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MED SURG II EXAM 2
Cirrhosis, Hepatitis, Pancreatitis, & Renal Failure Review
| Question | Answer |
|---|---|
| Most common hepatitis symptoms | Some are asymptomatic. GI symptoms include nausea, vomiting, stomach pain, loss of appetitie, fever, very tired, arthralgia, dark colored urine, clay colored stool |
| Hepatitis | Is the inflammation of the liver. Can be viral, causes by one or several viruses. it is the most common, such as hepatitis, A, B, C, D, E. Alcoholic which is caused by heavy alcohol use. Toxic which is caused by certain poisons, chemicals, medicines, or supplements, and autoimmune which is a chronic type in which your body's immune system attacks your liver. The cause is unknown and can be from genetics and the environment. |
| Preicteric | Body symptoms such as joint pain, fatigue, nausea, vomiting, abdominal pain, change in taste, liver enzymes and bilirubin |
| Icteric | Decrease in body in body symptoms but will have jaundice, dark urine, clay-colored stool, enlarged liver, and pain in this area |
| Posticteric | Convalescent stage. Jaundice and dark colored urine start to subside, stool returns to normal brown color. Liver enzymes and bilirubin decrease to normal |
| Hepatitis A and E | are transmitted the fecal oral route. There is no treatment, typically resolves with support treatment and bedrest. |
| Hepatitis B and C | transmitted through blood and body fluids. Treated with antiviral meds |
| Hepatitis D | Only occurs with a coinfection with hepatitis B. Treated with antivirals |
| Vaccines are available for | Hepatitis A and B |
| Nursing Care for Hepatitis | Small frequent meals, prevents nausea. Low protein, and low fat diet. Frequent rest periods, do not share razors or toothbrushes. Protected sex, avoid alcohol, acetaminophen. |
| Liver Enzymes | ALT normal level is 7-56, and will be elevated. AST normal level is 10-40, and will be elevated. Bilirubin normal level is less than 1, will be elevated. Ammonia level normal level is 15-45 and will be elevated. |
| Peginterferon Alfa | Can be given once per week and keeps blood levels constant. Has largely replaced other interferons for combination therapy with ribavirin |
| Aldesleukin | Black box warning of not to give with those that have cardiac and pulmonary dysfunction. Administration should be done in a hospital setting with critical care expertise and under the supervision of an oncologist |
| Oprelvekin | Black box warning for the risk of allergery or hypersentitivity reactions, including anaphylaxis |
| Nucleoside Analogs such as lamivudine | Black box warning reporting lactic acidosis and severe hepatomegaly with steatosis |
| Nonviral Hepatitis | Can be caused by chemicals such as carbon tetrachloride and phosphorus. Medications such as isoniazid, halothane, acetaminophen, methyldopa, and certain antibiotics, antimetabolites, anesthetics, antidepressants, psychotropic, anticonvulsants, and corticosteroids. Symptoms are usually more severe. |
| Causes of Pancreatitis | Post abdominal surgery, trauma, mumps, hiv, ulcers, cystic fibrosis, drugs, and thyroid or renal issues |
| Chronic Pancreatitis | Occurs around 30 to 40 years. Can be caused by alcohol ingestion, cystic fibrosis, high levels of calcium or fats in the blood and autoimmune conditions. Symptoms include extreme pain, often radiating to the back and sometimes is disabling. Malabsorption of food, leading to weight loss, or diarrhea and oily stools. Diabetes, nausea, vomiting, fever, and increased HR are also common |
| Acute Pancreatitis | Usually occurs suddenly and goes away in a few days without treatment. Often caused by gallstones. Symptoms typically include severe upper abdomen pain, nausea, and vomiting. |
| Pancreatitis Treatment | Goal is to improve nutritional and metabolic problems. Will be NPO initially to reduce pancreatic secretion. Typically given pancreatic enzymes and insulin to supplement what is not being secreted. In severe cases surgical drainage is needed of the pancreatic duct. Adjunct meds include antioxidants, antidepressants, and quitting smoking and alcohol. Can also include hospitalization, IV fluids, nutrtional support. |
| Pancreatitis Medications | H2RAs such as cimetidine, famotidine, nizatidine, and ranitidine. They inhibit the secretion of gastric acid. PPIs such as omeprazole, esomeprazole, lansoprazole, pantoprazole, rabeprazole, they bind irreversibly to the gastric proton pump to prevent the releaase of gastric acid from the parietal cells into the stomach lumen |
| Pancreatic Symptoms | Severe abdominal pain, board-like abdomen which may result in peritonitis, ecchymosis or bruising around flank or umbilicus which may indicate severe pancreatitis. Nausea and vomiting with emesis usually gastric in origin but may be bile stained. Hypotension which usually reflects hypovolemia. |
| Interstitial Pancreatitis | Causes inflammation and edema |
| Necrotizing Pancreatitis | A severe form of pancreatitisthat causes necrosis of the pancreas. Results from microcirculatory stasis within the gland and leads to infarction. Tissues surrounding the pancreas may also develop necrotic changes. It is the major cause of mortality in patients with pancreatitis as it results in hemorrhage, septic shock, and multiple organ failure |
| Cirrhosis | Is the scarring of normal healthy tissue. Stage one is the fatty liver, enlargement of the liver, which is reversible. Second stage includes hepatitis which is the irreversible fibrous scar tissue. The end stage includes fibrotic tissue replacing the normal tissue, resulting in little function of liver. |
| Cirrhosis Considerations | The blood cannot clot fast enough in liver disease, putting them at a high risk of bleeding. After a liver biopsy place the patient on their right side to prevent post op bleeding. Diet includes low protein to lower the ammonia in the blood, low sodium and low fluids to prevent ascites. No alcohol |
| Early Symptoms of Cirrhosis | Mild fever, epistaxis, hypotension, jaundice, weight loss, bruising, and weakness |
| Late Symptoms of Cirrhosis | Early Bleeding or Bruising, Jaundice, itchy skin, edema, ascites, brownish or orange urine, light colored stools, confusion, memory loss, personality changes, redness on the palms of the hands, spiderlike vessels on the skin. Men lose sex drive, develop gynecomastia and testicular atrophy. Women often have absent or loss of periods, not related to menopause. |
| Jaundice | Yellowing of the skin and eyes due to the build up of bilirubin |
| Portal Hypertension | High pressure in portal vein since the liver is hard as a rock |
| Ascites | The fluid fills up the abdomen due to the back flow of fluid from the hard liver, which spills into the third space. We perform a paracentesis to remove this fluid and monitor vital signs, measure abdomen circumference, and monitor weight. Keeping the HOB in HIGH-fowler's |
| Esophageal Varices | Enlargement of the veins in the esophagus as the backed up blood from the liver forces major pressure. The vessels bulge and can explode and block the airway. WE DO NOT WANT TO USE A NG TUBE, WE DO NOT WANT PATIENTS STRAINING WITH BOWEL MOVEMENTS |
| Hepatic Encephalopathy | A cloudy brain from ammonia, the liver cannot detox out of the blood. Symptoms include twitching of extremities arms flapping back and forth (Asterixis) and mental status changes. Key assessments are hand ovements with extended arms and mental status assessments, monitoring ammonia levels |
| Cirrhosis Management | There is no cure. We alleviate symptoms. Spironolactone to reduce retention of salt and water. Give with food, max effects take up to 6 weeks. Take at the same time every morning. Rosiglitazone restores the effectiveness of circulating insulin. Monitor liver enzymes every 2 months for a year, take with meals, monitor blood glucose, and assess cardiac and lung sounds. |
| Cirrhosis Nutrition | Unable to digest, ingest, or absorp nutrients. Give fat soluble vitamins A, D, E, K and absorption requires bile salts and pancreatic lipase. |
| Prerenal in Renal Failure | Hypoperfusion of the kidney. Sudden and severe drop in BP or interruption of blood flow to the kidneys. Often caused by volume depletion in burns, hemorrhage, GI losses. Sepsis, shock. |
| Intrarenal in Renal Failure | Damage to the kidney and nephrons. Direct damage is caused by inflammtion, infection, toxins, drugs, reduced blood supply |
| Postrenal in Renal Failure | Obstruction of urine flow. Preventing urine from draining. Pressure rises in the kidney tubules and GFR decreases. Obstruction is often from enlarged prostate, stones, clots, strictures, tumors, pregnancy |
| Acute Tubular Necrosis (ATN) | Damage to kidney tubules (most common). Includes intratubular obstruction, tubular back lead (abnormal reabsorption of filtrate and decreased urine flow through the tubule), vasoconstriction, and a change in the glomeruli permeability. All leads to a decrease in GFR, progressive azotemia, and fluid & electrolyte imbalances. Causes can be from CKD, diabetes, HF, hypertension, and cirrhosis |
| Radiocontrast-Induced Nephropathy (CIN) | Major cause of hospital acquired AKI. It is preventable. ASSESS baseline levels of creatinine greater than 2 mg/dL (indicates high risk patient). PREVENTION: Limit exposure, Monitor medications (nephrotoxic), Pre-hydrate before procedure with NS, Administer Bicarb before procedure |
| Initiation in Renal Failure | First initial insult. Few to no symptoms. |
| Oliguria in Renal Failure | Increase in serum concentration of substances usually excreted by the kidneys (urea, creatinine, uric acid, organic acids, phosphorus, and potassium & magnesium). The minimum amount of urine needed to rid the normal body of waste products is approximately 400 mL in 24 hours. HOWEVER in this phase, uremic symptoms first appear and life-threatening conditions such as hyperkalemia develop |
| Diuresis in Renal Failure | Marked by a gradual increase in urine output, which signals that the glomerular filtration has started to recover. Lab vales stabilize, eventually decreasing. Even though urinary output has reached normal, renal function may still be markedly abnormal, since filtration of urine creatinine has not yet commenced. Uremic symptoms may still be present, clinical management is needed. Observe closely for dehydration |
| Recovery in Renal Failure | Signals the improvement of renal function and may take 3-12 months. Lab values return to baseline. – BUT a permanent 1-3% reduction in GFR may occur. – not clinically significant. However, in patients with preexisting chronic kidney disease, these acute episodes may necessitate beginning of chronic renal failure. |
| Non-Oliguric Kidney Injuries | Some patients have decreased renal function with increasing nitrogen retention but actually excrete normal amounts of urine (1 to 2 L/day). Occurs predominantly after exposure of the patient to nephrotoxic agents (any substance or medication that damages kidney tissue), burns and traumatic injury. |
| Acute Renal Failure Symptoms | Not enough urine (oliguric). Swelling in legs, ankles, feet (retention), JVD. Feeling tired, or drowsy, lethargic. Trouble catching your breath. Feeling confused, twitching. Nausea. Pain or pressure in chest. Dry mucous membranes. SEVERE AKI = SEIZURES OR COMA |
| Acute Renal Failure Labs | Ultrasound, CT, MRI. Urinalysis. Renal Scan (how the kidneys are functioning). Biopsy. LOW specific gravity. Hematuria. PRERENAL AZOTEMIA – DECREASED SODIUM. INTRARENAL AZOTEMIA – INCREASED SODIUM. BUN LEVEL – INCREASES STEADILY. DECREASED GFR, oliguria, and anuria, HIGH RISK FOR HYPERKALEMIA. Phosphates INCREASED. Calcium DECREASED. LOW HEMOGLOBIN |
| Nursing Care in Renal Failure | DAILY WEIGHTS, I&O, HEART & LUNG SOUNDS, FLUID & ELECTROLYTES (HYPERKALEMIA). Most likely maintain bedrest, with foley care. Initially, HIGH-CALORIE, LOW-PROTEIN, LOW-POTASSIUM, LOW-SODIUM DIET . After Diuretic Phase – HIGH-PROTEIN & HIGH-CALORIE DIET. |
| Chronic Renal Failure | Begins with a slow decline in renal function. May be no signs & symptoms. early stages serum creatinine may be normal but kidneys begin leaking protein or RBC into the urine . By the time it is detected, GFR can be substantially reduced. ONCE YOU REACH END STAGE RENAL DISEASE you need a kidney transplant or dialysis to live. PREVENTABLE FACTORS include diabetes, hypertension, heart disease. NONPREVENTABLE FACTORS include family history, African American, Native American, Hispanic, and Asians |
| Medical Management in Renal Failure | Eliminating the underlying cause. Maintaining Fluid Balance. Avoiding fluid excess. Pharmacological include Calcium phosphorus, Antihypertensives, Anticonvulsants, Erythropoietin. Diet includes regulating protein intake, sodium, and potassium intake. No alcohol. Dialysis |
| Dialysis | Prevents hyperkalemia, metabolic acidosis, pulmonary edema. Corrects abnormalities such as liberalization of fluid, protein, and sodium intake. Diminishes bleeding tendencies, promotes wound healing, and does the work the kidneys no longer can. |
| Peritoneal Dialysis | Blood passes through the blood vessel lining, and waste products and excess fluid are drawn out of the blood into the dialysis fluid. BENEFITS it Uses the peritoneum as the filter, rather than a machine. Making it more natural. Gives patients control of their treatment, more flexible schedule, preservation of remaining kidney function, and leads to enhanced clinical outcomes, and better transplant outcomes. RISKS include the possibility of developing peritonitis |
| Hemodialysis | Most common type. Circulates the patient's blood through an artificial kidney (dialyzer) to remove products and excess fluid. Used in a facility (or at home with a smaller machine). Uses an external filter to clean toxins from your body. Can cause itchy skin, muscle cramps. |
| Nursing Care During Dialysis | LONGTERM DIALYSIS. Patients may begin to reevaluate their status, treatment modality. Their satisfaction with life, the impact of these factors on their families. PROVIDE opportunities for these patients to express their feelings and reactions, and to explore options. It is not uncommon for patients to consider discontinuing their treatment, these feelings should be taken seriously. Encourage the use of a psychologist, psychiatrist, psychiatric nurse, trusted friend, or spiritual advisor |
| Symptoms of Chronic Renal Failure | Nausea, Vomiting, Anorexia. Fatigue, Weakness. Changes in Urination. Chest pain (fluid building up around the lining of the heart). SOB (if fluid builds up in the lungs). Swelling in feet & ankles, Persistent itching. Hypertension that is difficult to control. Difficulty Sleeping, Headaches. Decreased Mental Sharpness. Metallic Taste in the Mouth. Asterixis (twitching) |
| Automatic Peritoneal Dialysis | Accomplished while they sleep. Machine cycles 4 or more exchanges per night, with 1-2 hours per exchange |
| Continuous Automatic Peritoneal Dialysis | Manual. 1.5-3 L of peritoneal dialysate. At least 4 times per day, with dwell times averaging 4 hours |
| Gortex Graft | Specialized vascular tube placed between an artery and vein in the arm or leg, creating an indirect connection |
| Cimino Fistual | Direct connection between an artery and vein in the arm. |
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