MS2 - Quiz - Lower GI/Hepatic Flashcards
1
Q
WBC
Normal range
A
5000 - 10,000/mm3
2
Q
Hemoglobin
Normal range
A
14-18 g/dL (male)
12-16 g/dL (female)
3
Q
Hematocrit
Normal range
A
42-52% (male)
37-47% (female)
4
Q
Sodium
Normal range
A
136-145 mEq/L
5
Q
Potassium
Normal range
A
3.5-5.0 mEq/L
6
Q
BUN
Normal range
A
10-20 mg/dL
7
Q
Creatinine
Normal range
A
- 6-1.2 mg/dL (male)
0. 5-1.1 mg/dL (female)
8
Q
Peritonitis
Clinical manifestations
A
- Abdominal pain (most common symptom)
- Tenderness over involved area (universal sign)
- Rebound tenderness
- Muscular rigidity
- Spasm
- Movement causes pain
- Also may see: abdominal distention, fever, tachycardia, tachypnea, nausea, vomiting, altered bowel habits
9
Q
Peritonitis - Lab Values
A
Infection:
- Elevated WBC (norm: 5,000-10,000/mm3)
Hemoconcentration:
- Elevated Hct (norm: 42-52% (male) 37-47% (female))
- Elevated Hgb (norm: 14-18 g/dL (male) 12-16 g/dL (female))
- Elevated Na+ (norm: 136-145 mEq/L)
10
Q
Gastroenteritis
A
- Inflammation of mucosa of stomach and small intestine
- Sudden diarrhea, accompanied by N&V, abdominal cramping
- Viruses most common cause (Norovirus leading cause)
- Most cases self-limiting (elderly, chronically ill may get dehydrated - IV fluids if necessary, oral fluids with glucose & electrolytes [i.e., Pedialyte] as soon as tolerated)
- Nursing mgmt same as acute diarrhea
11
Q
Ostomy teaching
A
- Teach ostomy use/care and have patient/SO demonstrate
- Minimal oozing of blood is normal, stoma has high vascular supply
- How to monitor for complications (e.g., mechanical breakdown, chemical breakdown, rash, leaks, dehydration, infection)
- Pt should chew thoroughly, avoid foods that caused digestive upset previously, add new foods one at a time
- Encourage support groups, resuming normal life
- Don’t use alkaline soap on the skin (to prevent skin irritation)
- Water does not harm stoma, bathing and swimming can be done with or without pouching system
- Pt can resume ADLs 6-8 wks but not heavy lifting
12
Q
Hepatitis A
A
- Mild flu-like illness or acute hep w/jaundice
- Does NOT result in chronic infection
- Fecal-oral route; fecal contamination of food or drinking water
- Incubation: 15-50 days (avg 28)
- Infectivity: Most infectious during 2 wk before onset of symptoms
- Preventative: Personal and environmental hygiene, handwashing, vaccination
13
Q
Hepatitis B
A
- Sexual transmission, percutaneous or permucosal exposure to blood, perinatal transmission
- Can cause either acute or chronic disease (infection resolves in most)
- If chronic infection - may have severe liver disease
- CAN (rarely) spread through saliva or shared food, stays on dry surfaces for up to 7 days) - not urine, feces (w/out GI bleed), breast milk, tears, sweat
- Much more infectious than HIV
- Incubation: 45-180 days (avg 56-96)
- Infectivity: Before and after symptoms appear, carriers continue to be infectious for life
- Preventative: precautions against bodily fluids, Hep B vaccination
14
Q
Hepatitis C
A
- Can become acute or chronic (majority chronic)
- Asymptomatic - difficult to detect without lab testing
- Most common causes injection drug use and high risk sexual behavior, also perinatal contact
- Chronic results in progressive liver disease - 20-30% develop cirrhosis
- No vaccination available
- Most common cause of chronic liver disease and most common indication for liver transplants
- Pts at risk for HBV and HIV infections (30-40% HIV-infected have HCV)
15
Q
Hepatitis D
A
- HBV precedes HDV - chronic carriers of HBV always at risk
- Range from asymptomatic carrier to acute liver failure
- No vaccine for HDV - vaccination of HBV reduces risk of co-infection
16
Q
Hepatitis E
A
- Fecal-oral route
- Usual mode of transmission contaminated water - mostly occurs in developing countries
17
Q
Nutrition for hepatitis patient
A
- No special diet required - emphasis on well-balanced diet as tolerated (decreased bile may lead to poor fat tolerance)
- Acute viral hep - adequate calories because patient can lose weight
- Vitamin supplements, especially B-complex vitamins, vitamin K
- Severe anorexia/N&V: IV solutions of glucose or enteral nutrition
- Adequate fluid intake (2.5-3 L/day)
- Drinking carbonated beverages and avoid very hot/cold foods
18
Q
Nursing care for hepatitis patient
A
- Manage fluid and electrolyte balance - adequate calories for acute viral hepatiis
- Assess presence and degree of jaundice (light-skinned first in sclera of eyes then in skin; dark skinned first hard palate of mouth and inner canthus of eyes); urine may be dark brown or brownish red from bilirubin
- Comfort measures for pruritis (if present), headache, arthralgias (joint pain)
- Rest periods, limit environmental stimuli
- Anorexia usually not as severe in morning, plan larger meals earlier in day
19
Q
Risks for hernia
A
- Ventral/incisional: obesity, multiple surgical procedures in same area, inadequate wound healing r/t poor nutrition or infection
20
Q
S/S for hernias
A
- May be readily visible
- Discomfort as a result of tension
- If hernia strangulated - severe pain, symptoms of bowel obstruction (cramping abdominal pain, vomiting, distention)
21
Q
Treatment for hernias
A
- Laparoscopic surgery treatment of choice (herniorrphaphy - surgical repair; hernioplasty - reinforcement of weakened area with wire, fascia, mesh)
- Strangulated hernias treated immediately with resection of involved area or temp colostomy to avoid necrosis and gangrene
Post op considerations: - After hernia repair, pt may have trouble voiding (measure I&O, observe distended bladder)
- Scrotal edema - painful complication after inguinal repair - scrotal support, application of ice bag
- Deep breathing but not coughing (splint incision, keep mouths open when coughing or sneezing)
- Restricted from heavy lifting for 6-8 weeks
22
Q
Types of cirrhosis
A
Alcoholic cirrhosis (Laennec’s cirrhosis)
- Alcohol causes metabolic changes in the liver - fatty infiltration - normally would heal but with continued abuse hepatocytes inflammed and eventually necrosis - necrosis causes fibrosis and scarring - scarring causes nodules to form - liver shrinks
- Malnutrition commonly present
Fatty liver
- Due to diets high in fat, epidemic of obesity
- Can cause liver failure
Biliary
- Primary - chronic inflammatory condition (exact cause unknown - genetic/environmental factors)
- Primary sclerosing cholangitis - associated w/ulcerative colitis
Posthepatic/postnecrotic
- Viral hepatitis
- Liver decreases in size, nodules and fibrosis
Cardiac cirrhosis
- Longstanded right-sided heart failure
- Liver is swollen
- Can be reversed if heart failure treated effectively (some fibrosis occurs)
23
Q
Cirrhosis - risk factors
A
- Any chronic liver disease can cause cirrhosis
- Most common causes in US: chronic hep C infection, alcohol-induced liver disease
- Environmental factors, genetic predisposition
- 10-20% of those w/hep B
24
Q
Cirrhosis - complications
A
- Portal hypertension with resultant esophageal and gastric varices
- Peripheral edema and ascites
- Hepatic encephalopathy (mental status changes, including coma)
- Hepatorenal coma
25
Toxic and drug induced hepatitis
- Drugs can cause hepatitis
| - Some of same symptoms as Hepatitis, depending on degree of inflammation
26
Autoimmune hepatitis
- Unknown cause, presence of antibodies and immunoglobins, frequently occurs with other autoimmune diseases
27
Fulminant hepatitis
- Rapidly progressive disease with liver failure within a couple of weeks of symptoms
- Rare
- Hep B, especially B+D
- Death usually occurs
28
Portal Hypertension and Esophageal & Gastric Varices - interventions
- Prevent bleeding and hemorrhage - avoid alcohol, aspirin, NSAIDs
- Upper endoscopy (EGD) to screen for varices
- B-blocker reduces incidence of hemorrhage, high portal pressure
Variceal bleeding:
- Stabilize patient, manage airway, IV therapy initiated (may include blood products) - combination of endoscopal therapy and drug therapy (vasopressin / nitroglycerin often combination therapy)
- Band ligation (band around base of varix) or sclerotherapy (injection of sclerosant solution) - may be used to prevent rebleeding
- Balloon tamponade if cannot be controlled via endoscopy and bleeding acute - mechanically compresses the varices (* deflate balloons for 5 min every 8-12 hrs to prevent tissue necrosis)
- Fresh frozen plasma, packed RBCs, vit K, PPIs, antibiotics to prevent infection
Shunting:
- Surgical and nonsurgical methods available
- Used more after 2nd major bleeding episode than 1st
- TIPS - nonsurgical - shunt between systemic and portal venous systems to redirect portal flow
- Surgical - usually portacaval shunt or distal splenorenal shunt
29
Interventions specific to balloon tamponade from bleeding varices
- Gastric balloon breaks or is deflated - esophageal balloon will slip upward, obstructing airway and causing asphyxiation - cut the tube or deflate balloon - keep scissors at bedside
- Minimize regurgitation - oral and pharyngeal suctioning, pt in semi-Fowler's
- Patient is unable to swallow saliva - encourage to expectorate, provide emesis basin and tissues
- Frequent oral and nasal care
30
Ascites
- Abdominal distention with weight gain
- Abdominal striae with distended abdominal wall veins
- Signs of dehydration (dry mouth/skin, sunken eyeballs, muscle weakness) and decreased urine output
- Hypokalemia common
Management
- Sodium restriction
- Diuretics
- Fluid removal (paracentesis - needle puncture of abdominal cavity to remove fluid or test for infection) - reserved for patient with impaired respiration or ab pain caused by severe ascites - temporary measure b/c fluid builds back up
- Usually NOT on fluid restriction unless severe ascites develops
- TIPS when ascites does not respond to diuretics
31
Interventions - Ascites/Edema
- Accurate I&O, daily weights
- Observe F&E imbalances - high risk for hypokalemia
- Measurements of abdominal girth and extremities
- Have patient void immediately before paracentesis to prevent bladder puncture
- After paracentesis - patient sits on side of bed or in high-Fowler's - monitor for hypovolemia, electrolyte imbalances; check dressing for bleeding/leakage
- Dyspnea - semi-Fowlers or Fowlers; use pillows to support arms and chest
- Edematous tissues subject to breakdown - meticulous skin care, turning schedule min 2 hr, alternating-air pressure mattress, ROM exercises, coughing/deep breathing
- Elevate lower extremities; scrotal support for scrotal edema
32
Hepatic encephalopathy
Clinical manifestations
- Changes in neurological/mental responsiveness
- Impaired consciousness
- Inappropriate behavior - range from sleep disturbances to lethargy to deep coma
- Asterixis - flapping tremors - characteristic manifestation
Goal of mgmt - reduce ammonia formation
- Lactulose - drug that traps ammonia in the gut and has laxative effect to expel (can be given orally, NG tube, enema)
- Antibiotics can be given
- Constipation should be prevented
- Treatment of precipitating causes (GI hemorrhage, constipation, hypokalemia, hypovolemia, infection, etc)
- Controlling GI bleeding, and removing blood from GI tract to decrease protein in intestine
33
Hepatic encephalopathy - nursing care
- Assess patient's level of responsiveness, sensory and motor abnormalities, fluid and electrolyte imbalances, acid-base imbalances, effect of treatment measures
- Neurologic status at least Q2H
- Institute measures to prevent constipation to reduce ammonia production - give drugs, laxatives and enemas as ordered, encouraged fluids if indicated
- Any GI bleeding will worsen encephalopathy
- Assess pt taking lactulose for diarrhea and excessive fluid/electrolyte losses
- Control factors known to precipitate, including anything that may cause constipation
34
Major classes of medications to treat IBD
Aminosalicylates - first line therapy for mild-moderate CD, more effective for UC - achieve and maintain remission
- Decrease GI inflammation through direct contact with bowel mucosa
- Yellowish orange discoloration of skin and urine
Antimicrobials
- Prevent or treat secondary infection
Corticosteroids - used to achieve remission - given for SHORTEST period of time
- Decrease inflammation
- Tapered to low levels when surgery is planned
Immunosuppressants - maintain remission after corticosteroid induction therapy
- Suppress immune response
- Require regular CBC monitoring - can suppress bone marrow and lead to inflammation of pancreas or gallbladder
- Delayed onset of action
Biologic and targeted therapy
- Inhibit cytokine tumor necrosis factor (TNF); prevent migration of leukocytes from bloodstream to inflamed tissue
- Do not work for everyone; costly and may produce allergic reactions
- Most effective when given at regular intervals and must not be d/c'd unless pt can't tolerate
- Before starting anti-TNF, pt must be tested for TB and hepatitis; cannot receive live virus immunizations
35
Nursing care plan - patient with inflammatory bowel disease (IBD)
- Instruct pt to record color, volume, frequency and consistency of stools
- Perform actions to rest bowel (NPO, liquid diet)
- Stress-reduction techniques
- Frequent, small feedings, add bulk gradually; eliminate gas-forming and spicy foods
- Low-fiber, high-protein, high-calorie diet
- Weigh at specified intervals
36
ESR (Erythrocyte Sedimentation Rate)
| Normal range
Female: less than 20 mm/hr
Male: less than 15 mm/hr
