Adult Health HESI Study Guide Part 6

Care of Patients with Liver Problems  The Liver: o Right upper quadrant o Should not be able to feel it  if too big = hepatomegaly o Sounds dull o Functions:   o o o o o o Produces bile Detoxifies  filters toxins … when liver stops working, toxins return to body (AMMONIA CONCERN *)  Metabolizes carbs to make glucose, proteins (clotÝng), and lipids  Produces protein  Oxidizes fatty acids  Stores iron, vitamin B12, vitamin A, vitamin D DAMAGE CAN LEAD TO B12 ANEMIA, IRON ANEMIA, LOW RBC COUNT Harmed by alcohol, hepatitis, drugs, etc. Bilirubin causes JAUNDICE ALT is specific to the liver  liver is damaged … ALT will be changed AST, ALT, LDH  liver function tests  When liver is damaged … these values INCREASE because they are released by the inflammation Liver Damage:  Liver pain in RUQ  o Fatigue  From anemia, glucose because of no carbs  Jaundice  Hepatomegaly  Dry skin, spider angioma Diagnosis:   ULTRASOUND – FIRST  Size, shape, feel of the liver LIVER BIOPSY – SECOND  What the liver consists of  Needle going inside into the RUQ  parallel to armpit on the side  RISK OF HITTING DIAPHRAGM AND LUNGS *** WATCH OUT  Put patients in supine position with right arm above their head  TAKE A BIG BREATH IN, RELEASE BREATH, HOLD  STICK NEEDLE IN  BREATH ONCE NEEDLE IS INSIDE **** o NEEDLE IS STUCK IN AFTER EXPIRATION     Need to monitor pulse ox and watch for shallow, rapid RR during procedure (if we hit the lungs – we will see changes) Need to monitor BP after procedure  BLEEDING AFTER PROCEDURE – put on right lateral side … liver falls on the rib causing body and liver to hold pressure … put pillow, arm, or wedge against rib cage to hold pressure too CHECK SHEETS FOR BLEEDING  Cirrhosis: o When the liver becomes damaged – IRREVERSABLE * WE ARE DONE AFTER THIS o SCARRING OF THE LIVER *** o Can regenerate itself when it is not scarred o o o  Fatty liver can regenerate itself by fixing problem (alcohol, cholesterol)  GETS TO LESS THAN 50% OF LIVER = REGENERATE  GETS TO MORE THAN 50% OF LIVER = IT WILL DIE 4 Types: must know Laennec’s Cirrhosis  ALCOHOLIC CIRRHOSIS Compensated Cirrhosis: no s/s … not really talked about Decompensated Cirrhosis: WORST  JAUNDICE (high bilirubin)  Sclera of the eyes – FIRST  Gums of the mouth - SECOND  URINE TURNS A TEA COLOR  STOOL IS CLAY COLORED  EDEMA  SPIDER ANGIOMAS  PRURITUS = ITCHY SKIN      Bile builds up (biliary obstruction decreases bile production) and comes out of the sweat … makes skin ITCHY Relief – do not sweat, cool environments, light blankets (“light linen blanket”), baking soda, corn starch, ANTIHISTAMINES SUCH AS QUESTRAN *** Also causes inability to absorb fat soluble vitamins = A, D, E, K … take them out of the diet * At risk for bleeding  clotÝng factors disrupted  Portal Hypertension: o MAJOR COMPLICATION OF CIRRHOSIS o PORTAL VEIN BACKING UP – NO PROPER BLOOD FLOW  CAUSES BACKUP  CAUSES HTN *****  CAUSES EXTREME EDEMA ***  Sodium and water enter third space like crazy  Inside of the veins become HYPOVOLEMIC (everything goes to outside … nothing on the inside)  CAUSES ASCITES  huge belly o Risk for GI hemorrhage, encephalopathy, malabsorption of fat vitamins Ascites: o Collection of fluid in peritoneal cavity o HYPOVOLEMIA AND EDEMA AT THE SAME TIME *** o SODIUM AND WATER RETENTION BECAUSE OF VASCONSTRICTION o Management:  o MEASURE ABDOMINAL GIRTH – FIRST  One inch above or below the umbilicus  MARK AREA ON THE BODY SO THERE IS ACCURATE MEASURING EVERY TIME  Measure laying down – at least 30 degrees  NEVER LAY THESE PATIENTS DOWN  FLUID PUSHES UP ON LUNGS. RR. MONITOR PULSE OX  Check weights  REMOVE FLUID  Cannot breathe = shallow and rapid RR  Heart is in severe HTN = fluid overload  GOAL IS TO HELP BREATHING AND LOWER BP Treatment:   DIURETIC ****  Get rid of excess fluid *  Watch electrolyte problems  SPIRALACTONE (potassium sparing diuretic) PARACENTESIS ****      Stick a needle or tiny tube in the stomach to release fluids VOID BEFORE PROCEDURE ***  DO NOT WANT TO HIT FULL BLADDER Sit them up so fluid can come down  usually drain 5 L WATCH FOR HYPOVOLEMIC SHOCK … too much fluid coming out o PALLOR o HR o LOW BP *** o DYSPNEA o OLIGURIA  CHECK VITALS FREQUENTLY  Do not want leakage  WE HAVE A PROBLEM  Do not want scrotal edema  WE HAVE A PROBLEM  SURGICAL MANAGEMENT – TIPS PROCEDURE / DENVER SHUNT ****  Shunt bypasses liver – shunts around the liver, shunts extra blood and fluid around the liver  Extreme risk for seizures and bleeding  60% death rate during procedure  Helps decrease pressure on the heart and increases flow of the system *  DECREASE FLUID ON THE BODY AND DECREASE BP = GOAL *  Increases blood volume, increases renal blood flow, reduces sodium retention  Low sodium diet (2 g, 2000 mg)  High fowlers position  Monitor electrolytes  Monitor I&O Esophageal Varices: o PORTAL HTN – backs up because liver is damaged … common place is next to the stomach and esophagus (varices dilated veins cause harm) o Appears as big bubbly blue veins along the esophagus o Risk for bleeding *** o Treatment:   o PUSH BLOOD THROUGH THEM AT ONCE – FIRST  Try to not have them dilate  Put them on BETA BLOCKER (no higher than 55 HR ***** not normal but needed in this unique situation) **** o Propranolol o Nadolol o Dose is increased every 3-5 days till HR reaches 55 Soft diet, no alcohol, look for s/s bleeding/clotÝng problems, do not strain/bleed/floss/blow nose, stool softeners Bleeding Esophageal Varices = LIFE THREATENING EMERGENCY     Severe blood loss Resulting from shock and hypovolemia Different levels of bleeding:  Tiny bit = stool shows blood (occult blood test)  Average amount = stool shows black  More than average = vomit has blood (looks like coffee grounds)  Ton of blood = vomit straight red blood (MEDICAL EMERGENCY) Managing Hemorrhages: o Bleeding a little bit = Tips Procedure helps blood flow a different way … no back up  first option o Take gum band and put it around the varices  second option o Go in surgery and sclerotherapy … burns the varices off (CAUDERIZE)  third option Esophageal Gastric Tamponade – NEED BLAKEMORE TUBE ***  Medical emergency  Blakemore tube: looks like an NG tube with 3 compartments, measure like NG tube, blow up the balloon with air in the stomach which then rises to the bottom of the esophagus to stop the bleeding  RISK OF THE ESOPHAGUS PERIFORATING AND ASPIRATION  Monitor: VITALS, HYPOVOLEMIC SHOCK, PERFORATED ESOPHAGUS Hepatic Encephalopathy: o Swelling of the brain from liver failure and cirrhosis o Most commonly from ammonia going into the brain (toxin) ** o Factors: high protein diet, infection, hypovolemia, GI bleed … portal vein shunted, nonabsorption, ammonia levels, protein not detoxified in liver o CONFUSION, STUPOROUS, THEN INTO A COMA  WATCH LOC IN ANY KIND OF LIVER FAILURE FOR THESE S/S  Sleep, mood disturbances (beer muscles) ***, LOC, liver flap, asterisks **, bad breath (fetor hepaticus) ** o Treatment: o     Get rid of ALCOHOL, DRUGS, ETC. RESTRICT PROTEINS THEN, DRUGS  Lactulose ***** need to know o Used to eliminate ammonia, 2-3 stools per day, decrease patient confusion  o Other drugs if that doesn’t work  Stool softener, stool laxative  NEED TO EXCRETE AMMONIA  NEED TO POOP AT LEAST 2-3 TIMES PER DAY  Want to see change in LOC – less confused, more alert * Spontaneous Bacterial Peritonitis (SBP): o Ascites building up too bad – get peritonitis Water sits in the body  bacteria  INFECTION Signs and Symptoms:  Rock hard, solid, painful belly  Guarding – patient does not want to have belly touched  Low fever (infection) Hepatorenal Syndrome: o Backs up into the kidneys leading to KIDNEY FAILURE *  Decrease in urine  Elevated BUN and creatinine levels  Increase urine osmolality o CHECK BUN AND CREATININE ** o MONTIOR OUTPUT EVERY SINGLE DAY o o     Liver Failure SIGNS: o HANDWRITING FAILS o BRAIN SWELLING o LIVER FLAP o ANEMIA o COMA * o FATIGUE o PALMAR ERYTHEMA (RED PALMS *** LATE SIGN OF LIVER FAILURE) Hepatitis: o One of the CAUSES of LIVER FAILURE  if hepatitis is getÝng worse, liver failure is coming FAST o Inflammation and cell necrosis o Signs and Symptoms:  Weight loss  N/V  Fatigue  Clay colored stools  Tea colored urine  Ecchymosis (loss of potassium absorption)  Pruritus Hepatitis C: o 2nd most common way to get cirrhosis of the liver ALCOHOL + HEPATITIS C = DEATH  2-3 drinks per day over 10 years … women  6 drinks per day over 10 years … men o Inflammation over time leads to SCARRING Prophylaxis: o Try to avoid getÝng hepatitis o HYGEINE UNIVERSAL PRECAUTIONS, BE SAFE, NO UNDERCOOKED MEALS, HEP B AND A VACCINATION, NO BLOOD **** Acute Vital Hepatitis: o WAYS YOU CAN GET HEPATITIS KINDS o A: ORAL/FECAL, 3RD WORLD o B: BLOOD  SEX, DRUGS, SALIVA, SEMEN o C: CLOSE CONTACT POST TRANSFUSION, FECAL/ORAL, CARRIER STATE o   o o  D: HEP D ALONG WITH HEP B, BLOOD ONLY (TO HAVE D YOU MUST HAVE B … BUT YOU CAN HAVE B ALONE) E: FECAL/ORAL, WATERBORNE, NO CARRIER STATE Liver Transplant: o If nothing worked – need a transplant! o Cirrhosis puts patient at the end of liver transplant list o Cannot receive transplant if other organs are also failing o Can have a live donor  regenerate themselves o Tend to reject o Tend to get infections – main supply of the body is the liver… Care of Patients with Biliary and Pancreas Problems   Liver, gallbladder, and pancreas work together  can backup to kidneys and heart Gallbladder: o Where the FAT happens  fat problem, eat too much fat, digest fats o Fat cannot process without BILE o Problems with Gallbladders:  Gallstones  Caused by cholesterol and fat  4 types: CHOLESTEROL STONES (most common) **, pigment stones, mixed stones, calcium content stones  Cholesterol stones = put them on LOW FAT DIET. HIGH HDL, LOW LDL FOODS … legumes, avocado, nuts ***  Risk Factors: o Age  40-year-old o Female o Diabetes o Obesity ** o o o Bad diet 4 F’s: FEMALE, FAT, FORTY, FERTILE, FAMILY  Edema  Stricture  Tumor Acute Cholecystitis:     Inflammation of the gallbladder Most likely caused by gallstones (cholesterol)  either: 1) rub against the sides causing inflammation or 2) stones stick in the ducts and cause backup and an obstruction ** Diagnosed by ultrasound Signs and Symptoms:  Upper abdominal pain radiating to the right shoulder ***  Murphy’s Sign: o Right subcostal palpation o Increased pain with inspiration o Guarding o Rigidity   Clay colored, fatty stool/steatorrhea **** GALLBLADDER ISSUE o Decreased fat absorption due to lack of BILE  Pain worsened after a meal Management:  Stop diet *** … NPO and then start low fat diet (if gallbladder is removed, be on low fat diet FOR LIFE)  Reduce pain ***  Insert NG tube *** o Anytime there is anything wrong in the stomach area, put in an NG tube on low suction … any surgery or procedure … need to decrease GI upset and rest o NG tube will GET AIR OUT OF THE STOMACH ** o NG tube will be used after surgery for feedings  Cholecystectomy o Very common o Fill up the belly with air – need NG tube to take it out o WANT PATIENTS TO PASS GAS o WANT PATIENTS TO GET UP AND MOVING (“walking gas”) JP drain  internal suctioning devices need to be squeezed shut off to suction *** Laparoscopic Surgery o Cannot lift 2-4 weeks o NPO until passing gas and positive bowel sounds o  o Start them on clear liquid diet then progress to normal Post-op:  Pain relief **  Incentive spirometer  Get up and move - AMBULATE  Watch for DVT  SCDs and ted hose  Watch for excessive fat intake for life ***  T-tube: TO DRAIN BILE … want the body to shunt the bile to other places, as well as drain the excess bile o NO LESS THAN 200 ML PER DAY o NO MORE THAN 1000 ML PER DAY Chronic Cholecystitis:  o   o  Only reason it is chronic if it happens multiple times over a long period Multiple episodes of acute will leave scarring on the gallbladder or an extended period with blocked duct resulting in failure  Can back up into the liver  jaundice, pruritus, clay stool, tea colored urine Acalculous Cholecystitis:  Inflammation without gallstones Pancreas: o When the pancreas fails, it goes to the gallbladder, when the gallbladder fails it goes to the liver o Turn patients diabetic when pancreas fails  no insulin o PANCREATIC ENZYMES: NEEDED ***   o Digests fats If we do not have these enzymes due to pancreas failing, we cannot absorb nutrients from the food we eat ***  WATCH FOR WEIGHT LOSS  EAT EVERYTHING IN SIGHT BUT WATCH FOR SUGARS – THEY ARE DIABETIC NOW (TYPE 1)  Polydipsia, polyuria, polyphagia * super high glucose now! Acute Pancreatitis     Need pancreatic enzymes *** Results in AUTO DIGESTION AND FIBROSIS Most common cause is alcohol Signs and Symptoms:  Jaundice  CULLEN’S SIGN: GREY-BLUE COLOR AROUND UMBILLICUS  TURNER’S SIGN: GREY-BLUE COLOR AROUND FLANK AREA o KEY SIGNS FOR PANCREAS PROBLEMS ***  No bowel sounds  Fluids pulled into pancreas and not in the cells – HYPOVOLEMIC SHOCK ** o WE NEED FLUIDS *  o WHEN PATIENT IS AT RISK FOR ACUTE PANCREATITIS WE WANT LABS  LIPASE = INDICATES ACUTE PANCREAS PROBLEM  AMYLASE = INDICATES BROAD PROBLEM WITH PANCREAS  MONITOR FOR GLUCOSE – THEY NEED INSULIN (NONE)  Treatment:  Treat PAIN!!  PCA morphine (PCA and PRN are the same thing)  NPO ***  Hydrate patient  Need to insert NG tube for severe case – diarrhea or vomiting  HIGH CARB, HIGH PROTEIN, LOW FAT MEALS  Avoid foods that cause GI irritation Chronic Pancreatitis:  Repeating occurrences of acute pancreatitis  Scarring  Signs and Symptoms:  Fatty stools  Jaundice  Dark urine  S/S DUE TO THE BACKUP TO THE GALLBLADDER AND LIVER  Diabetes  Treatment:  GIVE THEM PANCREATIC ENZYME **** o Must eat, drink water with capsules o High carb, high protein, low fat     BLOOD GLUCOSE, PANCREATIC ENZYME, AND INSULIN EVERY MEAL – WORRY ABOUT THIS! No alcohol, caffeine, sugary drinks WATER ** Pancreatic Abscess: o Fluid with pus in it causing infection o Need to get it cultured to know what antibiotic to go on Pancreatic Cancer: o Very hard to diagnose – by the time you do, probable it is in multiple stages o Appears as a liver problem o Interrelated S/S for liver, pancreas, gallbladder  o o Stent * Whipple Procedure ***  Life-long treatment of pancreatic enzyme    Pre-op:  TPN  mostly glucose and sugar *** watch for diabetes ***  MONITOR GLUCOSE IF THEY HAVE DIABETES OR NOT Post-op:  Watch for hemorrhages ***  Any abdominal operation is hard to see hemorrhage – CHECK BP FOR HYPOVOLEMIA ***** Fistulas: o Hole that develops that connects two areas o o o Small bowel intertwines and then leads to the hole  gastric juices escape and breakdown the skin … water and electrolytes also empty LEAD TO HYPOVOLEMIA AND ELECTROLYTE PROBLEMS ** Monitor for DECREASE BP, INCREASE HR, DECREASE URINE OUTPUT