Nur 302 Unit I

    Jaundice Hemolytic jaundice Hepatocellular Jaundice Obstructive jaundice

      Inflammation of the liver.
Types: A,B,C,D,E,G Epstein-Barr, herpes, cytomegalovirus, coxsackievirus, rubella Presence of antigens & antibodies Outbreaks of hepatitis – type A, 50% type B, 20% type C, 30% type A

    Fecal-oral route, outbreaks caused by fecal contaminated food or drinking water.
Crowded conditions, poor sanitation & hygiene, undeveloped countries, shellfish from contaminated water Most infectious 2 wks before s/s & 1wk after s/s start.
No chronic carrier

    Percutaneous, permucosal, or perinatal exposure, sexually transmitted disease.
100X more infectious than HIV; can live on dry surface for 7 days Carrier state - antigen HBsAg for 6-12 mo.
Immunity – antigen anti-HBs-Ag

  Transmission- pericutaneous At risk: IV drugs, bld transfusion, hemodialysis, tattooing, hi risk sexual behavior, organ transplants, health care workers

    Delta virus Transmission - percutaneous Can turn mild or chronic hepB into severe, chronic, progressive, active hepatitis & cirrhosis Can occur as coinfection with hepB or as superinfection

   Transmission – fecal-oral route, esp contaminated drinking water.
Enteric non-A, non-B hepatitis Occurs in developing countries, epidemics in India, Asia, Mexico, Africa. In US rarely, only after a person traveled.

    Recently discovered.
Found in blood donors & transmitted by transfusion.
Co-exists with other hepatitis viruses.
Not associated with chronic hepatitis or cirrhosis.

     Inflammation of liver -> Cell degeneration & necrosis Proliferation & enlargement of Kupffer cells Interrupted flow of bile & cholestasis If no complications, liver cells regenerate, resume normal appearance & function.
Rash, angioedema, arthritis, fever, malaise

      Rest, well balanced diet Antiemetics, Benadryl, NO phenothiazines Immunoglobulin for hepB or hepA Alpha inferon wks after exposure, hepA vaccine –pre exposure prophylaxis HepB vaccine prophylaxis, post exposure hepatitis B immune globulin

     Health Promotion Assessment of jaundice Adequate nutrition Rest Home Care

     Ingestion, inhalation, parenteral injection of chemicals Systemic poisons- carbon tetrachloride, gold compounds, converted toxic metabolites (acetaminophen) Drugs – Halothane, INH, Diuril, Aldomet Elderly, previous liver diseased Idiopathic - autoimmune

    Degeneration & destruction of liver cells Abnormal bld vessel & bile duct relationships from fibrosis Lobules of irreg size & shape & impeded bld flow from overgrowth of new & fibrous tissue Insidious, progressive, chronic disease

     Alcoholic, portal or nutritional cirrhosis: fat accumulation in liver cells, scar formation.
Post necrotic- re: hepatitis, broad bands scar tissue.
Biliary: due to chronic biliary obstruction or infection. Jaundice, diffuse fibrosis.
Cardiac: R heart failure, constrictive pericarditis, tricuspid insufficiency Cell necrosis, scar tissue, nodules, decr cellular nutrition, hypoxia-> decreased functioning of liver

      Insidious- anorexia, dyspepsia, n/v, flatulence, diarrhea or constipation, dull, heavy feeling in RUQ, enl liver & spleen Jaundice Skin lesions – spider angiomas, palmer erythema Hematologic – thrombocytopenia, anemia, leukopenia, coagulation disorders Endocrine disturbances – hormone inactivation Peripheral neuropathy – deficiency in folic

      Liver enzymes elevated, PT prolonged Cholesterol & Protein levels decreased Serum & urine bilirubin increased, stool decreased Liver scan,biopsy, analysis of ascitic fluid Esophagogastroduodenoscopy, angiogram Lytes, CBC, ammonia level

   Peripheral edema @ ankle & presacral area decr. albumin -> decr colloidal osmotic pressure. Increased portalcaval pressure from portal hypertension.
Ascites- hypertension in liver->proteins move bld via capillaries to lymph->leak into peritoneal cavity-> osmotic pres pulls water. Lo albumin & hyperaldosteronism adds to ascites formation.
S/S- abd distention, wt gain, distended abd wall veins, dehydration, decr output, hypokalemia.

     Na restriction: 250-500mg Na/day Salt poor albumin Diuretics: Aldactone, Dyrenium, Midamor, Lasix Fluid removal via paracentesis or retroperitoneal shunt Monitor lytes and fluid balance

   Compression, destruction of hepatic & portal veins & sinusoids-> obstruction portal bld flow-> portal hypertension.
Collateral circulation – lower esophagus, parietal peritoneum, rectum-> varices where collateral & systemic circulation meet.
Esophageal varices, fragile, tolerate hi pressure poorly, tortuous, bleed easily. Life threatening complication.

   Ammonia in systemic circulation without liver detoxification.
Ammonia from metabolism of P shunted past liver or liver unable to convert ammonia to urea-> lg amt ammonia-> crosses blood-brain barrier->neuro s/s S/S: LOC changes from lethargy to coma, disorientation, asterixis, writing impairments, hyperventilation, hypothermia, grimacing, grasping, fetor hepaticus

     Protein restriction Neomycin po or enemas Lactulose (Cephalac) Control GI blding, remove bld from intestinal tract, treat lyte & acid/base imbalance Liver transplant

    Neuro assessment q2h - LOC, reflexes, pupils, sensory & motor Check lytes, acid/base balance, ammonia Decrease ammonia with lactulose, enemas Possible tube feeding- lo-no protein, hi CHO & flds

   Renal failure- possibly due to redistribution of blood flow from kidneys or hypovolemia Follows diuretic therapy, GI hemorrhage or paracentesis Tx: salt poor albumin, salt & water restrictions, diuretic therapy

       Health Promotion Bed rest & prevent complications Nutrition- oral hygiene, supplements Assess: jaundice, edema, ascites, bleeding, LOC, dyspnea Skin care Altered body image Monitor lytes, liver & coag studies, ammonia, CBC

   Written instructions- fluid & diet restrictions Teach pt & family- s/s complications, meds & side effects, observe for bleeding, skin care, protection from infection Counseling & referral to community health nurse

      Metastasis, h/o cirrhosis, chronic hepB or C Malignant cells enlarge & mis-shape liver Hemorrhage or necrosis common Dx: hard to differentiate bet cirrhosis & Ca Rx: palliative, lobectomy, chemo, poor prognosis, death in 4-7 months Nsg care: same as advanced liver disease

   ERCP The scope is brought in through the esophagus, the stomach and into the bile ducts. A contrast fluid is injected. The gallbladder does not become visible. The hepatopancreatic duct does not show signs of obstruction.
Conclusion: No signs of obstruction of the hepatopancreatic duct, obstruction in the gallbladder or the cystic duct cannot be excluded. Nursing Care???

     Explain procedure & get consent NPO 8 hours before ERCP Sedation before & during ERCP Antibiotics if ordered Post ERCP – check perforation, infection, s/s pancreatitis, VS, check gag reflex

   S/S cholecystitis: indigestion, moderate-> severe pain, URQ tenderness, referred to R shoulder & scapula, n/v, restless, diaphoretic S/S cholelithiasis: none, s/s depend if stones are moving or not, spasms can be severe, tachycardia, diaphoresis, 3-6 hr after meal, when lie down, s/s bile blockage Dx: ultrasound, cholangiogram, cholecystogram

     Cholecystitis: control pain, antibiotics, flds Cholelithiasis: cholesterol solvents, lithotripsy, endoscopic sphincterotomy, surgery Surgery: cholecystectomy, laparoscopic cholecystectomy Transhepatic biliary catheter Meds: anticholinergics, analgesics, fat soluble vitamins, bile salts, Demerol, Questran, diet

    Health promotion Acute GB attack: relieve pain, n/v, assessment of progression of s/s & s/s obstruction bile duct, observe s/s bleeding at mucous membranes, assess for infection Post endoscopy; assess s/s pancreatitis, perforation, bleeding Post-op: referred pain to shoulder, place in Simm’s position, prevent resp complications, care of T-tube

     Uncommon Relationship bet Ca GB & chronic cholelithiasis or cholecystitis S/S: insidious, same as GB disease, later s/s biliary obstruction Rx: surgery, symptomatic, supportive Nursing care: supportive, pain relief, skin care, hydration, comfort

     Progressive destruction & fibrotic replacement of tissue Chronic obstructive pancreatitis Chronic calcifying pancreatitis S/S: pain, malabsorption with wt loss, jaundice, dark urine, steatorrhea, DM Dx: secretin stimulation test

    Diet, pancreatic enzyme replacement, control of diabetes Antacids, anticholinergic meds, H2 blockers, bile salts, insulin Surgery if obstruction Nursing Care: health promotion: diet, pancreatic enzymes, diabetic teaching, avoid alcohol, referrals for narcotic or alcohol dependence

     Over 50% tumors @ head of pancreas-> obstruction of common bile duct->jaundice S/S: pain, rapid wt loss, anorexia, nausea, jaundice Dx: CEA, CA19-9, ultrasound, CT, ERCP-> samples for cytology & biopsy Rx: Whipple’s procedure, radiation, chemo Nursing Care: supportive, comfort, help pt & family grieve