Unit 5: Hepatic/Pancreatic Dysfunction

* Functions of the liver * Metabolism of carbohydrates * Glucose energy * Dysfunction = fatigue * Metabolism of proteins * Proteins muscle * Dysfunction: weak, tired, fatigue, lethargic * Metabolism of fats * Dysfunction: atherosclerosis/ N&V * Production of bile: helps metabolize fats * Synthesis of blood clotting factors * Dysfunction: increased risk for bleeding * Blood storage: holds 400 ml – loss of blood and will put into system * Filters blood: decrease infections – remove bacteria from system * Metabolism of medications * Dysfunction: can’t metabolize and get hepatotoxicity

* Hepatitis A * Transmission: Fecal-oral route * Wash veggies b/c migrant workers use fields as bathrooms * Occurrence * Poor hygiene * Improper handling of food * Poor sanitation * Foods or water in third world country * Risk Factors * Close personal contact/ handling feces contaminated waste * Animal workers/handlers from endemic areas * Handling food * Day care center workers * Seafood – clams & muscles * Natural Course * Does not progress to chronic state * Symptoms resolve on their own * Treatment : None * Vaccine * International travelers * Military personnel * High risk individuals * Peace core

Hepatitis B and C * Transmission * Contact with contaminated body fluids * Risk/Occurrence * IV substance abusers * Blood transfusions * Pregnancy – mom to baby * Sexual activity – homosexual * Health care providers * Hemodialysis (Hep C more common) * Natural Course * Clears on its own * Maintain life long immunity * Chronic infection can progress to cirrhosis or liver cancer * Treatment * Usually none * Chronic infection: Interferon other antivirals * Vaccine * Newborns * Adolescents * health care workers * travelers * Signs & Symptoms * GI symptoms (liver enlarges and puts pressure on epigastric area) * Anorexia * Nausea/Vomiting * RUQ pain (When liver enlarges more than capsule * Fatigue – unable to metabolize carbs * Jaundic/ictorus – Bile circulating in blood. Look in white in eyes first * Palpate the enlarged liver

* Diagnostic Studies * Liver enzymes * Increase SGOT, SGPT, LDH * Decrease in liver enzymes show liver is repairing itself * Serum proteins * Albumin (3.5-5.5) maintain colloidal osmotic pressure (keeps fluid from entering interstitial space) * Serum bilirubin * Urine bilirubin * Prothrombin time (know time) INR, PT, PTT know values * Liver biopsy * Pre-procedure * Consent needed * Can do at the bed side or under fluoroscopy * Local anesthetic * Position: supine with right arm over head * May give vitamin K before procedure (if they are at great risk for bleeding) * Aquametafomin – IM = small gauage and apply pressure * After procedure * PC: Bleeding (liver stores 400 ml of blood) * Assess site/dressing * Apply pressure, place pt on affected side, pressure for 5 mins, * internal bleeding = bruising * * Medical & Nursing Care * Not admitted to hospital * Bed rest - decrease physical activity b/c they cant tolerate it * Balanced diet. Small frequent meal, oral hygiene, anti-emetic prior to meal, no Etoh * Know person is better by liver enzymes and level of energy. Repairing liver = more energy * Drug therapy * Not generally useful * Anti-emetics- administer ac (before meals) * Benadryl – helps with dry skin and itching they may have

* Cirrhosis
Chronic progressive disease of the liver characterized by degeneration & destruction of liver parenchymal cells
10% Drug toxicity, cancer, heart failure. 90% alcohol

Concept Map * Liver insult, alcohol ingestion, viral hepatitis, exposure to toxins * Cessation of alcohol ingestion or liver transplantation * Hepatocyte damage * Liver inflammation * Increased WBCs (>11) (from inflammatory response) [Nothing RN can do] * Fatigue (dysfunction of metabolism of carbs) * NIC: Energy management * Nausea/vomiting (metabolism of fats & increased size of liver – pressure in epigastric region) * Balanced nutrition & anti-emetics * Small frequent meals with high carbs and proteins and low in fats * Pain * Be careful with medications * Fever (inflammation) [can’t reduce inflammatory response] * Antipyretics & comfortable environment * Anorexia * Balanced diet with increased protein & carbs, supplements * Alteration in blood and lymph flow * Liver necrosis * Decreased ADH and aldosterone * Edema * Weight pt * I & O * Lung sounds * VS * Turgor, mucous membranes * LE edema & peripheral vascular status * Decreased androgen & estrogen production * Palmar erythema: palms are red * Psychosocial body image – s/s nothing RN can do
Psychosocial body image – s/s nothing RN can do
Spider angiomas: located on cheek & nose * Loss of body hair * Testicular atrophy * Gynecomastia * Menstrual changes * Decreased metabolism of protein and carbohydrate and decreased metabolism of fat * Decreased plasma proteins (albumin – keeps fluid in vascular bed) * Ascites * Edema – lungs, trunk, extremities * Hypoglycemia malnutrition * Prevention: * Multivitamins * Balanced nutrition – adequate carbs, fats, proteins * Decreased vitamin K absorption * Bleeding tendency * Avoid ASA, acetiminophen (SE hepatotoxicity), trauma to skin * Do: electric razors, Decrease needle sticks & use small gauge, assess gums, nose bleeds and blood in stool * Decreased bile for digestion * Clay-colored stools (bile gives stool brown color) [Nothing RN can do about this except assess] * Educate the patient about this to prevent them from getting upset * Bilirubin excretion in urine [No NI just assess it] * Dark clear urine * Decreased bilirubin metabolism [No NI just assess it] * Hyperbilirubinemia * Jaundice * Might cause alteration in body image and when bilirubin decrease=jaundice decrease=will hopefully go back to normal color

* Liver necrosis * Liver fibrosis and scarring (when you palpate can feel nodules on liver)

* Portal hypertension: Increase pressure in portal vein * Prevention: Portacaval shunt * Insert catheter in portal vein and valve diverts fluid to kidney * Pt taught to compress and force fluid to superior vena cava to heart and gotten rid of by kidneys * Signs and symptoms: * Edema * Bleeding
Bleeding
Esophageal varices * Hemmoroids * Superficial abdominal varices * Portal hypertension leads to: * Ascites (decreased amount of albumin) * Treatment * Fluid restriction * Make sure pt doesn’t over consume * Needs good communication to entire staff * Dietary takes bulk of fluids * Give meds with meals even though it might not say to do that * Diuretics * Lasix – SE: hypokalemia, hypotension, potential for dehydration * Foods high in potassium: fruits and veggies * Low potassium = cardiac dysrhythmias * Give Albumin IV * Protein – given IV * Will come from the lab * Does not require type and cross match * Infuse as fast as you want – no restrictions * The substance if very sticky * Does not fix this, ascites will occur again until portal hypertension is resolved * Paracentesis (see procedure further in notes) * Splenomegaly

* Anemia, thrombocytopenia, leucopenia * Signs and symptoms * Bleeding * Delayed wound healing * Infection * Liver failure * Inability to metabolize ammonia to urea * Keep protein in diet and carbs. High protein & carbs * Corticosteroids: Docs don’t use this anymore – SE – pts don’t need these * Hepatic encephalopathy * Signs and symptoms * Increased serum ammonia = decreased LOC * Treatment: decrease concentration of ammonia * Neomycin – antibiotic * Used for colostomy or ileostomy * Destroys normal flora of colon * Lactulose- cefulac = laxative * Give 30 ml instead of 5 ml * Decrease ammonia level in GI tract by ridding colon of ammonia * SE: Diarrhea (F/E problem) and K+ loss * Assess BM (#), F/E balance, check ammonia levels * Know it’s working by improvement of LOC * Alterations in sleep – sleep all the time * Foul breath * Confusion to hepatic coma death * NI: Safe environment and reality orientation * Respiratory acidosis * Deep rapid breathing to get rid of CO2 * Asterixis * Flappy hand tremor which indicates hepatic encephalopathy * No NI that the RN can do about it

Complications of Cirrhosis * Portal hypertension * Ascites * Nursing care: * VS – BP, Resp rate and rhythm, DIB – do they verbalize, * breath sounds – getting better or worse as fluid accumulates * measure abdominal girth and look at trend – after paracentesis and see how long the fluid comes back * check bowel sounds – they will be constipated * daily weight (not the best) * check albumin level and electrolytes * I & O – not the best to do * Lasix * low sodium diet * Administer albumin * Paracentesis – usually done to alleviate respiratory distress * Pre procedure * Requires consent form * Done at bed side or under fluoroscopy – most done at bedside * Catheter into peritoneal and attach to vacuum bottle and withdraw fluid * There is no limit as to amount of fluid doc can withdraw * RN job: monitor blood pressure because the massive fluid withdraw * Empty bladder before * Be in fowlers position * Post procedure * Breath sounds, VS, weight, measure abdominal girth, I & O * Know it worked because the patient is breathing better – pt verbalizes ease in breathing * Fluid will come back until they fix portal hypertension * Assess for hypovolemia

* Esophageal varices- twisted torturous vessels in esophagus * Develop because increase in portal hypertension * Pressure becomes so high they rupture * If varices bleeding are severe – the pt will be in the ICU * Treatment depends upon doctor * Transfusion: what you put in comes right back out- just restoring volume * Pitressin: IV = potent vasoconstrictor = decrease bleeding * Problem: not selective consctrictor * AAt risk for cardiac dys, angina, MI so pt needs to be on cardiac monitor * Stanson Blakemore tube * Double balloon tube – 3 lumens – pic in textbook * NG type tube * 1 lumen: Attach to suction * 2 lumen: Esophageal balloon * 3 lumen: gastric balloon * Once tube is in place – fill esophageal balloon with pressure and will push again varices and stop bleeding * PC * biggest risk = Respiratory distress – esophagus behind trachea – if this happens cut the balloon * Necrosis of tissue in the esophagus – to decrease risk release pressure of EB so many minutes per hour to avoid necrosis * Sclerotherapy * Ligation * Balloon tamponade * Assess for aspiration pneumonia * Place scissors at the bedside * Complications * Erosion of the esophagus * Aspiration of gastric contents * Occlusion of airway

* Hepatic encephalopathy * Assess neurological status * LOC * Sensory and motor functioning * Asteraxis * Big issue – creation of safe environment and reality orientation * Treatment * Check ammonia levels * Laculose * Increase carbs, fluids and proteins * Enemas

* Pancreatitis * Etiology/ Pathophysiology * Inappropriate intrapancreatic activation of proteases * Obstruction- pancreatic enzymes (digest food) don’t go into common bile duct and then back flows which causes * Autodigestion of the pancreas * Risk factors: * Alcohol (majority) * Biliary tract disease- gallstones or stone in biliary tree * Assessment * c/o abdominal pain = LUQ radiating to the back * Nausea and vomiting * Increase temperature * Tender abdomen – only use light palpation * Jaundice/ictorus * Increased WBC – inflammatory process * Decreased BP * Decreased body weight * Cullen’s sign: ecchymosis around umbilicus * Turner’s Sign: Bruising on the left upper aspect of abdomen * Complications * Pulmonary * Pancreas swells increase pressure on diaphragm * Atelectasis * Pneumonia * Pleural effusions * NI: directed towards adequate gas exchange * Cardiovascular * Autodigest blood vessels =decrease BPhemorrhage= shock * Diagnostic Studies * Serum amylase and lipase – enzymes secreted by pancreas * Amylase elevate with pancreatitis quickly then lipase elevates and will stay elevated while the pancreas is inflamed * Urine amylase= elevated * Blood glucose: increased since pancreas secretes insulin * Calcium: decreased – lose calcium = risk for nerve/cardiac/muscle conduction problems * Cat Scan & U/S = best way to diagnose * Endoscopy – goes through stomach into SI and can see the pancrea * Goals of care * Relief of pain * Prevention or alleviation of shock * Reduction of pancreatic enzymes * Control of fluid & electrolyte imbalances * Prevention or treatment of infections * Removal of precipitating cause – etoh, get rid of tumor, identify and get rid of obstruction * Nursing Intervention * Pain control * Analgesic – morphine, dilaudid * Position in fetal position = decrases pressure on abd cavity * NG tube – alleviates distention * PPI – nexium – reduce secretion of HCL * NPO * No ice chips, gum, hard candy – stimulate stomach stimulate pancreas * Give IV fluids – 600 cals/day for D5W to prevent ketoacidosis * Assess electrolytes * Serum amylase and lipase – use to determine that pancreas is resolving = decrease when pt improving * TPN * Solution with high concentration of glucose (20-90% glucose of solution), certain amino acids * Will add electrolytes, vitamins, regular insulin, heparin * Administration through a central line d/t high osmolarity * Never increase or decrease the rate unless doctor orders it * Change IV solution and tubing every 24h * Change dressing every 3 days with sterile technique or every 7 days when at home * Check serum glucose level every 4h atc and insulin coverage based on result * Complications of TPN * Hyperglycemia * Infection – dressing change of 3 days or policy of agency * When resolved: low protein and high carbs, need for fat soluble vitamins (ADEK) and pancreatic enzymes (end in –ase) and give with meals

Cholelithiasis – gallstones or stones in bile duct * S/S * N/V * Belching * Meal with high fat = vomit * Pain occurs with meal high in fat * Increased gas * Pain or biliary colic * Right Upper quadrant radiating to the back and right shoulder blade * Triggered by a high fat or high volume meal * Diagnostic Study * U/S: no prep and at bedside or lab * If they suspect: make NPO, give IV fluids and some docs insert NG * Medications * PPI – reduce HCL * H2 blockers * Morphine * Antiemetics * Nitroglycerin: vasodilates smooth muscle of biliary tree * antacid * Treatment * Avoid fats – low fat diet * Dissolution Therapy – when can’t do surgery – give Urosol (dissolves gallstones) * Surgical Therapy – doctors will determine which one * Laparoscopic cholecystectomy * 4 incisions – scope, carbon dioxide delivery, irrigation, grab gallbladder * Advantages * Smaller scar * Less bleeding, * Shorter hospitalization stay * “Quicker” recovery/return to work * Nursing Care * Handle pain - Morphine * Cough and deep breathe * Ambulate – get rid of the gas (CO2) * Incisional cholecystectomy * Post operative care – RUQ incision * Adequate ventilation * Prevent respiratory complications – atelectasis/pneumonia * Cough and deep breathe * Teach to splint the incision when coughing * Triflow * Ambulate * Maintain bile drainage * Observe T-tube functioning/drainage

* T Tube * Placed in common bile duct and other end brought out of adomen * Maintains patency of common bile duct * Nursing care: * Assess the amount, color,consistency of drainage * 50-100ml/shift drainage * As swelling decreases around the common bile duct the amount of drainage decreases * Inspect skin surrounding the T tube- bile has salts in it and is irritating to skin * Keep dressing clean and dry * Keep drainage system below the level of the incision (drains on principle of gravity) * Observe color of stools * If bile is not going into GI tract = clay color * Adequate bile in GI tract = brown color * Client teaching – Pt is d/c with t tube in place * Signs/symptoms of infection (happens 3-5 days post op) * Wound care * Wash area with soap and water and pat dry * Knowledge of medications * Activity and diet restrictions * Low fat diet, eat what you tolerate – keep things with smaller portions