Accessory Concept

8/8/2019 Accessory Concept

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August 16, 2010 ACCESSORY

Biliary tract and exocrine pancreas

y Accessory organs andits locations

y Liver largest organ

y Gallbladder R side

y Pancreas L side; headis nearS.I.; tailisnearspleeny Ampulla of Vater connection of the CBD

and pancreaticduct

y CBDcanaffect pancreas, gallbladder

Biliary tract

1. Commonbile duct

y Cystic, hepaticduct

2. Cysticduct

y From gallbladderto the CBD

3. Gallbladder

y Saclike organlocated under the R side ofliver

y Stimulated to contract by CCK and motilin

BILE fat emulsifierand helps with absorption;composed of (50% bile salts, H2O and electrolytes,bilirubin, lecithin, cholesterol)

Flow of Bile:

liver Hepaticduct R orL Common hepaticduct

gallbladder cysticduct sphincterof Oddi

Exocrine Pancreas

y Glandlocatedbehind the stomach on L sideofabdomen

y Pancreatic enzymes

y AMYLASE breaks down CHOy TRYPSIN breaks down CHON

y LIPASE breaks down FATS

SECRETIN secretion ofalkaline fluids; inhibitsaction of gastrin; decrease gastricacid secretionandmotility

Chyme induodenum

S cells produce secretin

Absorbedinintestine

Pancreas

Secrete alkaline rich fluid

Pancreatic enzymes do not work in an acidicenvironmentthe need foranalkaline rich fluid.

CCK stimulates gallbladderand pancreas

(CCK) Cholecystokininand Acetylcholine

yC and A acinarcells enzyme releasey Feedback mechanism inhibits secretion ofmore pancreatic enzymes

ALTERATIONS:

y Cholelithiasis

y Cholecyctitis

y Choledolithiasis

y Pancreatitis

CHOLELITHIASIS (gall stones)

y Formation of stones in gallbladder

y Lith stones

y Chole gallbladdery RF: (4Fs)

y F female

y F fat

y F forty (increasedcholesterol)

y F fertile

Gall stones are crystalline structures formedbyconcentration (hardening) oraccretion (adherence ofparticles, accumulation) ofnormal orabnormalbileconstituents (80% are cholesterol)

Theories of gallstone formation

1. Bile changes incomposition

2. Gallbladderstasis bile stasis (gallbladderonlycontracts with the presence of food)

3. Infection predisposes a person to stone formation

4. Genetics anddemography Caucasian

Cholesterol needs to combine with bile salts andlecithinin orderto dissolve in water

Pathophysiology:

Unconjugatedbile precipitate

Formation of PIGMENT stones (frbilirubin orsalts; isdifferent


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Malabsorptiondisorder

Malabsorption of bilesalts

Decreased bilesynthesis

Supersaturation ofbile with cholesterol

obesity, increased age

increased hepaticsecretion ofcholesterol

estrogen therapy

(multiple)pregnancy

gallbladder sludge

clofibrate meds (todec. cholesterol)

dec. serumcholesterol

inc. cholesterolexcretion into the bile

rapid weightloss

liver excretescholesterol

Supersaturation ofbile with cholesterol

cholesterol-saturated gall stones

irritates gallbladder

CHOLELITHIASIS

obstruction of thepassage of bile

contraction ofthe gallbladder

RUQ painreferred to the

shoulder

vagalstimulaiton

N/V

Abd. guarding,facial grimace

gallbladderdistention andinflammation

markedtenderness in the

RUQ on deepinspiration

prevents fullinspiratoryexcursion

dec. bile in theduodenum

malabsorption ofvit ADEK (fatsoluble vits)

S/Sx: A blurrevision

D dec. Caformation

E dec.antioxidant

K bledding

hemorrhag

retention in the

gallbladder

bile absorbed inthe circulation

jaundice

continuous bile retention inthe gallbladder

abscess, necrosis,perforation

seeping into the peritonealcavity

peritonitis (end complicationof cholelithiasis)

bile salts inthe skin

pruritus

dec. in GIT

inc. in KIDNEY

feces: clay colored;urine: very dark

Ultrasound,

cholecystogra

-phy, ERCP


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Assessment:1. Biliarycolic pain, pain occurs 3-6 hours afterheavymeals

2. Anorexia, N/V

3. Sensation of fullness, intolerance to fatty food

4. Steatorrhea, jaundice, bleeding tendencies, claycolored stool

Diagnostic tests:

1. ULTRASOUND

y Most sensitive/ accurate

y X eat (it willdistend gallbladder)y I: jaundice, allergic to contrast medium

2. ERCP (endoscopic retrogradecholangiopancreatography)

y Contrast mediumy Direct visualization of hepatobiliary system

performed with a flexible endoscopey Multiple positions requiredduring procedure

to pass the endoscope

PriorNursing responsibilities in ERCP:

1. Explain procedure

2. Assess allergy to seafood/iodine

3. NPO 4 hours

4. Explain to patient he willbe sedated (informed

consent)

5. Remove dentures to prevent aspiration

Post op Nursing responsibilities in ERCP: ( VS,monitorgag reflex)

3. MRI

y Remove magnetic things

y Assess claustrophobia

4. PTC (percutaneous transhepaticcholangiography)

y Cholangio-CBDy Injection ofdye (biliary tract)y Hepaticducts withinliver, CBD, cysticduct

and gallbladderare outlines

y NPO

y Allergy

y Informedconsent(sedated)

y Hct, prothrombin time, prone to bleeding?

y Administerantibiotic (prophylaxis)

5. Oral cholecystography

y To detect gall stone andassess ability of gallbladderto fill /concentrate its contents,contaract and empty

y Eg ofcontrast agentL IOPANIOC ACIDy Post: instruct client to eat in orderto contract

gallbladderthus excreting bile

Health promotion

y low fat diet

y idealbody weight

y limit numberof pregnanciesy TPN for1 month

Nursing management

y Pain medsy Comfort measures

y Diet modifications

y Weight loss

y IVF

y Refer forS ofdehydration

Medical management (palliative forsymptoms)

1. Meds

y Analgesics

y Antacids H2 blockers orPPI

y Antiemetics

y Antibioticsy Nitroglycerin

2. F&E

y IVF

Management

1. Gallstone dissolution

y Cholesteroldissolving agents (CDA)

y CDCA

y UDCAy MOA: dec. cholesterol synthesis inbile

y For6-12 months

Nonsurgical management

1. Endoscopy

Endoscope Duodenum CBD

Passage of stone Enlarges it Ampulla of Vater


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2. Extracorporeal shock wave lithotripsy

y I : symptomaticcholelithiasis with >4stonesy Stone yellow)y Painand tenderness in RUQ

y Increasedabdominal girthy Tachycardia

y Bil eorbloodleaking from wound

y Drop inBP

JP Drain

y The original suctiondrain.

y The drainitselfis inside the body. It is madeof Teflonand has multiple drainage holes.

y The drainis connected to clearplastic tubing

which is usually sutured to the skinat the

point it leaves the skin. The tubing connects

to abulbreservoir. The bulb, when

squeezed empty, applies constant suction to

the drainand pulls the fluid out of the body.

The drainis removed when the excess fluid

has stoppeddraining from the body.

y A JP drain maybe used, forexample,forabdominal orthoracicdrainage. JP

stands forJackson-Pratt.

T tube:

y keep the duct patent until edema subsides

y allows bile to drain out of the patient's bodyinto a small pouch, knownas abile bag

y The amount of bile, which varies in colorfrom deep gold to dark green, can then bemeasured.

y If a T-tube is put in place, it may remainattached to abile bag fora week or possibly

longer.y When the bile bag is removed the T-tube willbe t ied or capped. It will remain in place forseveral months so that it can be used forspecial testing.

Nursing responsibilities forPatients with T tube:1. Semi fowlers position

2. Characteristic ofdrainage (volume 350-400ml); forfoul odorand purulent drainage

3. Report suddenincrease inbile output

4. monitorforinflammationand protect skin from

irritation

5. drainage system below the gallbladder

6. JP drain willbe removedafter7-14 days

7. T tube removedafter6 weeks

Stool with bile- yellow > indicatorT tube canberemoved


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Clamp tube before a mealand observe forabdominaldiscomfort anddistention, N, chills orfever

Unclamp tube if N/V occurs

CHOLECYSTITIS

y Inflammation of gallbladder

y 3 types:1. Acalculous Cholecystitis (RF: 4Fs,sedentary)no stones2. Chronic Cholecystitis (less pain, noincrease in WBC)3. Acute inflammation

Assessment:

y (+) Murphys signy N/V

y Fevery Mildjaundice

y Guarding, rigid, rebound tenderness

Medical management

1. antibiotics

Surgical management

1. Cholecystectomy

2. cholecystostomy surgicaldrainage of gallbladder

Nursing management:

1. diet (low fat)

2. antibiotics, analgesics, antispasmodics

CHOLEDOCHOLITHIASIS

y Stones in CBDy JAUNDICE (intermittent orrecurrent)

Surgical management:

y Cholecystectomyy ERCP with endoscopic papillotomyand

stone extractiony Choledocolithotomy

PANCREATITIS

y Inflammation of pancreas

y Associated with escape of pancreaticenzymes into surrounding tissue

y Classifications: acute andchronicpancreatitis

Acute pancreatitis

y Acute inflammatory process of the pancreasresulting inauto digestion of the pancreas byits own enzymes

y Life threateningy Etiand RF: biliary tract obstruction,alcoholism, trauma

y Painaggravatedby supine positionandafterheavy meals

alcohol intake

stimualte HCLand secretin

roduction

pancreaticenzymes

stimulation

causeobstruction inthe sphincter

of pancreaticduct

gallstones

enter CBD

lodge at ampullaof vater

biliary tractobstruction

inactive enzyme backflow

activation of enzymes

auto digestion

production and releaseof pancreatic enzyme


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production and release ofpancreatic enzyme

(inc. serumlipase) fatty

acids arereleased

combines withionized Ca+

hypocalcemia

(inc. serumtrypsin)

release oftrypsin

polypeptideformation

thrombosis

gangrene

inc. serumamylase)release ofelastase

blood vesseland duct

destruction

necrosis

hemorrhage

release ofkallikrein

release ofvasoactivepeptides

vasodilation

inc. vascularpermeability

edema

irritation ofinflamedpancreas

abdominalpain,

tenderness,back pain

vagalstimulation

N/V

leukocytes clusteraround necroticareas (inc. WBC)

bacterialproliferation in

area

suppuration (pus)and lesionformation

destruction ofpancreatic islets

hyperglycemia

abscess pseudocyst (pus)

impedes bileflow through

CBD

JAUNDICE

hypovolemia

hypoTN,cyanosis,

coldclammy

skin

dec. inbowelsounds

exudates withpancreaticenzymes

frperitoneal

cavity viatransdiaphrag

matic lympchannels

atelactasis,pneumonia

S ofpancreatitis)

rigid,

boardlikeabdomen

CULLEN'SSIGN (bluisdiscoloratioof umbilicu

TURNER'SSIGN (bluisdiscoloratio

of flank -BACK)

Abdominal

guarding,facial grimace,

pain

aggravatedby

supine


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Assessment

PAIN - sudden onset of mid epigastric pain orLUQ radiating at the back after heavymeals/supine position

Diagnostic test

y Historyand PE

y ERCP

y CT scan

y Abdominal Xray

y Lab exam (alkaline phosphotase,bilirubin, BUN, glucose)

y 48-72 hours elevated AMYLASE

y 5-14 days elevated LIPASE

y (morphine-spasm of sphincter+pancreatitits)

Medical management (palliative)

y Pain mgt (Demerol, meperidine CNSdepression)

y Fluidvolume status, electrolyte balance

y Nutritional status (TPN, NGT forsuctioning)

y Decreased Endocrine function

y Treat complications (respiratory care) oxygen, turning, position

y NPO, semifowlers with flexed knees(chest knee)

Surgical management

1. laparotomy with sump drainage

2. debridement with surgicaldrainage orretroperitonealdrainage

3. subtotal pancreatectomy

4. Whipples surgery (remove distal 3rd

ofstomach, part ofduodenum, CBD, gallbladder,head of pancreas); complication: hemorrhage

Nursing management

y NPO and hydration, NGT suction (Xacidic environment), TPN

y Supplemental preparations

y Pain meds, antacids, H2 receptorantagonists (decrease acidity)andanticholinergics

y No alcohol

y Bedrest to decrease metabolicdemand

y Positioning

y Deep breathingandcoughing exercises

y Low fat and high calorie diet

Chronic Pancreatitis

y Continuous prolongedinflammationandfibrosing process of the pancreas

y Formation of scartissue

y Etiology

Alcoholism (70-80%)

Idiopathiccause

Hereditary

Biliary tract obstruction

Pathophysiology:etiologicagent

Inflammatory process

Attack ofacute pancreatitis

Continuous and prolongedinflammatory process

Scarring andcalcification of pancreatic tissue

Irreversible damage of endocrine and exocrinefunctions

S/SX

Types:

1. chronic obstructive pancreatitis

2. chroniccalcifying pancreatitis (akaalcoholinduced pancreatitis) most common,inflammationand sclerosis, mainlyat the headof pancreas and pancreaticduct

Assessment:DM manifestations, steatorrhea

Diagnostic test

y Historyand PE

y ERCP

y CT scan

y Abdominal Xrayy Lab exam (alkaline phosphotase,

bilirubin, BUN, glucose)

y 48-72 hours elevated AMYLASE

y 5-14 days elevated LIPASE

y (morphine-spasm of sphincter+pancreatitits)


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Medical management (palliative)

y Pain mgt (Demerol, meperidine CNSdepression)

y Fluidvolume status, electrolyte balance

y Nutritional status (TPN, NGT forsuctioning)

y Decreased Endocrine function

y Treat complications (respiratory care) oxygen, turning, position

y NPO, semifowlers with flexed knees(chest knee)

y Pancreatic enzyme replacement egpancrelipase (cotazyme). Pancreatin(viokase); take with meals, wipe mouth

enzymes are irritating to the skin(prevent stomatitis)

y Bile salts (synthetic)

Surgical management

1. Whipples procedure

2. Total pancreatectomy

3. cholecystojenostomy

4. Total pancreaticoduodenectomy withsplenectomy

5. Biliary stents

Nursing management

1. Medications

2. Assess respiratory function, CV status(hemorrhage), PQRST (pain)

3. NPO 3-7 days, gastric secretion

4. Physical movement and mental stimulation

5. Position forcomfort

6. IV fluidreplacement and electrolytes

Management ofclients with hepaticdisorders

Anatomyand physiology:LIVER

y RUQ

y R and L lobe

y Calciforum divides the lobe

y 3-4 hours

y Hepaticcells functional

y Sinusoid

y Bile at canaliculus

y Portalandarterial Circulation

y Dualcirculationy Arterialcirculation from hepaticartery

(O2 blood 300-400mL ofblood) fromportalvein GIT

y Portalveinis connected to liver(1000-1400ml ofblood)

y Kuppercells pick up organisms fromblood which came from GIT notalways sterile

y Specialcharacteristics:REGENERATIVE LIVER CELLS

FUNCTIONS:

1.Bile secretion/production (choleresis) 600-1200mL/day

Enterohepaticcirculation recycling ofbile salts,18 times

Hepatic secretion

Hepaticresecretion intestinalabsorption

2. Metabolism ofbilirubin (metabolism -converting substance to be excreted)

Hmg 120 days

Heme globin

Noniron pool biliverdin amino acid pool

Bilirubin

Plasma + albumin(oncotic pressure)

Unconjugatedbilirubin (X secreted easily)

Liver:

glucorganic

acid


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Unconjugatedbilirubin (X secreted easily)

Conjugatedbilirubin

Becomes constituent ofbile

S.I.

STERCOBILIN: feces UROBILINOGEN:urine

3.Vascularand hematologic functions

y Store blood

y Kuppercells

y Prothrombin, fibrinogen, factors I, II, VII,IX, X synthesis

y Vitamin K absorption

4.Fat metabolism

y Fats: synthesized from CHON and Fats

Absorbedbylacteals inthe intestinalvillilymphatics

(triglycerides)

(hydrolyzed)

LIVER (releasedin the bloodstream)

Lipoproteins

Storage ofadipose tissue

5. CHON metabolism

LIVER producesCHON albumin

Deamilation AA oncotic pressure

Ammonia

Removes ammonia urea

LIVER formation plasma CHONs

6. CHO metabolism

LIVER stores glycogen(glucose bufferfunction)

Converts galactose and fructose glucose

Converts CHO triglycerides adipose tissue

7.storage ofironandvitamin

Liver stores vits. A, D, B12

(Apoferritin + iron (extrain serum) =ferritin)

8.Metabolicdetoxification

Liver active chemical medium detoxify

Liver inactivates steroid hormones(testosterone,progesterone,

corticosteroids, aldosterone)Assessment

y Hepatotoxic substances with infectiousagents

y Occupational, recreational and travelhistory

y History ofalcoholanddrug use

y Past medical history

y S and sx that suggest liverdisease

Lab tests

Bile formationand secretion

Test Normalvalue

1. direct (conjugatedbilirubin

0.03 mg/Dl

2. indirect(unconjugatedbilirubin)

0.1 mg/Dl

3. total serum bilirubin 0.1-1.2 mg/Dl

Protein studies

Test Normalvalue

1. total serum CHON 7.0-7.5g/Dl2. serum albumin 3.5-5.5 g/Dl

3. serum globulin 2.5-3.5 g/Dl4. A/G ratio 1.5:1 to 2.5:1 g/Dl

ALT 2.5(JAUNDICE), definitive, increasedproblem in LIVER

AST foundinincrease metabolic substances

Increasedalkaline phosphotase inbile

obstruction

Coagulation studies

Test Normalvalue

1. PT 11.5-14 sec

2. PTT 25-40 sec


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Serum enzymes

Test Normalvalue

1. AST 8-20 u/Dl2. ALT 10-35 u/Dl

3. alkalinephosphotase

32-92 u/Dl

4. LDH LDH5.Blood ammonia 150-250 u/Dl

Diagnostic test

1. abdominal Xray

2. liverscan

y Contrast medium

y Assess allergy

y NPO 4 hours

3. Splenoportogram

y Determine adequacy of portalcirculation

y Contrast medium

4. MRI

5. CT scan

6. ERCP

7. Liverbiopsy

y Most specific

y Percutaneous liverbiopsy

Nursing preop responsibilities (liverbiopsy)

y PT and PTT (prolong vit K or post ponebiopsy)

y Consent

y NPO

y Baseline VS (bleeding)

Nursing during responsibilities (liverbiopsy)

y Expose R hypochondriac

y Client inhale and exhale thenhold

breathat the end of expiration (toprevent puncturing the diaphragm)

Nursing afterresponsibilities (liverbiopsy)

y R side lying with pillow on puncturedincision site

y Bedrest 24 hrs

y No coughing/straining/heavylifting

y VS

JAUNDICE

y Yellow/greenish yellow discoloration ofsclera skinanddeeper tissue

Types:

1. Hemolyticjaundice(prehepatic)

y Causes: BT reactions, immune reaction,membrane defects of erythrocytes , toxicsubstances incirculation

Inc. breakdown RBC

Inc. heme production

Inc. amt of unconjugatedbilirubin

2. Hepatocellularjaundice (intrahepatic)

Hepatitis cirrhosis, hepaticcancer

Alt. ability ofliverto conjugate bilirubin

Inc. amount of unconjugatedbilirubin

3. Obstructive jaundice (post hepatic)

Liver,tumor,hepatitis,cirrhosis

Swelling orfibrosis oflivercanaliculi &bile ducts

Bile cant pass through

Bile absorbedincirculation

Stones in CBD, Biliarystricture

CBDis occludedby gallstone

Bile cant pass through

Bile absorbedincirculation

CM

y Yellow sclera

y Yellowish orange skin

y Claycolored feces

y Teacolored uriney Pruritus

y Fatigue

y Anorexia


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Medical management

y Determine cause of jaundice healthhx, PE, liver function test, hematologictest

y Reduce pruritus and maintain skinintegrity oral cholestyramine resin,antihistamines, phenolbarbital

Nursing management(Assess S of jaundiceformation)

Interventions

y Tepidbath

y Lotion

y Loos clothing

y Soft bedding

y Short nails

y Keep room cool

Surgical management

y Choledochostomy-exploration of theCBD

HEPATITIS

y Inflammation of the liver caused byvirus, bacteria, or exposure tomedication orhepatotoxins

y Goal of therapy: rest the inflamedarea

Alcoholichepatitis

Inflammation

Degeneration

Necrosis of hepatocytes andinfiltration ofleukocytes

Mallorybodies

Manifestations:

y Anorexia, N/V

y Ascites

y Fever

y Encephalopathy

y Abdominal pain

y Splenomegaly

y Hepatomegaly

y Jaundice

y Anemia, leukocytosis, inc. bilirubinlvel

y Biopsy fatty hepatic tissue

Nursing management

y Increased VII, CHO diet

y Folicacidand thiamine supplement

y Parenteral fluids

y Liquid formulas to increase caloric

intakey No alcohol!

y Steroids

Viralhepatitis

Hepatitis ARNA

Hepatitis B DNA

Hepatitis CRNA

Hepatitis D,E,F,GRNA

HEPATITIS A (Infectious hepatitis)

CA Small, undeveloped,RNA contaminatingHAV

INCUBATIONPERIOD

15-45 days, mean 30;2-6 weeks

Ind @risk Young childrenandyoung adults; healthcare personnel

RF/transmission Fecal-oralroute,contaminated waterormilk; shellfish fromcontaminated water

Testing (+)acute HAV inbloodInc. IgM and IgGInc. IgM Abin 4-6 wksInc. IgG Ab

BET Gamma globulins

Outcome Mild with fullrecoveryFatalityrate less than1%No carrierstae orinc.risk ofchronicityMay progress tofuminant hepatitis

Prevention: HW, stool precautions, waterprecautions, vaccine

IgG Patient has immunity

IgM newly exposed o the disease (hepatitis)


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HEPATITISB

CA Double strandedDNAvirus (HBV)

INCUBATIONPERIOD

30-180days, mean 60-90; 6-24 weeks

Ind @risk Drug users, clients onlong term hemodialysisHealth care personnelYoung adults (sexualand percutaneous)Babies and toddlers

RF/transmission Blood orbloody fluidcontact, infected salivaorsemen,contaminatedneedles,sexualcontact,parenteralperinatal period, orbody fluidcontact at

birthTesting HbA g-Ab system in

bloodHbsAgHbsAg 6 weeks(newlyinfected carrierstate)

Acute HbsHbe Ag

POET HepaBimmuneglobulinForchronic hep B:interferon, adefovir(Hepsera)and

lamivudine (Epivir)Outcome Inc. risk for chronic

hepatitis, fulminanthepatitis, cirrhosis andhepaticcancerMaybe severe, fatalityrate 1-10%Possible carrierstate

Prevention: HW, screening ofblooddonors,testing of pregnant women, needle precautions,avidintimate sexualcontact if test forHbsAg is(+)

HEPATITIS C (NANB/POST TRANSFUSIONHEPATITIS)

CA Single stranded RNAvirus

INCUBATIONPERIOD

15-160 days, 505-10 weeks/2-12 wks

Ind @risk Parenteraldrug useClientsreceivingfrequent bloodtransfusionsHealth care personnel

RF/transmission Blood orbloody fluidcontact, infected salivaorsemen,contaminatedneedles,sexualcontact,parenteralperinatal period, orbody fluidcontact at

birthTesting Anti HCV- most

accurate indetecting

POET Alpha interferon orpegylatedinterferon +ribavin

Outcome Frequent occurrenceofchroniccarrierstateandchronicliverdiseases

Inc. risk of 1rHepatocellularcarcinoma

Prevention: needle/ blood precautions, HW

Immunitybyvaccine orhistoryofhepatitis

HEP C > carcinoma, FH, chronic hepatitis>most fatal


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HDV (B) (DELTA AGENTS HEPATITIS)

CA HDV, delta hepatitisagentDefective RNA virus

INCUBATIONPERIOD

30-180days, mean 60-90; 7-8 weeks/2-10wks

Ind @risk Drug users, clients onfrequent BT, clientreceiving hemodialysis

RF/transmission Blood orbloody fluidcontact, occurs as dualinfection with HBVHDAg earlyincourseofinfectionHDAb laterdiseasestage

Testing HbA g-Ab system inbloodHbsAg

HbsAg 6 weeks(newlyinfected carrierstate)

Acute HbsHbe Ag

POET interferon

HEPATITIS E (A) (ENTERICALLYTRANSMITTED OR EPIDEMIC NANBHEPATITIS)

CA Unenveloped, singlestranded RNA virus

INCUBATIONPERIOD

14-60 days, mean 40;2-9 weeks

Ind @risk Travelers to countrieswith high incidence ifhepatitis EEating/ drinkingfood/watercontaminated withvirus

RF/transmission Fecal-oralroute

Testing Anti HEVOutcome Mild with fullrecovery

Fatalityrate less than

1%No carrierstae orinc.risk ofchronicityMay progress tofuminant hepatitis

Stages of Hepatitis

1. Pre-icteric orprodromal stage

y (Interic=jaundice)

y CM: fatigue, malaise, fever

y ranging from severaldays to more thana week, characterizedby theappearance of symptoms like loss ofappetite, fatigue, abdominal pain,

nauseaandvomiting, fever, diarrhoea,dark urine and pale stools

2. Icteric stage

y CM: liveris enlarged

y jaundice develops at totalbilirubinlevelsexceeding 20 - 40 mg/l

3. Post icteric (recovery phase)

y Pain subsides, increased energylevel

6-8weeks afterexposure, jaundice is subsides

2-12 weeks afteronsetof jaundice liverfunction

Management:

y Bedrest

y High calorie, low fat diet

y IVF, TPN

y Bile acid sequestrants

y Immunoglobulins andvaccines to family

y Avoid hepatotoxicdrugs such as(Tylenol); chlorpromazine

yHCV: INTERFERONy HBV: EPIVIR

y Lamivudine

LIVER CIRRHOSIS

y Chronic, progressive disease oflivercharacterizedbydiffuse degenerationfibrosis (scarring)andnodule formation

y Cirrhosis is acomplication of manyliverdiseases that is characterizedbyabnormal structure and function of theliver.

y The diseases that lead to cirrhosis do sobecause theyinjure andkilllivercells,and the inflammationandrepairthat isassociated with the dying livercellscauses scartissue to form. The livercells that do not die multiplyinanattempt to replace the cells that havedied. This results inclusters ofnewly-formedlivercells (regenerative nodules)within the scartissue.


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y There are manycauses ofcirrhosis;theyinclude chemicals (such as alcohol,fat, andcertain medications), viruses,toxic metals (such as ironandcopperthat accumulate in the liveras aresultof geneticdiseases),andautoimmuneliverdisease in whichthe body's immune system attacks theliver.

y CM: jaundice (due to the accumulationofbilirubinin the blood), fatigue,weakness, loss ofappetite, itching, easybruising

CARDIAC CIRRHOSISSevere R sided HF

Enlarged, edematous, congestedliver

Liveranoxia

Livernecrosis and scarring

Liverdamage

Decreasedliverfunction

Chronicalcoholism

Toxins form alcohol: release ofacetyldehyde

Damage hepatocytes

Necrosis of hepatocytes

Fibrosis

Livercells regenerate dec. liverfunctionInabnormal pattern

Livercells loaded with fat

Enlargement

Irritates glissoncapsule

PAIN

H+ ion >acidity


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Esophageal varisces

y Complex torturous collateralveins atlowerend of the esophagus due toprolonged evaluation of pressure

y Cardinal sign - ESOPHAGEALBLEEDING

yPainless

Assessment

y Hematemesis

y Melena

y Anorexia

y Nausea

y Splenomegal

y Caput medusa

y osplenicdullness

Diagnostic test

y Barium swallow (NPO, allergy, inc. fluidintake, laxatives, stool-whitish)

y Esophagoscopy

Medical management

1. Sclerotherapy

Endoscopy

Esophagus

Inject sclerosing

Inflammationand fibrosis

Solidifying and stop circulation to the varix

2. Transjugualrintrahepatic portosystemic shunt(TIPS)

3. Vasopressin

y Stop varicealbleeding

y MOA qportalvenous blood flow byconstricting afferent arterioles

y SE hypothermia, MI, GI ischemiaand

acute renal failurey CI patients with recent MI

4. Balloon tamponade SengstakenBlakemoretube/Minnesota

y Pressure of the esophagealand gastric

balloonpstop the bleeding

y Complications: esophagealrupture,aspiration, pneumonia

Care of patients with SengstakenBlakemore

y Semi fowlers

y Maintain tractiony Scissors at bedside

y Monitorrespiratory status

y Label each lumen

y Maintain prescribedamount of pressurey Mouth andnasalcare every 1-2 hours

Surgical management

1. Endoscopicbandligation

y Device with smallrubberbands (o rings)

at the end of the endoscope p overthevarix

2. Portosystemic shunt

y Anastamosing = high pressure portal

venous system to the low pressuresystemicvenous system

Perioperative nursing management

Preop

y Explain

y Tests

y Consent

Post op

y Assess

y Nutrition

y IVF

y Dressing

y Bloodand urine values

Nursing management

y Nutritionalnadneurological status

y Patient airway

y Gastriclavage with cool saline

y Quiet environment

y s/sx ofbleeding and shock

y vasopressin

Health education

y qesophagealirritation

y No oinabdominal, thoracicand portalpressure

y S of hemorrhage


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Ascites

y Accumulation of fluidin the peritonealcavity that results from severalPathophysiology

Assessment/Dx test

y Percuss abdomen dull

y Detect fluid wave

y Paracentesis

y Abdominal X ray studies

y Ultrasonography

y CT scan

Paracentesis

y Transabdominalremoval of fluidfromthe peritonealcavity

Nursing responsibilities (qsalt, qfluidintake,avoid NSAIDS, aspirin)

Pre op

y Explain

y Consent

y VS,abdominal girth, weight

y Emptybladder

y Positionthe patient high fowlers

Post op

y Comfortable position

y Assess: VS, abdominal girth, weight

status, S of hypovolemiay Dressing

y Patient education

Medical management

y Paracentesis

y Albumin, IV

y F&E balance

y Diet modifications

y Diuretics

y Maintain skinintegrity

y Transjugularintrahepatic portosystemic

Surgical management

y LeVeen shunt (peritoneal shunt)

y a peritoneal-venous shunt usedin thecontrol ofascites

y It routes excess ascitic fluid out of theperitonealcavityandinto the superiorvenacava or the jugularvein

Hepatic encephalopathy

y Portal systemic encephalopathy

y Accumulation ofammoniaand othermetabolities inblood

y Altered LOC, impaired thinking,neuromusculardisturbances

liverdamage/cirrhosis

presenceof fibroustissue&no

dules

ocapillarypressure

obstructionofvenous

flow inliver

splanchnicarterial

vasodilation

qbloodvolume

activationof RAASsystem

albuminsynthesis

qoncoticpressure

esp inpreitoneal

cavity

qmetabolismof

aldosterone

Na&H2Oretention

bykidneys

hypovolemia

ASCITES

fluidwave

downwardprotrudingumbilicus

weight gain

oabd. girth dyspnea

striae&distended

veins

abd.distention

F&Eimbalance

bulgingflanks


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Stages of H.E.

1. Prodromal

y Not obvious

y CM: agitation, forgetfulness, restless,inability to concentrate

2. Impending

y CM: lethargic, confused, handwritingproblems

3. Stuporous

y Severe mentaldeficit, intolerance,hyperreflexia

4. Coma

y Comatose

y (+)babinskireflex

y Fetorhepaticus (A peculiarodorof thebreath inindividuals with severe liverdisease causedbyvolatile aromaticsubstances that accumulate in the bloodand urine)

Assessment andDx test

y EEG

y Serum ammoniaand CSF

y Gluatmine levels

yElectrolyte levely Blood gases

y Hepatic function test results (egprothrombin, bilirubin, albuminandenzymes)

Medical management

y Assess etiology

y Neomycin (Mycifradin) CI: renalinsufficiency

y Lactulose

y Antibiotics (to killbacteriain theintestine)

y Oral MgSO4/ enemas afterhemorrhagey IV fluids andvitamins

Nursing management

y Assess neuro status

y Restrict CHON, oCHO andvitamin Ksupplements

y Medications

y Protect client from injury

y Bedrest ( to decrease metabolicdemand)

Livertransplantation

Livertransplant

y Forend stage liverdisease

y Duration: 6-18 hours

Complications

y Rejection (occur4-10thday)pjaundice,

encephalopathy

y Infection

y Hemorrhage

y Atelactasis

Signs/symptoms of REJECTION

y Tachycardia

y Pain on the RUQ orflank

y ojaundice

y Fever(early sign)

Nursing management

Post op

y Monitor

y Drugs to prevent infection:CYCLOSPORINE

y Discharge instructions (s/sx ofrejection,etc)

Accessory Concept

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