week 7 Flashcards
(132 cards)
1
Q
liver and its associated structures, including the gallbladder, bile ducts, and pancreas.
- These organs play a crucial role in digestion and metabolism.
A
Hepatobiliary
2
Q
large, complex organ located in the upper right quadrant of the abdomen.
Functions:
- Filtering blood: The liver removes toxins and waste products from the blood.
- Producing bile: Bile is a fluid that helps to break down fats in the small intestine.
- Storing glucose: The liver stores excess glucose as glycogen.
- Synthesizing proteins: The liver produces many proteins, including albumin and clotting factors.
A
liver
3
Q
is a small, pear-shaped organ located beneath the liver.
Functions:
- It stores bile produced by the liver.
- When food enters the small intestine, the ___ contracts and releases bile into the duodenum, where it helps to break down fats.
A
The gallbladder
4
Q
________ are a network of tubes that carry bile from the liver and gallbladder to the small intestine.
A
The bile ducts
5
Q
is a gland located behind the stomach.
Functions:
- It produces digestive enzymes that help to break down carbohydrates, proteins, and fats
- produces insulin, a hormone that helps to regulate blood sugar levels
A
The pancreas
6
Q
- detects tumors, cysts, and stones
- conducive gel used
- NPO 8 hours before (b/c food causes gallbladder to contract and alters results)
A
abdominal ultrasound
7
Q
MRI vs CT
____________
- Allows for exposure at different depths
- With or without use of oral and IV contrast medium – accentuates density differences
- If using IV contrast –
o Assess renal function – BUN and Cr labs
o Assess iodine and shellfish allergy
o Warn about “flushed feeling” with IV contrast admin
o Force fluids afterwards
______________
- Noninvasive
- Radiofrequency waves and magnetic field
- Detects disease, lesions, sources of GI bleed
- With or without IV contrast – gadolinium
- Contraindicated for
o Person with metal implants
o Pregnant person
A
CT
MRI
8
Q
If using IV contrast –
o Assess renal function – BUN and Cr labs
o Assess iodine and shellfish allergy
o Warn about “flushed feeling” with IV contrast admin
o NPO 8 hours
o Force fluids afterwards
A
o Assess renal function – BUN and Cr labs
o Assess iodine and shellfish allergy
o Warn about “flushed feeling” with IV contrast admin
Xo NPO 8 hours
o Force fluids afterwards
remember IV contrast and kidneys!
9
Q
________________
- Indicated if diagnosis of cholecystitis (gallstones) remains uncertain FOLLOWING an ultrasound
- ________ is a nuclear medicine study
- Nuclear medicine is what is injected IV
- Nuclear medicine is taken up by hepatocytes and excrete into bile
- A series of images are created to show the flow of bile from your liver to your gallbladder and then into your small intestine.
- Demonstrates patency of common bile duct and ampulla
A
HIDA scan – hepatobiliary scintigraphy
10
Q
HIDA scan Demonstrates patency of common bile duct and ampulla
o The common bile duct is a tube that carries bile from the _____ and _____ to the _____________
o The ampulla is a small opening in the ___________, the first part of the small intestine. The common bile duct and the pancreatic duct join together at the ampulla.
A
o The common bile duct is a tube that carries bile from the liver and gallbladder to the small intestine.
o The ampulla is a small opening in the duodenum, the first part of the small intestine. The common bile duct and the pancreatic duct join together at the ampulla.
11
Q
- visualizes and accesses the pancreatic, hepatic, and common bile ducts
- the endoscope is inserted through the mouth and advanced into the duodenum, the first part of the small intestine.
- The contrast dye is then injected into the common bile duct, which flows retrograde (backward) towards the liver and gallbladder.
A
ERCP - Endoscopic retrograde Cholangiopancreatography
12
Q
ERCP - Endoscopic retrograde Cholangiopancreatography
Pre-procedure
- NPO 8 hours
- Consent form signed
- Admin sedation
Post-procedure
- Check vitals – looking for signs of ________- or __________
- ___________– most common complication
- Check for return of gag reflex
A
perforation or infection
pancreatitis
13
Q
- Percutaneous procedure
- Needle inserted at ICS on right side where liver is located
- Aspirate to obtain hepatic tissue
- Ultrasound/CT guidance used concurrently sometimes
- Liver is very vascular
A
Liver biopsy
14
Q
liver biopsy
Pre-procedure
- Check ________
- Make sure patient’s blood is _________
- Consent form signed
- Baseline vitals
- Explain – hold breath after ________ when need is inserted
A
Pre-procedure
- Check coags
- Make sure patient’s blood is typed and cross matched
- Consent form signed
- Baseline vitals
- Explain – hold breath after expiration when need is inserted
15
Q
liver biopsy
Post-procedure
- Frequent vitals – looking for signs of internal bleeding =
increased HR #1
increased RR
BP decreased (later)
- Keep on _______ side for 2 hours
- HOB _______ for 12-24 hours
- Assess for complications – pneumothorax, peritonitis, shock
A
Post-procedure
- Frequent vitals – looking for signs of internal bleeding =
increased HR #1,
increased RR,
BP decreased (later)
- Keep on right side for 2 hours – the side of the liver/effected side b/c we want to put pressure on the liver to prevent bleeding
- HOB flat for 12-24 hours
- Assess for complications – pneumothorax, peritonitis, shock
16
Q
Liver enzymes – ALT, AST, Alk Phos
elevated levels good or bad?
which one is specific to liver?
which 2 are not specific to liver?
A
Liver enzymes – ALT, AST, Alk Phos
Elevated = liver disease
ALT – specific to liver
AST and Alk Phos – not specific to liver
17
Q
Liver enzymes – (3)
A
ALT, AST, Alk Phos
18
Q
Serum Bilirubin
Elevated = _______ disease
Bilirubin – the product of RBC breakdown
Total bilirubin = conjugated/direct bilirubin + unconjugated/indirect bilirubin
A
liver
19
Q
Conjugated/direct bilirubin vs Unconjugated/indirect bilirubin
________________
- Bilirubin that made it to the liver
- Water soluble
- Can be found in urine
- Elevated levels associated with obstructive jaundice – can’t get out of the body normally (stool) b/c of obstruction so its peed out
_________________
- Bilirubin did not make it to the liver (has not been conjugated by the liver)
- Not water soluble
- Can’t be found in urine
- Elevated levels associated with hepatocellular and hemolytic conditions – issue with liver itself or prior to the liver
A
Conjugated/direct bilirubin
- Bilirubin that made it to the liver (has been conjugated by the liver)
Unconjugated/indirect bilirubin
- Bilirubin did not make it to the liver (has not been conjugated by the liver)
20
Q
Elevated levels associated with obstructive jaundice – can’t get out of the body normally (stool) b/c of obstruction so its peed out
Conjugated/direct bilirubin vs Unconjugated/indirect bilirubin
A
Conjugated/direct bilirubin
21
Q
- Elevated levels associated with hepatocellular and hemolytic conditions – issue with liver itself or prior to the liver
Conjugated/direct bilirubin vs Unconjugated/indirect bilirubin
A
Unconjugated/indirect bilirubin
22
Q
If obstructed from entering intestines excess Bilirubin
- Deposits in _____ – yellow color, itching
- Deposits in urine – _____ color urine
- Clay colored ______ (lacking brown color) – bilirubin isn’t getting to small intestines
A
If obstructed from entering intestines excess Bilirubin
- Deposits in skin – yellow color, itching
- Deposits in urine – dark color urine
- Clay colored stool (lacking brown color) – bilirubin isn’t getting to small intestines
23
Q
Serum ammonium
Elevated = _____ disease
A
liver
Normally ammonia is converted to urea in liver
- So an increase would mean there is an issue (with the liver) and ammonia is building up, not being converted to urea
24
Q
Normally ammonia is converted to ____ in liver
- So an increase in ammonia would mean there is an issue (with the liver) and ammonia is building up, not being converted to _____
A
urea
25
Built up ammonia results in ___________ (related to cirrhosis which damages liver function)
Ammonia crosses the blood brain barrier
- _____ changes
- ________ function changes
- _________ function changes
- End stage if not fixed = ______
Built up ammonia results in hepatic encephalopathy (related to cirrhosis which damages liver function)
Ammonia crosses the blood brain barrier
- LOC changes
- Intellectual function changes
- Neurological function changes
- End stage if not fixed = coma
26
Serum protein and albumin
Low = _______ disease
Protein and albumin are made in liver
- So a decrease would mean there is an issue with the liver and protein/albumin is not being made
27
Serum protein and albumin
Low or high = liver disease
LOW
Protein and albumin are made in liver
- So a decrease would mean there is an issue with the liver and protein/albumin is not being made
28
Prothrombin time (PT)
Prolonged =
bleed risk
29
Prothrombin (protein) made in _______ and is essential for _________
- So a decrease in prothrombin would mean there is an issue with the _______ and prothrombin is not being made
Prothrombin (protein) made in liver and is essential for clotting
- So a decrease in prothrombin would mean there is an issue with the liver and prothrombin is not being made
30
Prothrombin time (PT) is how long it takes to clot
- Quick/low number =
- Prolonged/high number =
- Quick/low number = good
- Prolonged/high number = bad (bleed risk) and this is what we see with liver dysfunction
31
- So a ___crease in prothrombin would mean there is an issue with the liver and prothrombin is not being made
- So an ___crease in prothrombin TIME would mean there is an issue with the liver making prothrombin and thus the clotting time is longer
decrease in prothrombin
increase in clotting time
32
1. Only way to distinguish between the hepatitis viruses
2. For Hep __ and Hep __ – a viral genotype is done
3. used to identify different strains or variants of a particular virus.
4. T/F - Hep B has at least 8 different genotypes
5. T/F - Hep C has 6 genotypes (50 subtypes)
1. Antigen/antibody testing for viral hepatitis
2. B and C
3. viral genotype
4. T
5. T
33
Pancreatic enzymes
Elevated = good or bad?
BAD
Pancreatic enzymes
Elevated = pancreas injury
34
Serum lipase vs Serum amylase
_________________
- Enzyme digests carbohydrates
- Elevated within 12 hours of acute insult (pancreatitis)
- Peaks in 24 hours
- Returns to normal in 48-72 hours
____________
- Enzyme digests fat
- Elevated within 24-48 hours of acute insult (pancreatitis)
- Returns to normal in 5-7 DAYS
Serum amylase
Serum lipase
35
Hepatitis
Liver inflammation
s/s
- Asymptomatic
- Anorexia, n/v, weight loss or gain?
- _____ pain – liver location
- Malaise
- is liver palpable?
- _______– high bilirubin
- _______– high bile salts
- _______ – bile excreted via urine
Hepatitis
Liver inflammation
s/s
- Asymptomatic
- Anorexia, n/v, weight loss
- RUQ pain – liver location
- Malaise
- Hepatomegaly – enlarged liver, palpable
- Jaundice – high bilirubin
- Pruritis – high bile salts
- Dark urine – bile excreted via urine
36
Clinical course of viral hepatitis
_________________
- varies
- Abrupt or insidious
- Lasts 5-10 days
- s/s –
o flu like symptoms – chills, fever, malaise, myalgia (achy muscles), athralgias (achy joints), fatigue, anorexia, weight loss, headache
o n/v
o diarrhea or constipation
o RUQ pain
#1 incubation period
37
Clinical course of viral hepatitis
1. _________ period - time between exposure to a pathogen and the onset of symptoms.
2. _________ period - rapid onset of symptoms and a strong immune response.
3. _________ period – recovery
Acute infection
convalescence
Incubation
1. Incubation period - time between exposure to a pathogen and the onset of symptoms.
2. Acute infection period - rapid onset of symptoms and a strong immune response.
3. convalescence period – recovery
38
flu like symptoms – (9)
chills,
fever,
malaise,
myalgia (achy muscles),
athralgias (achy joints),
fatigue,
anorexia,
weight loss,
headache
39
Clinical course of viral hepatitis
_________________
- Lasts 1-4 months
- s/s –
o icteric – jaundice
o anicteric – not jaundice
o palpable liver
o some flu like symptoms may continue
#2 acute infection period
40
Clinical course of viral hepatitis
_________________
- symptom recovery 2-3 weeks
- full recovery 2-4 months
- s/s –
o malaise
o fatigue
#3 convalescence period – recovery
41
Hep ____ virus
- Transmission – fecal-oral, contaminated food/water
- s/s – mild, flu-like, less severe Hep virus
- prevention – hand hygiene, Hep A vaccine, gamma-globulin injection after exposure
- chronic infection – never
- incubation period – 2-4 weeks
A
42
Hep ___ virus
- Transmission – infected blood, perinatal
- s/s – ranges from asymptomatic to fulminant (sever) liver failure
- prevention – good hygiene, Hep B vaccine, Hep B immune globulin within 7 days of exposure
- chronic infection – low
- incubation period – 1-4 months
B
43
Hep ___ virus
- Transmission – infected blood, perinatal
- s/s – acute infection, asymptomatic or mild, but infection rarely completely resolves
- prevention – good hygiene, screening blood
- chronic infection – high
- incubation period – 7-8 weeks
C
44
prevention
Hep ____
-vaccine - for all kids starting at 12 y/o and special high-risk adult populations
-pre-exposure prophylaxis = vaccine
-post-exposure prophylaxis =
o vaccine or
o immune globulin – for short-term protection (about 2 months), given within 2 weeks of exposure
A
45
prevention
Hep ___
-vaccine 3 doses, several months apart - for all kids beginning in newborns and special high-risk adult populations
-post exposure prophylaxis = vaccine
o within ideally 24 hours of exposure, but up to 7 days max
B
46
hep ____
- no vaccine
C
47
viral hep education
- hygiene – wash hands after ______
- drink ________ water
- if traveling to _____________ – drink bottled water, avoid washing food in tap water, avoid ice
- don’t share ________, eating utensils, or drinking glasses
- don’t share ________ for injection, body piercing, or tattoos
- don’t share razors, _______ or toothbrushes
- use condoms
- cover cuts/sores with band aids
- if _______ – never donate blood, body organs or tissues
education
- hygiene – wash hands after toilet
- drink treated water
- if traveling to underdeveloped countries – drink bottled water, avoid food washing tap water, avoid ice
- don’t share bed linens, eating utensils, or drinking glasses
- don’t share needles for injection, body piercing, or tattoos
- don’t share razors, nail clippers, or toothbrushes
- use condom
- cover cuts/sores with band aids
- if infected – never donate blood, body organs or tissues
48
viral hep care
T/F
1. rest
2. nutrition - well balanced
3. adequate calorie
4. if fat isnt tolerated - low fat
5. vitamin supplements like b complex and vitamin K
6. antihistamines for pruritis relief
7. no alcohol
8. low doses of tylenol and/or isoniazid
9. notify contacts for testing
10. no hep A drug therapy
11. drug therapy for Hep B only if chronic
12. drug therapy for Hep C only if chronic
13. must genotype for drug therapy for Hep A, B and C
1. rest
2. nutrition - well balanced
3. adequate calorie
4. if fat isnt tolerated - low fat
5. vitamin supplements like b complex and vitamin K
6. antihistamines for pruritis relief
7. no alcohol
X 8. no hepatoxic drugs - tylenol and/or isoniazid
9. notify contacts for testing
10. no hep A drug therapy
X 11. drug therapy for Hep B only if severe with liver failure
12. drug therapy for Hep C only if chronic
X 13. must genotype for drug therapy for Hep B and C
49
icterus is ________
yellow pigment of sclera, skin, and hard palate
cause by high bilirubin in blood (>____)
a symptom or a disease?
jaundice
>2.5
a symptom, not a disease
50
bilirubin normally excreted via_______, so if everything is working right = brown poop and yellow pee
but if there is an obstruction of bile flow (____________ jaundice) = bilirubin is excreted via ____ tract (brown pee) and no bilirubin is excreted via ____ tract (white poop)
normally excreted via stool, so if everything is working right = brown poop and yellow pee
but if there is an obstruction of bile flow (obstructive jaundice) = bilirubin is excreted via GU tract (brown pee) and no bilirubin is excreted via GI tract (white poop)
51
s/s
- urine dark brown
- clay colored stool – if obstructive jaundice
- yellow skin, sclera, hard palate, etc.
jaundice
52
types of jaundice
- ________– increased breakdown of RBC
- __________– liver unable to take up/conjugate bilirubin from blood
- _________– decreased or obstructed flow of bile
hepatocellular
hemolytic
obstructive
- hemolytic – increased breakdown of RBC
- hepatocellular – liver unable to take up/conjugate bilirubin from blood
- obstructive – decreased or obstructed flow of bile
53
types of jaundice
- hemolytic – increased breakdown of RBC
- hepatocellular – liver unable to take up/conjugate bilirubin from blood
- obstructive – decreased or obstructed flow of bile
o ________ obstruction – inside liver
o ________ obstruction – outside liver, ex: gallstones causing obstruction
extrahepatic
intrahepatic
o intrahepatic obstruction – inside liver
o extrahepatic obstruction – outside liver, ex: gallstones causing obstruction
54
cirrhosis
chronic ______ disease characterized by the replacement of healthy ______- tissue with scar tissue.
liver
55
________ s/s
- Jaundice
- Low serum albumin and prothrombin time (PT)
- Asterixis (Liver flap)
- Portal hypertension
- Ascites
- Splenomegaly
- Spider angiomas
- caput medusae
- Esophageal varices
- anorectal varices
_________ s/s
- weight loss
- weakness
- GI disturbances - Anorexia, n/v, flatulence, change in bowel habits
- Hepatomegaly – liver enlargement
- RUQ pain – liver location
- Palpable liver – RUQ
early vs late s/s of cirrhosis
late
early
56
Early s/s of cirrhosis
- insidious
- weight _____
- weakness
- GI disturbances - Anorexia, n/v, flatulence, change in bowel habits
- Hepatomegaly - is liver palpable?
- ______ pain – liver location
Early s/s
- insidious
- weight loss
- weakness
- GI disturbances - Anorexia, n/v, flatulence, change in bowel habits
- Hepatomegaly – liver enlargement
- RUQ pain – liver location
- Palpable liver – RUQ
57
Late s/s of cirrhosis
- Jaundice
- ____ serum albumin and prothrombin time (PT)
- ________ (Liver flap)
- ______ hypertension
o ________ – 3rd spacing and fluid shifting in abdomen
o Splenomegaly – spleen enlargement, ___UQ, spleen filters blood, backup of blood
o Engorged microvasculature -
Spider angiomas
caput medusae
o Engorged/varicose veins (bigger vessels) –
Esophageal varices
anorectal varices
Late s/s
- Jaundice
- Low serum albumin and prothrombin time (PT) - proteins made in liver, bleeding risk
- Asterixis (Liver flap) - neurological sign characterized by a rapid, involuntary flapping movement of the wrists
- Portal hypertension - blood pressure in the portal vein, a large blood vessel that carries blood from the intestines to the liver, is abnormally high = congestion/back up of fluid
o Ascites – 3rd spacing and fluid shifting in abdomen
o Splenomegaly – spleen enlargement, LUQ, spleen filters blood, backup of blood
o Engorged microvasculature -
Spider angiomas - small, red, spider-like vascular lesions that typically have a central red dot surrounded by radiating branches
caput medusae - network of dilated veins around the umbilicus, resembling the head and neck of Medusa from Greek mythology.
o Engorged/varicose veins (bigger vessels) –
Esophageal varices - enlarged veins in the esophagus
anorectal varices - enlarged veins in the rectum and anus.
Severe bleeding if these varices burst
58
- Asterixis (Liver flap) - neurological sign characterized by a rapid, involuntary flapping movement of the wrists
associated with
cirrhosis
59
Spider angiomas
caput medusae
varicose veins
Esophageal varices
anorectal varices
associated with
cirrhosis
60
- Reversible neuropsychiatric manifestations of impaired liver function
Hepatic encephalopathy
assocaited with cirrhosis
61
_________ effect ranges from changes in LOC to coma depending on stage of encephalopathy
- Sedative
o LOC – changes in sleep pattern to coma
o Intellectual function – subtly impaired to no intellect
o Personality/behavior – exaggeration of normal behavior to no personality
o Neuromuscular abnormalities – tremor to coma
62
Goal of treatment
- Reduce ammonia formation
- Maintain safe environment – CNS depressant
Hepatic encephalopathy
63
Care hepatic enceophalopathy (end stage cirrhosis pt)
1. Diet
o ________ protein
o _____ calorie
o ______ carbs
2. Control GI bleeding
o bleeding __crease ammonia b/c blood is nitrogen rich
o bleeding __creases protein b/c blood is protein rich
3. Avoid constipation
o T/F - BM removes ammonia from body
o T/F - Constipation increases ammonia in body
4. Medications
o _______ – stool softener, titrate to 2-4 stools per day
o ________ – abx
5. Assess EMV
6. Safety precautions
7. Teaching
1.Diet
o Restrict protein
o High calorie
o High carbs
2.Control GI bleeding
o Increase ammonia b/c blood is nitrogen rich
o Increases protein b/c blood is protein rich
3. Avoid constipation
o BM removes ammonia from body
o Constipation increases ammonia in body
4. Medications
o Lactulose – stool softener, titrate to 2-4 stools per day
o Neomycin – abx
5. Assess EMV
6. Safety precautions
7. Teaching
64
Control GI bleeding is important for cirrhosis b/c
blood is rich in ______ and _______ which is bad for a damaged liver b/c it increases ________
nitrogen = increases ammonia
protein = increases ammonia
65
care cirrhosis
1. Rest
2. Manage ascites/FVE
3. Teaching
4. Enhance nutrition
o _____ calorie, _____ carb, and _____ fat
o Severe encephalopathy – protein restriction
o FVE/ascites – low sodium
5. Bleeding precautions – r/t varices
o High calorie, high carb, and mod/low fat
66
cirrhosis vs hepatic encephalopathy diet
o High calorie, high carb, and mod/low fat
o High calorie, High carbs, Restrict protein
cirrhosis
hepatic encephalopathy
67
cirrhosis care
Manage ascites/FVE
- Daily weights or abdominal girth measurement is more reliable for monitoring FV and retention?
- Measure abdominal girth – at level of ______, mark on skin where tape lies so it is measure in the ______ each time
- Sodium/fluid restriction or adequate?
- Diuretics – ______ and ______
- IV albumin removal or replacement?
- Fluid removal
1. ________ – relieves respiratory distress
2. _________– reduces pressure
Manage ascites/FVE
- Daily weights is more reliable for monitoring FV and retention
- Measure abdominal girth – at level of umbilicus, mark on skin where tape lies so it is measure in the same spot each time
- Sodium restriction/fluid restriction
- Diuretics – spironolactone and loop
- IV albumin replacement
- Fluid removal
1. Paracentesis – relieves respiratory distress
2. Trans-jugular intrahepatic Portal-systemic shunt (TIPS) – reduces pressure
68
Fluid removal
1. Paracentesis - inserting a needle into the abdomen to drain excess fluid.
- Must get informed consent
- Baseline vitals
- Void beforehand – so bladder doesn’t get in the way of the liver
- Position – supine or high fowlers
2. Trans-jugular intrahepatic Portal-systemic shunt (TIPS) - involves creating a shunt between the portal vein and the hepatic vein, bypassing the liver.
- This can help to reduce pressure in the portal vein and alleviate ascites
- Non-surgical procedure
- Controls long term ascites and reduce variceal bleeding
- Makes portal vein more patent
assocaited with
cirrhosis
69
fluid removal
associated with cirrhosis
_________ - inserting a needle into the abdomen to drain excess fluid.
- Must get informed consent
- Baseline vitals
- ______ beforehand – so bladder doesn’t get in the way of the liver
- Position – _______ or ______
- Must get informed consent
- Baseline vitals
- Void beforehand – so bladder doesn’t get in the way of the liver
- Position – supine or high fowlers
70
fluid removal
associated with cirrhosis
Trans-jugular intrahepatic Portal-systemic shunt (TIPS) - involves creating a ______ between the portal vein and the hepatic vein, bypassing the liver.
- This can help to reduce pressure in the portal vein and alleviate _____
- Surgical or Non-surgical procedure?
- Controls long term ascites
- reduces ________ bleeding
- Makes portal vein more ________
Trans-jugular intrahepatic Portal-systemic shunt (TIPS) - involves creating a shunt between the portal vein and the hepatic vein, bypassing the liver.
- This can help to reduce pressure in the portal vein and alleviate ascites
- Non-surgical procedure
- Controls long term ascites
- reduce variceal bleeding
- Makes portal vein more patent
71
Bleeding precautions – r/t varices
- Monitor coags – ______, ______, ______
- Assess ______ – 1st place we’ll see bleeding
- Monitor for bruising: _______, ______, _______
- Protect from falls
- diet - No _____, _____, _______
- drugs - No _____
- No injections
- Avoid vigorous nose blowing
- Avoid straining with BM – give stool softeners
- Soft toothbrush
- Avoid rectal temps/enemas
- Apply pressure to any bleeding for 5 mins
- Patient teaching
varices are associated with cirrhosis
Bleeding precautions – r/t varices
- Monitor coags – platelets, PT, PTT
- Assess oral cavity – 1st place we’ll see bleeding
- Monitor for ecchymosis, purpura, and petechiae
- Protect from falls
- No spicy foods, alcohol, bulky foods,
- No aspirin
- No injections
- Avoid vigorous nose blowing
- Avoid straining with BM – give stool softeners
- Soft toothbrush
- Avoid rectal temps/enemas
- Apply pressure to any bleeding for 5 mins
- Patient teaching
72
Varices active bleed
1. ___________ – varices infected with sclerosing agent (stops bleeding) via a catheter
2. ___________ – involves application of a small O band around the base of the varices to decrease the blood supply to the varices, causes no discomfort to person
3. __________ – temporary, emergency option, catheter inserted via esophagus, balloon inflated, applies direct pressure to the bleeding
- Variceal banding
- Balloon tamponade “sendstaken-blakemore or minnesota tube”
- Endoscopic sclerotherapy
Varices active bleed
1. Endoscopic sclerotherapy – varices infected with sclerosing agent (stops bleeding) via a catheter
2. Variceal banding – involves application of a small O band around the base of the varices to decrease the blood supply to the varices, causes no discomfort to person
3. Balloon tamponade “sendstaken-blakemore or minnesota tube” – temporary, emergency option, catheter inserted via esophagus, balloon inflated, applies direct pressure to the bleeding
73
premature activation of excessive pancreatic enzymes that destroy pancreatic cells, results in autodigestion and fibrosis of pancreas (pancreatic enzymes eat pancreas)
Acute Pancreatitis
74
Acute Pancreatitis
1. T/F - Ranges from mild edema to severe hemorrhagic necrosis
2. common Causes – ________ and _________
3. MRI or CT – best imaging, Shows pancreatic diameter, calcifications, pancreatic cysts or pseudocysts
1. T
2. gallstones and alcohol
3. CT scan
75
turner’s sign – bluish flank discoloration
cullen’s sign – blusih periumbilical discoloration
assocaited with
acute pancreatitis
76
s/s acute pancreatitis (1/2)
-______ = distention of pancreas, peritoneal irritation, and related inflammation
-n/v = associated with ________
-low grade fever and leukocytosis (increased WBC) = _________ process
-_________ = hepatobiliary obstructive process, elevated bilirubin
-_______= peritoneal irritation causes intestinal motility to slow down/stop
- Pain = distention of pancreas, peritoneal irritation, and related inflammation
- n/v = associated with visceral pain
- low grade fever and leukocytosis (increased WBC) = inflammatory process
- jaundice = hepatobiliary obstructive process, elevated bilirubin
- paralytic ileus = peritoneal irritation causes intestinal motility to slow down/stop
77
s/s acute pancreatitis (2/2)
-cullen’s and turner’s sign = _________ leakage into SQ tissue, bruising discoloration around belly button or flank
-hypovolemia and tachycardia = plasma volume is being lost as inflammatory mediators are released into circulation, __creased vascular permeability, ______tion of vessels
-__creased serum amylase and lipase = pancreatic cell injury
-__creased serum triglycerides = happens with fat necrosis
-____ serum calcium = happens with fat necrosis
- cullen’s and turner’s sign = pancreatic enzyme leakage into SQ tissue, bruising discoloration around belly button or flank
- hypovolemia and tachycardia = plasma volume is being lost as inflammatory mediators are released into circulation, increased vascular permeability, vessels dilate
- increased serum amylase and lipase = pancreatic cell injury
- increased serum triglycerides = happens with fat necrosis
- low serum calcium = happens with fat necrosis
78
complications of ___________
pseudocyst – cavity filled with necrotic products, surrounding outside of pancreas
abscess – large fluid containing cavity, within the pancreas
acute pancreatitis
79
complications of acute pancreatitis
_________– cavity filled with necrotic products, surrounding outside of pancreas
_________– large fluid containing cavity, within the pancreas
abscess, pseudocyst
pseudocyst – cavity filled with necrotic products, surrounding outside of pancreas
abscess – large fluid containing cavity, within the pancreas
80
complications of acute pancreatitis
pseudocyst – cavity filled with necrotic products, surrounding outside of pancreas
what can happen next? (2)
abscess – large fluid containing cavity, within the pancreas
what can happen next? (2)
pseudocyst =
resolves spontaneously or perforates into peritoneum
abscess =
results in extensive necrosis of pancreas
needs prompt surgical drainage
81
care acute pancreatitis
1. treat pain – can cause ________
- drugs?
- Position?
2. Maintain F&E balance
- Monitor vitals – can be labile/unpredictable
- Monitor for F&E imbalances
- hydration - IV or PO?
3. Rest pancreas and suppress pancreatic enzyme stimulation
- best way to rest gut = _____
- Oral care
4. Monitor stool
- stool oily and floaty __________
5. Monitor for _____glycemia – pancreas makes insulin
6. Diet after no longer NPO
- _____ carbs
- _____ fat
- encourage no ______
1. treat pain – can cause hemodynamic compromise
- IV morphine
- Position in way that flexes the trunk – less stretch on peritoneum
2. Maintain F&E balance
- Monitor vitals – can be labile/unpredictable
- Monitor for F&E imbalances
- Aggressive IV hydration
3. Rest pancreas and suppress pancreatic enzyme stimulation
- NPO – NG to LWS
- Oral care
4. Monitor stool
- Impaired protein/fat metabolism – excreted in stool, makes stool oily and floaty “steatorrhea” – d/t body cant digest fats in the GI tract
5. Monitor for hyperglycemia – pancreas makes insulin
-6. Diet after no longer NPO
- high carbs (encouraged)
- restrict fat
- encourage no alcohol
82
for acute pancreatitis
T/F
1. there is Impaired protein and fat metabolism
2. body cant digest fats in the GI tract, so protein and fat are excreted in stool = makes stool oily and floaty “steatorrhea”
3. this is why we want to restrict fat in diet
4. this is why we want to restrict carbs in diet
1. T
2. T
3. T
4. F - encourage carbs - less stimulating on pancreas
83
Progressive and destructive
With remissions and flares
Caused by inflammation and fibrosis of tissues in pancreas
Chronic pancreatitis
84
s/s acute vs chronic pancreatitis?
____________
- Intense abdominal pain
- mass – suspect pseudocyst or abscess
- ascites
- respiratory compromise – from ascites
- steatorrhea
- dark urine – from bilirubin in urine
_________
- pain
-n/v
-fever and leukocytosis
- jaundice
-paralytic ileus
-cullens and turners sign
- hypovolemia and tachycardia
- increased serum amylase and lipase
-increased serum triglycerides
- low serum calcium
chronic
acute
85
care for chronic or acute pancreatits?
1. pain control = opioid
2. PERT – pancreatic enzyme replacement therapy
3. treat/prevent weight loss = consider TPN, if PO increase calories significantly
chronic
86
chronic pancreatitis care
PERT – pancreatic enzyme replacement therapy
T/F
1. Prevents malnutrition, malabsorption, and excessive weight loss
2. Pancrelipase – contains amylase, lipase, and protease
3. Record number and consistency of stools per day – monitors effectiveness of enzyme therapy
4. Goal = less frequent stools and less fatty stools
5. Take enzymes after meals and snacks
6. Sometimes given with antacid or H2 blockers
7. an acidic stomach improves the absorption of pancreatic enzymes
8. decreased pH (high acid) stomach
inactivates drug
9. swallow, don’t chew tablet – minimize oral irritation
10. avoid lip/skin contact with enzyme – wipe lips prn after digesting
11. dont mix powder form in applesauce or fruit juice
12. do not mix in protein-containing foods
13. do not crush enteric coated preparation
1. T
2. T
3. T
4. T
5. F - before or with meals
6. T
7. F - acidic stomach decreases absorption
8. T
9. T
10. T
11. F - can mix with these
12. T
13. T
87
prevention of exacerbations of chronic pancreatitis
T/F
1. avoid things that make symptoms worse – caffeine
2. avoid alcohol
3. avoid nicotine
4. high protein, high carb, high fat
5. eat bland food, avoid gastric stimulants – spices
6. one large meal per day
7. take prescribed pancreatic enzymes with meals
8. rest
1. T
2. T
3. T
4. F - LOW fat
5. T
6. F -small frequent meals – high in calories
7. T
8. T
88
(infiltration+ it’s a vesicant) =
Extravasation
89
__________ – gallstones
_________ – gallbladder inflammation
acute and chronic forms
cholelithiasis
cholecystitis
90
risk factors
- middle age
- female
- fair skin
- overweight
- high fat diet
- oral contraceptives
cholelithiasis/cholecystitis
91
s/s
- episodic/vague upper abdominal pain – radiates to right shoulder
- pain triggered by high fat or high volume meal
- n/v
- dyspepsia – indigestion
- eructation – belching
- flatulence
- fever – r/t inflammation
- jaundice, clay colored stool, dark urine, steatorrhea
cholelithiasis/cholecystitis
92
care for cholelithiasis/cholecystitis
non-surgical
- avoid _______ foods
- ________ if major flare
- Biliary pain – meds?
- Anti________ and anti__________
- Rare – lithotripsy or ERCP with sphincterotomy (opens sphincter to be bigger and allows gallstones to pass)
- avoid fatty foods
- NPO if major flare
- Biliary pain – opioids indicated
- Antiemetics and antispasmodics
- Rare – lithotripsy or ERCP with sphincterotomy (opens sphincter to be bigger and allows gallstones to pass)
93
Surgical treatment for ?
- Laparoscopic cholecystectomy
- Open cholecystectomy with T tube
cholelithiasis/cholecystitis
94
surgical treatment for cholelithiasis/cholecystitis
________________
- Small incisions
- Removes gallbladder
________________
- Bigger incisions – made through right subcostal incision
- Has temporary T tube
o Ensures patency of common bile duct until inflammation from procedure goes down
o Has bile bag to collect bile drainage
Open cholecystectomy with T tube, Laparoscopic cholecystectomy
Laparoscopic cholecystectomy
- Small incisions
- Removes gallbladder
Open cholecystectomy with T tube
- Bigger incisions – made through right subcostal incision
- Has temporary T tube
o Ensures patency of common bile duct until inflammation from procedure goes down
o Has bile bag to collect bile drainage
95
Laparoscopic cholecystectomy
- Small incisions
- Removes gallbladder
Postop
T/F
1. Remove bandages at puncture sites day after surgery, than may shower
2. assess puncture site for bleeding
3. monitor abdominal dressing for bleeding
4. Notify HCP if Redness, swelling, purulent/bile colored drainage from site
5. Notify HCP if Severe abdominal pain, n/v, fever, chills
6. Gradually resume activities, return to work in 1 week
7. Eventually resume usual diet, Low fat diet better tolerated for several weeks after surgery
1. T
2. T
3. F - no dressings for this procedure - just bandages
4. T
5. T
6. T
7. T
96
Prevention/early detection for cancer
- Avoid _________- Excessive alcohol, dietary habits, tobacco, sun exposure
- Diet, exercise, rest
- Regular health exams
- Regular cancer screening
- Learn/practice _________ - Breast and testicular
- Know the 7 warning signs
carcinogens
self exams
97
7 warning signs of cancer
C – change in ___________
A – a sore that _______
U – unusual bleeding/discharge from ______
T – _______ or a lump in the breast or elsewhere
I – indigestion or difficulty in _______
O – obvious _______ in a wart or mole
N – nagging cough or _________
7 warning signs of cancer
C – change in bowel or bladder habits
A – a sore that doesn’t heal
U – unusual bleeding/discharge from any-body orifice
T – Thickening or a lump in the breast or elsewhere
I – indigestion or difficulty in swallowing
O – obvious change in a wart or mole
N – nagging cough or hoarseness
98
cancer Treatment
1. Diagnosis
2. Treatment options – (4)
Treatment goal
1. Cure
2. Control
3. Palliative care
chemo, surgery, radiation, biologic and targeted therapy
99
which cancer treatment?
- Prophylaxis
- Diagnosis (biopsy)
- Cure
- Control = Debulking procedure – reduces size of tumor, makes radiation/chemo more effective, not curative, just control
- Palliation
- “Second look”
- Reconstructive/rehabilitation
surgery
100
Debulking procedure
T/F
1. reduces size of tumor
2. makes radiation/chemo more effective
3. curative
4. control
5. type of cancer treatment - surgery
1. T
2. T
3. F
4. T
5. T
101
Chemotherapy
T/F
1. Mainstay of cancer therapy
2. Used to treat solid tumors
3. used to treat hematologic malignancies
4. localized
Radiation therapy
T/F
1. Local Control
2. Carefully defined area of body
3. Can't use independently
4. can use with chemo
5. can use with surgery
1. T
2. T
3. T
4. F - systemic!!!
1. T
2. T
3. F
4. T
5. T
102
Administering chemo drugs
T/F
1. Must have certification to admin chemo drugs
2. Toxic agent - protect patient, self, and environment by following protocols
3. Double check dose/order with 2nd RN
4. Avoid extravasation
5. chemo is a vesicant
6. CVC (central line) is required
7. Pre-medication common
o Anti-______
o Anti-______
o Anti-______
8. Monitor lab values - Hold chemo if ___ or ______ are too low
9. Provide support
1. T
2. T
3. T
4. T
5. T
6. F - preferred but not required
7. Anti-emetic, Anti-inflammatory, Anti-allergy
8. WBC or platelets
9. T
103
central line required?
1. TPN
2. chemo
1. yes
2. preferred but not required
104
Extravasation
Infiltration of vesicant drugs into tissues surrounding infusion site
1. can cause severe necrosis
2. Prevention is key
3. Monitor IV patency often, ensure constant free—flow IV
4. Cardinal s/s – pain (not always)
5. stays localized
1. T
2. T
3. T
4. T
5. F
105
- What to do if Extravasation happens?
T/F
1. Stop infusion STAT
2. Attach disposable syringe at IV exit site
3. Aspirate slowly and gently to get as much solution back as possible
4. Remove original cannula
5. let arm dangle
6. Infuse antidote intradermal per protocol
1. T
2. T
3. T
4. T
5. F - elevate arm
6. T
106
Types of radiation
1. ________ - teletherapy
2. ________ – brachytherapy
External, Internal
1. External - teletherapy
2. Internal – brachytherapy
107
Types of radiation
1. External - ___________
- Radioactive source is external
- Patient is not radioactive – no risk of them exposing anyone to radiation
2. Internal – __________
- Radioactive source is internal
- Patient emits radiation for a period of time – hazard to others
telegraphy
brachytherapy
108
telegraphy, brachytherapy, Temporary implants (sealed), Radiopharmaceutical therapy (unsealed) radiation?
1. Patient is not radioactive – no risk of them exposing anyone to radiation
2.Patient emits radiation for a period of time – hazard to others
1. telegraphy
2. brachytherapy, Temporary implants (sealed), Radiopharmaceutical therapy (unsealed)
109
telegraphy vs brachytherapy radiation?
1. Temporary implants (sealed)
- Solid implants
- Patients emits radiation while implant is active
- Excretions are not radioactive
2. Radiopharmaceutical therapy (unsealed)
- Suspended in a fluid
- Ingested and eventually eliminated in waste products
- Waste products are radioactive
- Ex: radioactive iodine pills for thyroid cancer
both types of brachytherapy radiation
- Radioactive source is internal
- Patient emits radiation for a period of time – hazard to others
110
brachytherapy radiation
1._____________ (sealed)
- Solid implants
- Patients emits radiation while implant is active
- Excretions are not radioactive
2. ______________ (unsealed)
- Suspended in a fluid
- Ingested and eventually eliminated in waste products
- Waste products are radioactive
- Ex: radioactive iodine pills for thyroid cancer
Radiopharmaceutical therapy
Temporary implants
Temporary implants (sealed)
- Solid implants
- Patients emits radiation while implant is active
- Excretions are not radioactive
Radiopharmaceutical therapy (unsealed)
- Suspended in a fluid
- Ingested and eventually eliminated in waste products
- Waste products are radioactive
- Ex: radioactive iodine pills for thyroid cancer
111
temporary implants = sealed or unsealed?
Radiopharmaceutical therapy = sealed or unsealed?
Temporary implants (sealed)
- Solid implants
- Patients emits radiation while implant is active
- Excretions are not radioactive
Radiopharmaceutical therapy (unsealed)
- Suspended in a fluid
- Ingested and eventually eliminated in waste products
- Waste products are radioactive
- Ex: radioactive iodine pills for thyroid cancer
112
Radiopharmaceutical therapy (unsealed) vs Temporary implants (sealed) or BOTH?
1. Radioactive source is internal
2. Patient emits radiation for a period of time – hazard to others
3. Waste products are radioactive
4. Patients emits radiation while implant is active
5. Excretions are not radioactive
Radiopharmaceutical therapy (unsealed)
6. Suspended in a fluid
7. Ingested and eventually eliminated in waste products
8. Solid implants
9. Ex: radioactive iodine pills for thyroid cancer
1. B
2. B
3. R
4. T
5. T
6. R
7. R
8. T
9. R
113
How close can I get to radiation?
- depends on Time, distance, shielding
- The further away the better
-__________– nurse wears to keep track of how much radiation you’ve been exposed to
dosimeter
114
Care for patient with Internal/brachytherapy: _____________
- Private room/bath
- Caution – radioactive material sign on door
- Where dosimeter AAT and don’t share it (its not protective, just informational)
- No pregnant women or kids < 16 y/o
- Limit each visitor to 30 min/day and keep 6 feet from source
- Never touch radioactive source with hands, use forceps and keep lead in container in room
- Save all dressings and bed linens until after radioactive source is removed, then discard in usually manner, other equipment can be removed at any time
Temporary implants (sealed)
115
radiation Education includes:
- Wash irritated area daily, with water or mild soap with water
- Use hand rather than wash cloth
- Rinse soap thoroughly
- Dry skin with patting, no rubbing
- Don’t use powders, lotions, creams at site unless prescribed by radiologist
- Wear soft clothing
- Avoid anything that binds/rubs site
- Avoid sun exposure to irritated area
- Avoid temp extremes
which radiation do we teach: Don’t wash away marker markings on skin - for purpose of indicating where radiation should be focused
External - teletherapy
116
s/e of chemo and radiation treatment (3)
bone marrow suppression
GI effects
skin reactions
117
s/e of chemo and radiation treatment : Bone marrow suppression (3)
- Neutropenia – low WBC = high infection risk
- Thrombocytopenia – low platelets = high bleed risk
- Anemia – low RBC = excessive fatigue and other complications based on comorbidities
118
s/e of chemo and radiation treatment : bone marrow suppression
1. monitor for WBC (2)
2. Changes in lab values may result in _______ or _______ chemo dosing
3. Teach about infection risk
4. Admin WBC growth factors –
o CBC with diff (%)
o ANC - Absolute neutrophil count (actual number)
delayed or decreased
filgastrim
119
_____________ precautions
Infection prevention
- Isolation protocol
- Screen visitors
- No fresh flowers
- Neutropenic precautions
- s/s of infection
- monitor WBC
- teach how to avoid infections
- take abx as prescribed
neutropenia
120
ANC - Absolute neutrophil count (actual number)
The actual number of neutrophils (segs and bands) present to fight infections
> 2500 =
> 1000 =
< 1000 =
< 500 =
> 2500 = normal
> 1000 = safe
< 1000 = neutropenia
< 500 = precautions and protective isolations
121
_______– time after chemo dose, when the WBC or platelet count is at its lowest point
teach pt at this point
- not going to feel good
- limit exposure to people
Nadir
122
neutropenic diet
1. raw fruits and veg that cant be peeled (berries) =
2. raw fruits and veg that can be peeled (pineapple, banana) =
3. food and flat wear is wrapped for delivery =
4. raw nuts and seeds =
1. NO
2. OK
3. OK
4. NO
123
thrombocytopenia
monitor platelet count
< 50,000 =
< 20,000 =
thrombocytopenia
monitor platelet count
< 50,000 = risk of serious bleeding
< 20,000 = platelet transfusion
124
Anemia
- monitor H&H
- teach energy conservation – encourage activities with periods of rest
- adequate nutrition
- hgb < 11= often given _______ (RBC growth factor)
- extremely anemia = give ______
epoetin
PRBCs
125
s/e of chemo and radiation treatment :GI effects
- taste changes are common, focus on food they like
- anti-emetics - anticipate n/v or treat it
- monitor weight daily
- monitor relevant lab values
- encourage small frequent meals
- _____ protein and _____ calorie
- nutritional supplements
high and high
126
s/e of chemo and radiation treatment :GI effects
chemo kills rapidly dividing cells and the GI tract is rapidly producing cells naturally, so lots of GI s/e with chemo
- Anorexia
- n/v
- ______ – inflammation of any part of the mouth
- _______ – inflammation of the mucous membranes lining the mouth, throat, and digestive tract
- altered bowel patterns (usually diarrhea)
*remember with localized radiation – s/e will be determined based on radiation site
- neck radiation = maybe swallowing or taste issues
- bowel radiation = maybe diarrhea
o stomatitis – inflammation of any part of the mouth
o mucositis – inflammation of the mucous membranes lining the mouth, throat, and digestive tract
127
stomatitis - irritated inflamed and/or ulcerated mucosa in oral cavity
T/F
1. assess mouth thoroughly
2. mouth care
3. bursh teeth and floss – unless contraindicated
4. mouth wash - saline gargles
5. mouth wash - swish and spit or swish and swallow mixtures
anesthetic
anti-inflammatory
antifungal
6. mouth wash - alcohol mouth
7. artificial saliva
8. soft, non-irritating food
1. T
2. T
3. T
4. T
5. T
6. F - NO
7. T
8. T
128
s/e of chemo and radiation treatment:
skin reactions
radiation = ________ problems
chemo = ___________ problems
_________– dry and wet skin rash
radiation = localized problems
chemo = generalized problems
- desquamation – dry and wet skin rash
129
s/e of chemo and radiation treatment: others
- fatigue – r/t anemia and cancer
- ________ - hair loss
- pulmonary effects – lung damage r/t radiation/drug adverse effects
- CV effects – heart damage r/t radiation/drug adverse effects
- Reproductive effects – potentially infertile
alopecia
130
Complimentary/alternative treatment
- Support pts right to chose
- Encourage continuation of treatment plan
- Support healing environment – calm, present, quiet, etc. unique to person
cancer
131
Concerns
Psychosocial
- Disfigurement – hair loss, body part loss, etc.
- Support pts decision
- Provide information
- Secondary cancers
- Recurrence after cure
- Disability and death
cancer
132
Coping
- Hope is positive reappraisal
- Nurses can enable hope by
o Helping pt be aware of life
o Identify reason for living
o Helping establish support system - Provide assistance, listen, shoulder to cry on, educate on support groups
o Incorporate religion - May have positive or negative impact. Angry, fear or faith renewed
o Incorporate humor
cancer
