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183 Cards in this Set

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Hepatitis A is spread through...

Common sources of infection...
fecal-oral route

Day cares, poor personal hygiene, contaminated food
Hep B is spread by...
Sex (oral, vaginal, anal), needles, blood products, perinatally
Hep C is spread by...
Sex, needles, blood products
Hep D can only cause infection when...
Person already has Hep B.
Hep D is spread by...
Sex, needles, blood products
Hep E is spread by...
Fecal-oral route.
Common sources of infection of Hep E...
Contaminated water, poor sanitation. Found in Asia, Africa, and Mexico; not common in U.S.
Stool is positive for Hep A when?
2-4 months after infection
What ethnic groups are at increased risk for Hep B and C?
African Americans, Asians
What ethnic groups are at greater risk for gallbladder disease
Whites, Native Americans
Patho of hepatitis
Virus damages liver cells, makes them necrotic, then liver degerates itself.
Systemic effects of hepatitis
Rash, angioedema, arthritis, fever, malaise
How long does the acute phase of hepatitis usually last?
2-4 months
Acute hepatitis symptoms
malaise, anorexia, fatigue, nausea, vomiting, RUQ pain, distaste for cigarettes if they are a smoker, decreased sense of smell, headache, low-grade fever, arthralgias, skin rashes, hepatomegaly, lymphadenopaty, sometimes splenomegaly.
Affects of jaundice on the skin
Pruritis due to bile salt accumulation under the skin
Symptoms of chronic hepatitis
Malaise, fatigability, hepatomegaly, myalgias/arthralgias, elevated AST and ALT
Term for hepatitis without jaundice
anicteric hepatitis
Term for severe impairment or necrosis of liver cells and potential liver failure
fulminant
IgM presence in HepA means
acute infection
IgG presence in Hep A indicates
chronic infection
Test for Hep C
Enzyme immunoassay
Labs in hepatitis
Increased AST, ALT, GGT, Albumin, bilirubin,prothrombin time
Drug therapy for Hep B and Hep C
Interferon SQ in acute C and chronic B/C

Nuceloside analogs to suppress Hep B replication (HepBar)
For people on interferon they should have
blood counts and liver panels q 4-6weeks
What do the fovir drugs kill?
Kidneys. Check serum creatinine regularly.
Ribaviron drug alert
avoid pregnancy (both male and female)

used for hepC
Preicteric stage of hepatitis symptoms
flulike
anorexia, N/V, diarrhea
pain - headache, muscle aces, polyarthritis
serum bilirubin <1.5mg/dL) and enzyme levels elevated
Stages of hepatitis
preicteric
icteric
posticteric
Icteric stage of hepatitis symptoms
jaundice, pruritus, dark/tea-colored urine, clay colored stools, decrease in preicteric-phase symptoms
Posticteric stage of hepatitis symptoms
increased energy, subsiding of pain, minimal GI symptoms, bilirubin and enzyme levels return to normal
ALT normal level
10-35 IU
AST normal level
0-35 IU
Normal bilirubin level
<1.5mg/dL
What is key to prevent spread of all types of hepatitis?
Strict handwashing
Does hepatitis always produce symptoms?
No. SILENT KILLER.
People undergoing hemodialysis are at increased risk for
hepB
Homecare for hepatitis
Strict, frequent handwashing.
Do not share bathrooms unless the client strictly adheres to personal hygiene measures.
Individual washcloths, towels, drinking/eating utensils, toothbrushes, razors.
Client should not prepare food for other family members.
Avoid alcohol and OTC meds like Tylenol and sedatives b/c they are hapatotoxic.
Discourage kissing until hep B antigen tests are neg.
Medic-Alert card noting the date of onset.
Dietary considerations for hepatitis patient.
Small, frequent meals that are low-fat and nutrient rich
Nursing diagnoses for hepatitis
Imbalanced nutrition:less than body requirements

Activity intolerance

Risk for impaired liver function
Nursing intervention for an incontinent person with hepatitis A
private room
In light skinned persons, jaundice is first observed in...
the sclera of the eyes, later in the skin
In dark skinned persons, jaundice is first observed in...
the inner canthus of the eyes and the hard palate of the mouth.
Jaundice causes the urine to be
dark brown or brownish red
Meds for autoimmune hepatitis
prednisone and imuran
Wilson's disease is
progressive, familial, terminal neurologic disease accompanied by chronic liver disease leading to cirrhosis. It is associated with increased storage of copper.
Hallmark of Wilson's disease
corneal Kayser-Fleischer rings - brownish red rings around the cornea near the limbus
Hemochromotosis is
increased and inappropriate absorption of dietary iron.
Cholestasis is
blockage of bile flow
Steatosis is
accumulation of fat in the liver
Nonalcoholic steatohepatitis risk factors
Obesity, diabetes, hypertriglyceridemia, severe weight loss, metabolic syndrome, poor diet, TB, intestinal bypass, corticosteroids
What is cirrhosis?
progressive disease characterized by repeated destruction of hepatic cells and formation of scar tissue.
Complications of cirrhosis
portal hypertension, ascites, esophageal varices, coagulation defects b/c of decreased absorption of fat-soluble vitamins like vit K, jaundice, portal systemic encephalapathy, hepatorenal syndrome
What is portal systemic encephalapathy?
end-stage hepatic failure characterized by altered LOC, impaired thinking, and neuromuscular disturbances b/c of failure of the diseased liver to detoxify neurotoxic agents like ammonia.
What is hepatorenal syndrome?
Progressive renal failure associated with hepatic failure characterized by sudden decrease in urinary output, elevated BUN and creatinine, decreased urine Na, increased urine osmolarity.
Hemochromotosis is
increased and inappropriate absorption of dietary iron.
Interventions for cirrhosis
Elevate HOB to minimize SOB.

If ascites and edema are absent, high-protein diet with vit B, C, K, folic acid, thiamine.

Na and fluid restriction.

Measure abdominal girth, daily weights.

Monitor LOC.

Monitor for corase tremors characterized by rapid nonrhythmic extensions and flexions in the wrist and fingers (asterixix).

Monitor for fetor hapaticus.

Administer lactulose which decreases the production of ammonia and facilitates excretion.

Paracentesis.

Avoid hepatotoxic meds like opiods, sedatives, and barbiturates.

Administer antibiotics to inhibit protein synthesis in bacteria and decrease production of ammonia.
Cholestasis is
blockage of bile flow
How to measure abdominal girth.
With client supine, measure at level of umbilicus. Mark along sides of tape on the client's flanks and midline so later measurements are taken at the same place.
Steatosis is
accumulation of fat in the liver
Nonalcoholic steatohepatitis risk factors
Obesity, diabetes, hypertriglyceridemia, severe weight loss, metabolic syndrome, poor diet, TB, intestinal bypass, corticosteroids
What is cirrhosis?
progressive disease characterized by repeated destruction of hepatic cells and formation of scar tissue.
Complications of cirrhosis
portal hypertension, ascites, esophageal varices, coagulation defects b/c of decreased absorption of fat-soluble vitamins like vit K, jaundice, portal systemic encephalapathy, hepatorenal syndrome
Hemochromotosis is
increased and inappropriate absorption of dietary iron.
What is portal systemic encephalapathy?
end-stage hepatic failure characterized by altered LOC, impaired thinking, and neuromuscular disturbances b/c of failure of the diseased liver to detoxify neurotoxic agents like ammonia.
What is hepatorenal syndrome?
Progressive renal failure associated with hepatic failure characterized by sudden decrease in urinary output, elevated BUN and creatinine, decreased urine Na, increased urine osmolarity.
Cholestasis is
blockage of bile flow
Steatosis is
accumulation of fat in the liver
Interventions for cirrhosis
Elevate HOB to minimize SOB.

If ascites and edema are absent, high-protein diet with vit B, C, K, folic acid, thiamine.

Na and fluid restriction.

Measure abdominal girth, daily weights.

Monitor LOC.

Monitor for corase tremors characterized by rapid nonrhythmic extensions and flexions in the wrist and fingers (asterixis).

Monitor for fetor hapaticus.

Administer lactulose which decreases the production of ammonia and facilitates excretion.

Paracentesis.

Avoid hepatotoxic meds like opiods, sedatives, and barbiturates.

Administer antibiotics to inhibit protein synthesis in bacteria and decrease production of ammonia.

REST TO PROMOTE LIVER REGENERATION/DECREASE METABOLIC DEMANDS.
Nonalcoholic steatohepatitis risk factors
Obesity, diabetes, hypertriglyceridemia, severe weight loss, metabolic syndrome, poor diet, TB, intestinal bypass, corticosteroids
How to measure abdominal girth.
With client supine, measure at level of umbilicus. Mark along sides of tape on the client's flanks and midline so later measurements are taken at the same place.
What is cirrhosis?
progressive disease characterized by repeated destruction of hepatic cells and formation of scar tissue.
Complications of cirrhosis
portal hypertension, ascites, esophageal varices, coagulation defects b/c of decreased absorption of fat-soluble vitamins like vit K, jaundice, portal systemic encephalapathy, hepatorenal syndrome
What is portal systemic encephalapathy?
end-stage hepatic failure characterized by altered LOC, impaired thinking, and neuromuscular disturbances b/c of failure of the diseased liver to detoxify neurotoxic agents like ammonia.
What is hepatorenal syndrome?
Progressive renal failure associated with hepatic failure characterized by sudden decrease in urinary output, elevated BUN and creatinine, decreased urine Na, increased urine osmolarity.
Ammonia level should be...
<60
Types of cirrhosis
Alcoholic, postnecrotic (autoimmune), biliary (from chronic biliary obstruction), and cardiac (from right sided heart failure)
Primary sclerosing cholangitis is
a chronic inflammatory condition affecting the liver and bile ducts associated with ulcerative colitis.
Cardiac cirrhosis is
hepatic derangements resulting from long-standing, severe right-sided heart failure.
Effects of liver damage on the endocrine system...
Increased steroid hormones due to the damaged liver's inability to metabolize them.

Spider angiomas and palmar erythmia due to increased estrogens because the liver can not metabolize them.
Hematologic effects of liver damage...
Thrombocytopenia, leukpenia, anemia due to splenomagaly. Over activity of enlarged spleen increases removal of blood cells from circulation.

Coagulation problems from liver's inability to produce prothrombin.
Caput medusae is...
a ring of varices around the umbilcus associated with cirrhosis
Most life threatening complication of cirrhosis
bleeding esophageal varices
Peripheral edema and ascites from cirrhosis results from
decreased oncotic pressure from impaired liver synthesis of albumin and increased protacaval pressure from portal hypertension.
Lab to watch with ascites
Potassium
Spontaneous bacterial peritonitis is
bacterial infection of the ascites fluid from alterations in immune function
Hepatic encephalopathy
Too much ammonia on brain, terminal consequence of liver damage.
Factors precipitating hepatic encephalapathy
GI hemorrhage, constipation, hypokalemia, hypovolemia, infection, cerebral depressant, metabolic alkalosis, paracentesis, dehydration, increased metabolism, renal failure
Grading scale for hepatic encephalapathy
0-4

0 and 1 (early) - eupphoria, depression, irritability, confusion, drowsiness, insomnia, agitation

2 and 3 (later stages) - hiccups, slow, deep respirations, hyperactive reflexes, positive Babinski's reflex

Signs of impending coma (stage 4) include disorientation as to time, place, or person
Asterixis is -
hand flapping tremors characteristic of hepatic encephalapathy.
Apraxia is
inability to construct simple figures in writing. Characteristic of hepatic encephalapathy.
Fetor hepaticus is...
musty, sweet odor of patient's breath. When you see it, look for jaundice and check glucose in case it is DKA. Also check liver enzymes.
Aldactone is what kind of diuretic?
Potassium sparing. Used with a loop diuretic. Antagonizes aldosterone.
What do you do when variceal bleeding occurs?
Manage the airway!
Sandostatin
Used for esophageal bleeding, acromegaly, diarrhea in AIDS pts
Drug therapy for esophageal varices
Sandostatin, vasopressin, nitroglycerin, beta blockers
What would you want to AVOID in a pt with esophageal varices?
NG tubes (except Sengstakin-Blakemore tube, of course)
Why is nitroglycerin given with vasopressin in esophageal varices?
b/c vasopressin causes decreased coronary blood flow, dysrhythmias, increased BP
Endoscopic sclerotherapy is
treatment for bleeding varices. Sclerosing agent introduced via endoscopy, thromboses and obliterates the distended veins.
What tube is used for bleeding esophageal varices?
Sengstaken-Blakemore tube.
Nursing interventions with Sengstaken-Blakemore tube
Label lumes to avoid confusion. Deflate balloons for 5min q 8-12 hrs to prevent tissue necrosis.
Portal shunts increase the risk of ________ because ________
hepatic encephalapthy

blood is going past the liver, so liver isn't taking the ammonia out
Why do you want to reduce bacterial flora in the intestine when there is hepatic encephalapathy?
B/c the flora in the intestine acts on protein in the feces and results in ammonia production.
Mg in liver disfunction
decreased
Diet for a person with cirrhosis
HIgh calorie (3000/day), low-fat
Focus of nursing care of cirrhosis pt
Conserve strength so liver can fix itself
Cholestyramine is...
for pruritis r/t too much ammonia. Binds to bile in GI tract. Administer BEFORE meals.
Nursing measures to help the pruritis...
baking soda or Alpha Keri baths, calamine lotion, antihistamines, soft old linen, control of temperature. Keep pt nails short and clean and teach to scratch with knuckles, not nails.
Nursing interventions for paracentesis...
Have pt void to prevent bladder puncture.

High Fowler position or sitting on side of bed.

Monitor for hypovolemia and electrolyte imbalances.

Check dressing for bleeding and leakage.
Nursing dx for cirrhosis
Imblanced nutrition: less than body requirements

Impaired skin integrity r/t peripheral edema, ascites, and pruritus.

Dysfunctional famiy processes r/t abuse of alcohol

Excess fluid volume r/t portal HTN and hyperaldosteronism

Hemorrhage r/t bleeding tendency secondary to altered clotting factors and rupture of esophageal or gastic varices

Hepatic encephalopathy r/t increased serum ammonia
Most common complication of balloon temponade therapy (Sengstein-Blakemore tube)
Aspiration pneumonia
Nursing care to prevent aspiration or asphixiation from balloon temponade therapy
Keep scissors at bedside, oral/pharyngeal suctioning, pt in semi-Fowler's position
Nursing care for pt with hepatic encephalopathy
Assess neuro status q2h

Prevent constipation to reduce ammonia production.
Why do you want to give cirrhosis pt high carb foods?
Liver is not synthesizing and storing glucose.
What do you teach the pt with cirrhosis to avoid?
Alcohol, NSAIDS, aspirin, due to hepatotoxic effects & straining at stool, coughing, sneezing, vomiting due to danger of hemorrhage
Drugs that cause fulminant hepatic failure
Alcohol with tylonol, isoniazid, halothane, sulfas, NSAIDS
Mushroom that causes fulminant hepatic failure
Amanita phalloides "death cap"

Pale olive green to white
First sign of acute liver failure
Change in mental status
Nursing interventions for fulminant hepatic failure....
Mental status checks
Quiet environment
Pad berails in case of seizure
Renal function (I&O)
Skin/oral care to avoid breakdown and infection

PREVENT INCREASED ICP
Labs to monitor in fulminant hepatic failure
Glucose, electrolytes, acid-base status
About 80% of people with liver cancer have
cirrhosis and 50-60% of those have HepC
Primary way of preventing liver cancer?
Prevent hepB and C
Nursing care for postop liver transplant
Assess LOC, monitor for hemorrhage, prevent pulmonary complications, monitor drainage, electrolyte levels, urinary output, s/s of infection/rejection.
Age related changes to the liver
liver size decreases, decreased drug metabolism, altered hepatobiliary function, decreased ability to respond to injury
Acute pancreatitis typically occurs in what ethinicity?
African Americans
Where is the pain in acute pancreatitis?
Upper left quadrant of abdomen, radiates to the back, aggrevated by eating
Symptoms of pancreatitis
Abdominal distention, crackles in lungs, absent or decreased bowel sounds, yellow-brown discoloration of the abdominal wall, ecchymoses on the flanks (Grey Turner's spots), periumbilical ecchymoses (Cullen's sign)
Complication of acute pancreatitis
Pseudocyst - cavity surrounding the outside of the pancreas filled with necrotic products that can burst and cause peritonitis
Electrolyte to watch in acute pancreatitis
Calcium - Ca binds with fatty acids during fat necrosis
Diagnostic studies for acute pancreatitis
Serum amylase and lipase
Serum lipase level
20-180 IU
Why would pancreatitis affect the lungs?
The enzymes eat at the diaphram, causing inadequate expansion. Crackles, atelectasis, pneumonia
Fluids for acute pancreatitis
Calcium gluconate, lactated Ringer's
Meds for acute pancreatitis
Morphine, Zantac or Prilosec, antibiotics if it's necrotizing, albumin if there is shock, antacids b/c HCl stimulates pancreas
How do you reduce the pancreatic enzymes in a pt with acute pancreatitis?
Maintain NPO status, use NG suction to reduce vomiting and gastric distention
Nursing dx for acute pancreatitis
Acute pain
Deficient fluid vomume
Imbalanced nutrition: less than body requirements
Ineffective self-health management
Safety Alert: acute pancreatitis
Assess lung sounds and O2 sats regularly

Pancreatic enzymes may eat at the diaphragm causing inadequate expansion.
Positioning for acute pancreatitis
Side lying with HOB elevated 45 degrees may help reduce pain
Nursing intervention for acute pancreatitis
Turning, deep breathing, frequent oral care, side lying position
Pt with acute pancreatitis should abstain from
drinking and smoking.
Home care dietary instruction for pancreatitis pt
Low fat (as to not stimulate the pancreas) high carb
Pain with chronic pancreatitis is...
gnawing or burning, unrelieved by food or antacids
Other clinical manifestations of chronic pancreatitis include
malabsorption, weight loss, jaundice, dark urine, steatorrhea, diabetes

frothy urine and stool
Symptom of steatorrhea
severe, voluminous, foul-smelling fatty stools. may be frothy
Meds specific to chronic pancreatitis
Creon, Zenpep, Pancrease. Take with meals or snack. Observe stool for steathorea to determine effectiveness.
What kinds of drugs to people with chronic pancreatitis take?
Creon, Zenpep, Pancrease (with meals)

Antacids (after meals)

Diabetes meds
Who is at most at risk for pancreatic cancer?
SMOKERS

African Americans, people with chronic pancreatitis
Hallmarks of pancreatic cancer
Pancreatic pain, jaundice, weight loss
Nursing interventions for pancreatic cancer
Small, frequent meals

Pain control

Help family through grieving process b/c prognosis is poor.

Observe for bleeding due to poor vit K production.
What is cholelithiasis?
Gallstones
What is cholecystitis?
Inflammation of the gallbladder.
Who is at high risk for gallbladder disease?
Whites

Women

Post-menopausal
Other than gallstones, what can cause cholecystitis?
Prolonged immobility and fasting, prolonged parenteral nutrition, diabetes, bacteria reaching gallbladder via vascular of lymphatic route, chemical irritants in bile, anesthesia, narcotics
What can cause gallstones?
infection, disturbances in metabolism of cholesterol (bile supersaturated with cholesterol)
Surgical tx for pancreatic cancer
Whipple procedure
Can you infect others with hepatitis before you have symptoms?
YES
Hepatitis saying
Hepatitis with a vowel comes from the bowel.
What foods do you avoid with esophageal varices?
Spicy or sharp foods
Ascites effects on lungs
Compresses lungs. Low albumin causes lymph leakage in to lungs.
S/S of ascites
Abdominal striae, dehydration, hypokalemia
What should ascites fluid look like?
Serous fluid
If a pt with hepatic encephalapthy refuses their Lactulose, what do you do?
They are not in their right mind, so you can give it without their consent.

Oral or rectal, their choice. :)
Nursing intervention post hepatic angiography
Bedrest for 24-48 hrs
Nursing intervention before paracentesis
Have pt empty their bladder to reduce chance of rupturing it
Breath with fector hepaticus smells
Fruity and musty
Portacaval shunt is
The blood directed around the liver b/c it can't go through. Ammonia isn't taken out of the blood, so monitor for hepatic encephalapathy.
Important care of NG tube with a pt with bowel obstruction
Oral care
What does a transhepatic biliary catheter do and how do you take care of it?
Drains bile preoperatively in biliary obstruction. Cleanse around the cathetar site with antiseptic q daily and observe insertion site for bile.
What vitamins are given with chronic gallbladder disease or any biliary tract obstruction?
Fat-soluble vitamins - A, D, E, and K
What does cholestyramine do?
Binds to bile salts in the intestine - can treat the pruritis.
What kind of diet can precipitate gallbladder disease?
Extensive fasting/weight loss
Will urobilinogen be in urine with biliary obstruction?
No
What level of bilirubin will be in urine with biliary obstruction?
Increased
What is a common post-op gallbladder surgery complication and what do you do about it?
Retained CO2. Causes referred pain to the shoulder. Put pt in Sims' position.
What does the T-tube do, and how do you care for it?
Keeps the common bile duct open after gall bladder removal surgery (may close due to swelling).

Use sterile pouching to protect the skin, and assess patency, amount, and color of the bile.
During the assessment of a pt with obstructive jaundice, the nurse would expect to find...

a. Clay colored stools.
b. Dark colored urine/stools
c. Pyrexia and severe pruritus.
d. elevated urinary urobilinogen
A.
Monitoring the pt with acute pancreatitis includes....
Checking for signs of hypocalcemia and monitoring for infection, particularly respiratory infection
What is the Whipple procedure?
Removal of part of pancreas, stomach, duodenum, and gallbladder with joining of the pancreatic duct, common bile duct and stomach into the jejunum.
What is abdominal compartment syndrome?
Organ dysfunction caused by intrabdominal hypertension from peritoneal bleeding.

Requires surgery
What do you find on assessment if the diaphragm ruptures?
Bowel sounds in chest.
What do you do for abdominal trauma?
O2 via non-rebreather mask - ensure patent airway.

Control bleeding with pressure. Establish IV access with two large-bore catheters and infuse warm NS or lactated Ringer's.
What will the labs be like when there is abdominal hemmorhage from trauma?
Normal H and H until there is fluid resuscitation.
Most sensitive technique for detecting injuries to hollow organs...
peritoneal lavage. If the RBC >100,000, WBC >500, high amylase level, or presence of bacteria, bile, or fecal material, immediate surgery is indicated.
Which drug is contraindicated for hepatic encephalapthy?
Valium