30

Hepa***is is a disease that requires mandatory reporting.

What are some risk factors for getting hepa***is A?

Back 30

Household contacts
crowded conditions / ins***utionalized- prison, day care
poor sanitation
poor personal hygeine

contaminated food, milk, shellfish, water

sexual contact
food handlers
farm workers
recent travel esp. to areas of poor water sanitation
injection/oral/nasal

Front 31

Who is at risk of getting hepa***is B?

Back 31

IVDA
multiple sex partners
(esp. high risk sexual activity)
health care workers
hemophiliacs
hemodialysis
blood transfusions
tattoos
manicure/pedicure
dental work
birth (perinatally from mother)
organ transplants

household contact with someone chronically infected

Front 32

True or False: HIV is much more infectious than HBV

Back 32

False: HBV is much more infectious than HIV

Front 33

There is no evidence that urine, feces, (without GI bleeding), breast milk, tears, and sweat are infective of Hep B virus.

Back 33

True.
Semen and saliva have low concentrations
Blood has highest concentration

(HBsAg has been detected in almost every body fluid...)

Front 34

True or False: You can get Hep B from kissing due to the exchange of saliva

Hep B can live on a dry surface for ___ days.

Back 34

true! lower risk of transmission but it can happen

Hep B can live on a dry surface for 7 days.

Front 35

Hepa***is C is primarily spread through the ______ route.

Back 35

percutaneous

Front 36

What is the incubation period and communicability for Hep A

Back 36

15-50 days
most infectious 2 weeks prior to onset of s/s
Patient remains infectious until up to 2 weeks after the start of symptoms.

Front 37

What is the incubation period and communicability for Hep B?

Back 37

45-180 days
communicable weeks before s/s occur and throughout acute course (infectious for 4-6 months).
In carriers, communicability continues throughout lifetime.

Front 38

Do people with Hep B always have symptoms?

Back 38

Sometimes symptoms do not appear at all (30% of cases).

Front 39

What is the incubation period and communicability for Hep C?

Back 39

14-180 days
communicable 1-2 weeks prior to onset of s/s and throughout clinical course.

Front 40

Thirty percent of people with Hepa***is ___ and eighty percent of people with Hepa***is ____ will be asymptomatic.

Back 40

Thirty percent of people with Hepa***is B and eighty percent of people with Hepa***is C will be asymptomatic.

Front 41

What are the symptoms of the pre-icteric phase of hepa***is?

Back 41

BH WHARF MAN
Bowel changes
Headache
Weight loss
Hepatosplenomegaly
Anorexia
RUQ pain/discomfort
Fever
Malaise
Arthralgias
Nausea/vomiting

Front 42

Describe the icteric phase of hepa***is.

Back 42

Jaundice
Pruritis (bile salts)
Dark urine
Light stools
more Fatigue
Hepatomegaly
Wt loss

Front 43

Describe the post-icteric phase of hepa***is. It is also known as...
What does the pt. complain of ?

Back 43

also called convalescent or recovery phase

Pt.complains mostly of being easily fatigued and malaise

Hepatomegaly persists.
Jaundice decreases.
GI symptoms decrease.
Color of stool and urine return to normal.

Front 44

When jaundice occurs, the ____ usually subsides. (all forms of hepa***is)

Back 44

fever

Front 45

True or False: The acute phase of hepa***is is the period of maximal infectivity.

Back 45

true

Front 46

There is slight variation in manifestations between the different types of viral hepa***is. In Hepa***is __ the onset is more acute, and the symptoms are usually mild and flu-like. In Hepa***is __, the onset is more insidious and the symptoms are usually more severe. In Hepa***is ___ the majority of cases are asymptomatic or mild. However, Hepa***is __ has a high rate of persistence.

Back 46

There is slight variation in manifestations between the different types of viral hepa***is. In Hepa***is A the onset is more acute, and the symptoms are usually mild and flu-like. In Hepa***is B, the onset is more insidious and the symptoms are usually more severe. In Hepa***is C the majority of cases are asymptomatic or mild. However, Hepa***is C has a high rate of persistence.

Front 47

What is the term for viral hepa***is in which jaundice is not manifested?

Back 47

anicteric hepa***is

Front 48

True or False: All people who are infected with Hepa***is C will have it for life (chronic Hep C)

Back 48

False. 75-85 % will develop Chronic Hep C

Front 49

Chronic HBV is identified by the persistence of _____ for longer than __ months.

Back 49

Chronic HBV is identified by the persistence of HBsAg for longer than 6 months.

Front 50

Almost all cases of acute hepa***is ___ resolve, although a small number may have a viral relapse in the first 2-3 months after infection. An important teaching point for all types of hepa***is is that the disappearance of _____ does not mean that the patient has recovered or that they're "better."

Back 50

Almost all cases of acute HAV resolve, although a small number may have a viral relapse in the first 2-3 months after infection. An important teaching point is that the disappearance of jaundice does not mean that the patient has recovered or that they're "better."

Front 51

Most patients with acute viral hepa***is recover completely with no complications. The mortality rate is higher among ____ adults and those with underlying debilitating illnesses. What are some complications of hepa***is (7)?

Back 51

Hemolytic anemia
Bleeding disorders (liver's inability to produce clotting factors)
Ascites
Fulminant Viral Hepa***is (severe impairment or necrosis of liver cells and potential liver failure- mostly occurs w/ HBV)
Chronic Hepa***is
Cirrhosis of the Liver
Hepatocellular Carcinoma

Front 52

Both chronic Hepa***is B and C are at risk for what 2 complications?

Back 52

cirrhosis and liver cancer

Front 53

Review lab tests in red on page 5 of notes, also on p. 1064

Back 53

...

Front 54

In some places, HBV _____ing can be performed before starting treatment. This may be useful in predicting disease and tx outcomes.

Back 54

In some places, HBV genotyping can be performed before starting treatment. This may be useful in predicting disease and tx outcomes.

Front 55

When then is a liver biopsy done? (acute/chronic hepa***is)

Back 55

not indicated in acute unless dx is in doubt
may be done in chronic
A biopsy allows histologic examination of liver cells and characterization of the degree of inflammation, fibrosis, or cirrhosis that may be present.

Someone with a bleeding disorder may not be a candidate because of risk of bleeding. (may do a transjugular biopsy instead..?) that's what it says p 1064.

Front 56

Newer techniques like the _____ may provide info about the degree of liver scarring, which is sometimes referred to as as "stiffness" of the liver

Back 56

fibroscan/sonogram

Front 57

True or False: there is no specific tx or therapy for acute viral hepa***is.

Back 57

true. Emphasis is on measures to rest the body and assist the liver in regenerating (healing itself)

Front 58

Drug therapy for chronic hepa***is B (HBV) is focused on decreasing what 4 things?
Long term goals are... (3)

Back 58

viral load
liver enzyme levels
rate of disease progression
rate of drug-resistant HBV

Long term goals are prevention of cirrhosis, hepatic failure, and hepatocellular cancer.

Front 59

Treatment for all forms of hepa***is is ______.
Treatment is non-specific. If current exposure was within __ weeks, ____ ____ can be given. Someone with Hep A can go into complete liver failure within a few days in severe cases, necessitating a ____ _____.

Back 59

Treatment for all hep A is supportive.
Treatment is non-specific. If current exposure was within 2 weeks, immune globulin can be given. Someone with Hep A can go into complete liver failure within a few days in severe cases, necessitating a liver transplant.

Front 60

What are some drugs that can treat Hep B?

Back 60

pegalated- long acting :alpha interferon (1x/week subq)
lamivudine (Epivir)
telhivudine (Tyzeka)
tenofovir (Viread)
These are antivirals that help liver kill and clear the virus.

Front 61

About 40% of patients with hepa***is respond to alpha interferon.
What are some SE of alpha-Interferon?

Back 61

severe flu-like symptoms (myalgias- body/muscle aches, h/a, N/V, diarrhea)
weight loss- anorexia worsens
Depression, suicidal thoughts (need frequent monitoring)
Hair Loss
Skin changes
Numbness in fingers/toes
thyroid dysfunction
profound weakness
↓ CD4 count
↓ WBC, PLTs (bone marrow suppression)

Front 62

C________ is a major issue with alpha interferon. The flu-like symptoms, fatigue, and depression are sometimes worse than living with the chronic disease to some patients. They need a lot of support and monitoring. A pre-*****sment for depression and suicide attempts or thoughts should be done. A mini ____ ____ exam should be done before tx and pt's at high risk of suicide need even closer monitoring.

Back 62

Compliance is a major issue with alpha interferon. The flu-like symptoms, fatigue, and depression are sometimes worse than living with the chronic disease to some patients. They need a lot of support and monitoring. A pre-*****sment for depression and suicide attempts or thoughts should be done. A mini mental status exam should be done before tx and pt's at high risk of suicide need even closer monitoring.

Front 63

What is a serious adverse effect of Epivir? What should be done if this occurs?

Back 63

Steven-Johnson's Syndrome- rash that looks like a burn. Stop drug and send them to burn unit.

Front 64

The goal of alpha-interferon is to ↓ the ____ ____. The normal dose is _____ million mg/units ___ times per ____ for one/five ____.

Back 64

The goal of alpha-interferon is to ↓ the viral load The normal dose is three million units 3 times per week for one year.

Front 65

Lamivudine (Epivir) is used to treat Hepa***is ___. What are some SE and potential complications?

Back 65

Lamivudine (Epivir) is used to treat Hepa***is B. The goal is to decrease the viral load and liver damage. The dosage is 1000 mg daily (QD) for up to one year. SE include flu-like symptoms, diarrhea, neutropenia, neuropathy, and weakness. Some complications include SJS and pancrea***is. (check this.. drug guide differs)

Front 66

Ribavirin (Rebetol) is used to treat Hepa***is ___, it potentiates ___ ____. What are some SE and potential complications?

Back 66

Ribavirin (Rebetol) is used to treat Hepa***is C, it potentiates alpha interferon.
SE include anemia, anorexia, dyspnea, rash, emotional lability, arthralgia, eye changes, increased uric acid, fatigue, cough, pruritis rash, emotional issues.
Complications: Cardiac arrest, SJ Syndrome

(Check dosage)- p. 6 of notes/compare with drug guide)

Front 67

True or False: People vaccinated against Hep A and Hep B have no reduction in their chances of getting Hep C

Back 67

False. Some studies suggest that are vaccinated against Hep A and B are less likely to get Hep C.

Front 68

Ways to prevent Hep A

Back 68

hand hygiene
clean water
safe sex
vaccine
wash fruit/veggies

Front 69

Ways to prevent Hep B

Back 69

Vaccinate!!!!
safe sex
No drugs
Ask about sterilization process of needles etc (10% bleach to clean blood)
Don't share needles
Hand hygiene

Front 70

What can be done about exposure to Hep B

Back 70

HB immunoglobulin can help prevent this virus
need to get HB vaccine to achieve immunity
Bloodwork followup

(can fight offf infection completely, clear it from liver and have immunity or be a carrier for life)

Front 71

Ways to Prevent Hep C

Back 71

Hygiene
Don't share needles
safe sex
Hep A & B vaccine
PPE (health care workers

Front 72

What are some other causes of hepa***is besides viral?

Back 72

autoimmune-
Wilson's, Primary Biliary Cirrhosis

metabolic-
hemachromatosis
NAFLD, NASH

Alcohol
Bacteria
Drugs

Front 73

What are some medications that can cause hepa***is?

Back 73

anifungals- nizeral
antibiotics- arthythromycin
antivirals
TB- isoniazids such as rifampin