Nursing Care of Patients with Hepatitis, Cirrhosis…. – Exam 3 – Flashcards
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A 28-year-old client is admitted with Crohn's disease. Which therapies should the nurse expect to be part of the care plan. Select all that apply: a. Prednisone b. Lactulose c. High-fiber diet d Milkshakes e. Mesalamine
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a, e - check this Lactulose is used to bind to ammonia and pulls the ammonia out of the body via stool so it is used in cirrhosis of the liver Patients with Crohn's are supposed to avoid dairy because it destroys the digestive tract/the mucosal lining so you can not break down the sugar in the dairy products Mesalamine decreases inflammation when it comes in contact with the GI tract
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The nurse is caring for a patient with an ileostomy. Which of the following should be included in the patient teaching? a. Additional fluid intake may be necessary b. Encourage the patient to eat raw vegetables c. The opening in the bag should be cut 1/2 inch bigger than the stoma d. The ostomy bag must be changed daily
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a
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What is hepatitis?
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Destruction of liver tissue This is an autoimmune disease (the immune system is attacking the liver)
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What is unique about the liver?
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It can rejuvenate itself With proper rest and relaxation it can heal itself It need protein to do this
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What are the causes of hepatitis?
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Viral hepatitis (most common) --Hepatitis A, B, C, D, & E Chemicals & drugs Autoimmune hepatitis, nonalcoholic steatohepatitis (NASH)
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What chemicals and drugs can cause hepatitis?
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Alcohol Acetaminophen (Tylenol) overdose, isoniazid (INH), statins, methotrexate Tylenol is one of the most common drugs that causes hepatitis A These all cause liver toxicity
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What has to happen in order for a patient to get hepatitis D?
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They must have already had hepatitis B
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Where is hepatitis E more common?
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Foreign countries
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How is hepatitis A transmitted?
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Fecal oral route Small outbreaks Fecal contamination of food &/or water Overcrowding, poor hygiene, improper handling of food
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When is a person with hepatitis A infectious?
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Infectious 2 weeks before symptoms & until 1 week after symptoms (virus in feces during this time frame)
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Who is usually symptomatic with hepatitis A?
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Most adults and older children have symptoms Symptoms can last 2-6 months Almost all cases resolve
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Who gets hepatitis A vaccinations?
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Can get a vaccination if you are traveling abroad to somewhere where it is more prominent or doesn't have clean water - 3rd word countries Food workers need the vaccine too
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Who is usually asymptomatic with hepatitis A?
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Patients less than 6 years old
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What is the incubation period with hepatitis A?
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The time it is in your body without symptoms (before you become symptomatic) 15-50 days
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How is hepatitis B transmitted?
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Perinatally Parenteral/Mucosal exposure Sexually transmitted --Especially with men who have sex with men or anal sex, in general because of the fecal route. It is also vascular so there is a higher chance of bleeding Kissing/sharing food items (saliva)
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How does the parenteral/mucosal exposure work with transmitting hepatitis B?
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Blood, blood products, organ transplant IV drug use, needlesticks, tattoo/body piercing Other body fluids (semen, vaginal secretions, saliva, gastric secretions
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What kind of virus is hepatitis B?
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DNA virus FIGURE out what this means
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How long can hepatitis B live on a surface and be transmitted?
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7 days - it is more infectious than HIV !!
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When is hepatitis B infectious?
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Before & after symptoms Patient is infectious before symptoms appear For 4-6 months (acute infection) --The antigen will leave the body For life, for chronic carriers --It will continuously damage the liver
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What is true about those infected with HBV?
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Only about 5% of adults become chronically infected 90% of infants and 25-50% of children 1 to 5 years of age become chronically infected 15% to 25% of chronically infected persons die from liver disease
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How long is the incubation period with hepatitis B?
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14-180 days
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How is hepatitis C transmitted?
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IV drug use (most common in US) Needlesticks Perinatally Sexually transmitted Sharing razors and toothbrushes (blood) Parenteral/Mucosal exposure --Blood, blood products, organ transplant
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What is the most common route of transmission with hepatitis C?
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IV drug use
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What kind of virus is hepatitis C?
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RNA virus
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What is unique about hepatitis C?
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There is no vaccine and immunity You can be reinfected with different strands of C - with A and B, if you get it you cant be reinfected (you are immune) You will not become immune to hepatitis C if you get it once
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What happens with those infected with HCV?
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Most have chronic lifelong infection (75-85%) 60-70% of those with chronic infection develop chronic liver disease and 5-20% develop cirrhosis
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What are the symptoms of hepatitis C?
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Most are asymptomatic or have mild symptoms
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What are the CDC screening recommendations for hepatitis C?
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Individuals born between 1945-1965 --During this period of time, blood products were not tested for hepatitis C so those with blood transfusions may be susceptible Anyone who has ever done IV drug use Blood transfusion, organ transplant, or clotting factor recipient before 1992 Ever on long-term hemodialysis Individuals with HIV Signs & symptoms of liver disease Known exposures: --Needlesticks, sharps, mucosal exposure --Children born to mothers with HCV
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When should an infant born to a mother with hepatitis C get screening?
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At least 18 months after they are born It takes at least 18 months for the mother's antibodies to leave the body - after 18 months, there will only be the baby's antibodies that will be detected
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What are the clinical manifestations of the acute phase of hepatitis, in general?
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Jaundice!!! Pruritis Dark urine!!! RUQ discomfort!!! Low-grade fever Arthralgias Hepatomegaly, splenomegaly Anorexia, n/v Light colored stools Fatigue
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How long can the acute phase last?
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1-4 months Can transmit the virus more frequently - they are the most infective
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Why is pruritus present with acute hepatitis?
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Itching caused by the buildup of toxins
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Why is dark urine present with acute hepatitis?
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Excessive bilirubin being excreted
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Why are patients anorexic with acute hepatitis?
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The smell of food makes them nauseous
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Why are light stools present with acute hepatitis?
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The conjugated bilirubin cannot flow of the liver
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What are the clinical manifestations of chronic hepatitis?
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Malaise Fatigues easily Hepatomegaly Arthralgias
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How long does the chronic phase of hepatitis last?
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2-4 months Jaundice is gone in this phase
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What are the complications associated with hepatitis?
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Fulminant hepatic failure - this is the main complications and is more common with hep B but can happen with all --Severe liver cell impairment or necrosis Chronic hepatitis (Hep B & C) Cirrhosis (Hep B & C) Hepatocellular carcinoma (Hep B & C) --80% of all primary liver cancer is from chronic HBV and/or HCV
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Which hepatitis viruses are chronic hepatitis?
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Hep B and C
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Which hepatitis viruses does cirrhosis occur with?
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Hep B and C
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Which hepatitis viruses does hepatocellular carcinoma occur with?
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Hep B and C 80% of all primary liver cancer is from chronic HBV and/or HCV
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What are the diagnostic tests for hepatitis A?
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Antibodies (anti HAV IgM, IgG)
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What do antibodies (Anti HAV IgG, IgG) show with hepatitis A?
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This means that they have had previous infection or immunity to it Don't check for antigens because they will be gone - they are only present very briefly
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What are the diagnostic tests for hepatitis B?
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Antigen (HBsAg) Antibodies (Anti-HBs, Anti-HBc (core)) HBV genotype
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What do the antibodies (Anti-HBs, Anti-HBc) indicate?
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Immunity to hep B
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How long is the surface antigen (HBsAg) present in the blood?
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6 months after they have been exposed CHECK
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What does HBsAG show with hepatitis B?
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This is the hepatitis B surface antigen Tells you that they either have immunity or they have come in contact with it
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Why do you need a HBV genotype?
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Will tell you the response to therapy
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If a person has chronic HBV, will they have antigens and antibodies?
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No, you will only have antigens and no antibodies (antibodies should that you are immune and you are not immune to it with chronic) Antigens are present, antibodies are not
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What are the diagnostic tests for hepatitis C?
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Antibody (acute or chronic infection) HCV RNA (active/acute infection, viral load) HCV genotype (for treatment options)
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When will you not have immunity with hepatitis?
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Hepatitis C and chronic hepatitis B
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What are the diagnostic tests for hepatitis?
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Labs Liver US Liver biopsy
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What labs are done to diagnose hepatitis?
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Liver function tests: ↑ AST, ALT, GGT, alkaline phosphatase (alk phos) ↓ albumin ↑ Serum & urine bilirubin ↑ PT, PTT
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Why is albumin decreased in hepatitis?
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Decreases due to liver cell damage
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What does alk phos measure?
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Will show impairment in the excretory factor of the liver
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What kind of virus is hep B?
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DNA virus
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What will an increase in PT and PTT indicate with hepatitis?
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They will need bleeding precautions
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What is the collaborative care for hepatitis?
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No specific treatment for acute hepatitis - just rest Most can be managed at home Adequate rest & nutrition Antiemetics for nausea Regular f/u for at least 1 year Avoid alcohol!!! Chronic hepatitis B & C --Interferon- subcutaneous injection --Antivirals- oral Avoid liver toxic meds like Tylenol
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What are the chronic hepatitis B and C medications?
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Interferon - SC Antivirals - PO
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What are hepatitis medications used for?
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To decrease the viral load This means that there is less traceable viral load in the body - not present in his bodily fluids Can still be transmitted though - especially to someone with a weak immune system These are maintenance drugs
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The nurse is caring for a woman recently diagnosed with viral hepatitis A. Which individual should the nurse refer for immunoglobulin (IG) treatment? a. A caregiver who lives in the same household with the patient b. A friend who delivers meals to the patient and family each week c. A relative with a history of hepatitis A who visits the patient daily d. A child living in the home who received hepatitis A vaccine 3 months ago
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a
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What is the collaborative care in terms of prevention of hepatitis A?
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Initial vaccine & booster 6-12 mos later --Pre-exposure prophylaxis - helps treat the exposure of the virus once you come in contact (within 1-2 weeks) Immune globulin (IG) --Post-exposure (within 1-2 weeks) --Pre-exposure Twinrix (Hep A & B vaccine) 0, 1, 6 mos
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What is the collaborative care in terms of prevention with hepatitis B?
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Routine vaccination (0, 1, 6 mos) - preexposure Hepatitis B immune globulin (HBIG) --Post exposure prophylaxis --Given with vaccine if they didnt already have it - CHECK --Within 24 hours of exposure!!
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What is the collaborative care in terms of prevention of hepatitis C?
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No vaccine or IG
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What is the collaborative care in terms of prevention of hepatitis, in general?
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Good personal hygiene Wearing gloves (health care, food, & day care) Universal precations!! Needleless sytem (health care) Immunization (Hepatitis A & B) Avoid sharing personal items Modifying high risk behaviors Patient teaching!!
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What are the modifiable high risk factors for getting hepatitis?
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Multiple sex partners Sharing needles --The start of clean needle programs in cities decreases the presence of hep B and C --They can exchange dirty needles for clean needles
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What patient teaching should be done with hepatitis?
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How it is transmitted How important vaccinations are - especially with high risk behaviors
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What is cirrhosis?
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Chronic progressive liver disease Insidious onset Fibrosis, scar tissue, abnormal portal circulation and bile ducts impaired liver function Continuously trying to rebuild itself with scar tissue - it forms abnormal structure and overgrowth of tissue Higher incidence in men There is poor SOMETHING nutrition, hypoxia because of the decrease of blood flow to the area - all contributes to the decrease in liver function
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What are the causes of cirrhosis?
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Anything that causes chronic liver disease (i.e.: NAFLD, excessive alcohol, chronic hepatitis B or C) The most common cause is alcohol abuse
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What are the clinical manifestations of cirrhosis?
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Early- asymptomatic or fatigue Jaundice Ascites, peripheral edema - causes HTN Spider angiomas (telangiectasia) Spleenomegaly → Thrombocytopenia, anemia, leukopenia ↑PT, PTT, petechiae, ecchymosis Males: gynecomastia, impotence Females: amenorrhea Peripheral neuropathy Dark amber or brown urine Tan or gray colored stools Portal HTN Esophageal varices Risk for spontaneous bacterial peritonitis (SBP) due to ascites Hepatic encephalopathy- lethargy, asterixis, confusion, coma Hepatorenal syndrome
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Why does ascites occur with cirrhosis?
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Accumulation of protein out of the cells into lymph spaces
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Why does splenomegaly happen with cirrhosis?
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There is a backup of blood to the spleen causing enlargement, thrombocytopenia, anemia, leukopenia
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Since there is an increase PT and PTT, what bleeding precautions should be put into place with cirrhosis?
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Electric razor, everything needs to be within reach, soft bristled tooth brush, check urine and feces for blood, avoid IM injections, nonskid socks (fall precautions) If IV and they're going home, hold the IV for 5 minutes when taking it out
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Why do males experience gynecomastia and impotence with cirrhosis?
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Liver metabolizes those hormones and if the liver isn't working correctly they cannot be excreted easily
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Other than the skin and sclera, where else can you assess for jaundice?
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Palms of hands
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What causes the bleeding of esophageal varices?
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The backup of blood and increase of pressure
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How does lactulose treat hepatic encephalopathy?
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It removes the ammonia from the body Confusion is one of the main symptoms of hepatic encephalopathy SE of lactulose is diarrhea - electrolyte imbalance, dehydration, impaired skin integrity, and incontinence can occur from this
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What is hepatorenal syndrome?
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Portal HTN leads to renal vasoconstriction → renal failure
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What are the diagnostic tests for cirrhosis?
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Liver function tests: ↑ AST, ALT, GGT, alkaline phosphatase (alk phos) ↓ albumin (normal: 3.5-5) ↑ Serum & urine bilirubin ↑ PT, PTT, ↓platelets ↓Hgb, Hct, WBC Liver ultrasound - visualize the liver Liver biopsy - will show if it is cancerous
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What is the collaborative care for cirrhosis?
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Low sodium, low protein diet Low sodium because sodium attracts water and they will already have fluid overload Low protein because the liver plays a significant role in the metabolism of protein I & O, daily weights, monitor electrolytes You should anticipate weight gain because of the edema Albumin infusion because it will be low Paracentesis --Monitor BP after to make sure they do not become hypotensive Avoid alcohol, aspirin, acetaminophen, and NSAIDs because these are all hard on the liver Lactulose because it will remove the accumulation of ammonia from the body, which is the cause of hepatic encephalopathy
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Why will a patient need a paracentesis with cirrhosis?
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To remove fluid from abdomen (ascites) This can cause hypotension, though if you take off too much fluid
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What other collaborative care should be done with cirrhosis?
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Bleeding precautions Fall precautions Monitor level of consciousness Monitor ammonia levels (hepatic encephalopathy) and other labs EGD (upper endoscopy)- diagnose & treat varices FFP, Vitamin K, PRBCs if needed
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What drug therapy is used for cirrhosis?
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These are to manage symptoms Potassium sparing diuretics- spironolactone (Aldactone) Nonselective β-blocker- propranolol (Inderal) lactulose (Cephulac) and rifaximin (Xifaxan) Rifaximin treats hepatic encephalopathy by stopping the growth of bacteria that produce toxins and that may worsen liver disease
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Why are potassium sparing diuretics used with cirrhosis?
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The patient will have diarrhea due to the lactulose and you don't want to get off too much K with that because it can cause dysrhythmias
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Why is propranolol used with cirrhosis?
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Reduces portal vein pressure
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What is a transjugular intrahepatic portosystemic shunt (TIPS)?
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Improves varices and ascites, but higher risk of hepatic encephalopathy https://www.youtube.com/watch?v=O2u4_hF3234 Contraindicated with thrombosis or when the cancer is present
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The nurse is providing discharge instructions for a 64-year-old woman with ascites and peripheral edema related to cirrhosis. Which statement, if made by the patient, indicates teaching was effective? a. "It is safe to take acetaminophen four to five times a day for pain" b. "Lactulose should be taken every day to prevent constipation" c. "I will need to watch the amount of salt in the foods that I eat" d. "I will eat foods high in potassium while take spironolactone"
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c acetaminophen will cause more problems Lactulose is not given every day and it doesn't prevent constipation Don't want to eat more foods high in potassium because you are already saving potassium and don't want to get it too high
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What are the most common causes of pancreatitis?
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Gallbladder disease Chronic alcohol intake
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What are the other causes of pancreatitis?
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Smoking, trauma, post ERCP ERCP is a therapy used in gallbladder disease and for diagnosing pancreatitis Viral infections Corticosteroids, other medications
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What is pancreatitis?
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Autodigestion of pancreas (it attacks itself) The enzymes that the pancreas usually secretes to break down and digest food is now not being excreted. It is now excreted within the pancreas causing its own digestion Mild- edematous pancreatitis Causes cellular death Severe- necrotizing pancreatitis --Life-threatening (25% mortality)
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What are the clinical manifestations of pancreatitis?
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LUQ or midepigastric abdominal pain!!! --Sudden onset, radiates to back --Aggravated by eating --Unrelieved by vomiting Nausea/vomiting ↓ or absent bowel sounds Low-grade fever, ↑ WBC Jaundice
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What helps to relieve the pain with pancreatitis?
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Sitting up or leaning forward
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Why is pancreatitis aggravated by eating?
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That is when the digestive enzymes are released
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With pancreatitis, the patient may have a nonfunctional GI tract so what will they need?
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Feed through TPN or PPN They will need complete rest with chronic pancreatitis
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What are gray turner spots with pancreatitis?
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These are gray spots on the flank of their abdomen
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How does pancreatitis affect the respiratory system?
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Wheezing and crackles because the exudate from the pancreas flows through the lymph system to the respiratory system
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What are the complications of pancreatitis?
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Pseudocyst Abscess Systemic complications Chronic pancreatitis --Patients are at higher risk for diabetes
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What is a pseudocyst with pancreatitis?
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Cyst outside of the pancreas filled with necrotic products and secretions If not resolved, it can burst and cause peritonitis Cyst may need to be surgically removed or drained
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What are the systemic complications associated with pancreatitis?
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Pleural effusion, pneumonia (crackles, dyspnea, respiratory distress) Hypocalcemia → tetany --Digestive enzymes are not present so calcium is not able to be broken down and absorbed Severe tetany can cause respiratory complications Hypotension → shock --Cold and clammy skin, rapid pulse, low BP
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What labs are done to diagnose pancreatitis?
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↑ amylase and lipase --Amylase will be elevated the 1st 24-72 hours and will prob decrease before lipase ↓ calcium, ↑ glucose
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What diagnostic tests are done with pancreatitis?
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Abdominal CT ERCP --endoscopic retrograde cholangiopancreatography --This is a diagnostic test for pancreatitis BUT can also cause it --You can also get a tissue biopsy with ERCP MRCP --magnetic resonance cholangiopancreatography
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What collaborative care is used for pancreatitis?
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Pain control (hydromorphone IV [Dilaudid]) Suppress pancreatic secretions- NPO Fluid/electrolyte balance- IV fluids Antibiotics if pseudocyst or abscess present Prevent or alleviate shock Removal of the precipitating cause --May remove gallbladder and stop alcohol consumption Surgery Avoid caffeine, smoking, or alcohol Low-fat diet --Less stimulating for the pancreas and it takes a long time to break down fat
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What is true of chronic pancreatitis?
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May lead to DM May experience steatorrhea --Pancreatic enzymes w/food ------pancrealipase (Pancrease)
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What is steatorrhea with chronic pancreatitis
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Fatty, frothy, fowl smelling stools
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Who is there a higher incidence of gallbladder disease in?
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Women Higher incidence in women with multiple children, multiple pregnancies Over 40 years of age
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What are other risk factors for gallbladder disease?
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Obesity --Increase secretion of cholesterol in the bowel Sedentary lifestyle Family history Pregnancy
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What is cholelithiasis with gallbladder disease?
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With stones, bile stasis Alteration in balance that keeps cholesterol, bile salts, & calcium in solution Predominantly cholesterol stones most common!!! With this you have a delay in gallbladder emptying and decline in gallbladder flow In GB or move to cystic or CB duct
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What are the causes of cholelithiasis with gallbladder disease?
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Infection, immobility, pregnancy, obstructive lesions in biliary system
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How can cholelithiasis with gallbladder cause pancreatitis?
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The stones can move from the gallbladder to the hepatic duct and down to the ampulla of Vater causing pancreatitis
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What is the most common cause of cholecystitis?
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Most common cause is gallstones
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What are the other causes/risk factors of cholecystitis with gallbladder disease?
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Older adults Trauma, extensive burns, or recent surgery Bacteria Prolonged immunity --There is bile stasis Fasting Long-term TPN --This is because you are not utilizing the gallbladder
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What are the clinical manifestations of cholelithiasis with gallbladder disease?
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Severe or "silent" Severe pain (RUQ, shoulder, scapula) Tachycardia, diaphoresis Attacks 3-6 hrs after high-fat meal or after lying ↓
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What are the symptoms of obstructed bile flow with cholelithiasis in gallbladder disease?
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Jaundice Dark amber urine Clay-colored stools Steatorrhea
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What are the clinical manifestations of acute cholecystitis with gallbladder disease?
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Indigestion Moderate to severe pain (RUQ, shoulder, scapula) Fever, ↑ WBC Nausea, vomiting, diaphoresis Jaundice
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What are the clinical manifestations of chronic cholecystitis with gallbladder disease?
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Fat intolerance Dyspepsia Heartburn flatulence
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What are the diagnostic studies done with gallbladder disease?
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Ultrasound ERCP --Scope is placed in the gallbladder and stones are crushed and are passed on their own --Can cause pancreatitis ↑ WBC Common bile duct obstruction --Liver function tests (↑AST, ALT, alk phos, bilirubin) Obstruction near ampulla of Vater --↑ amylase, lipase
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What collaborative care is done for acute cholecystitis with gallbladder disease?
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Pain control Antibiotics If patient has an acute infection - must treat the infection before you take them to the surgery Fluid & electrolyte balance
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What drug therapy is done for gallbladder disease?
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Analgesics --hydromorphone (Dilaudid) --NSAIDs Anticholinergics, antispasmodics Anticholinergics like atropine are used to relax the smooth muscles Fat-soluble vitamins (A, D, E, K)
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What should the nutrition be like of someone with gallbladder disease?
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Low fat diet This is to decrease the stimulation of the gallbladder
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What surgical therapy and postop care is done with gallbladder disease?
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Laparoscopic cholecystectomy!! --90% of patients --Outpatient surgery Open cholecystectomy --T-tube sometimes inserted into CB duct --T-tube allows for the bile to drain Laparoscopically is preferred over open because there is less chance for infection and it is done in an outpatient setting After surgery, the patient should avoid heavy lifting for 4-6 weeks afterward Low fat diet should be implemented for both surgeries
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Placement of T-tube with open cholecystectomy:
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Used to drain bile Placed in the common bile duct
