Metabolism - Organ involved is the liver, kidney, and intestines - Liver- a chemical factory that manufactures, stores, alters, and excretes a large number of substances involved in metabolism. - The largest internal organ - ● ● Hepatic artery - supply blood in the liver Hepatic vein - blood from the liver back to the heart Metabolize- to breakdown Synthesize - to form ➔ Glucose - fuel the body from carbohydrates - which includes the glucose, fructose and galactose ➔ Proteins ➔ Fats ➔ Vitamins and minerals Glycogen- a stored glucose when no energy is needed in the body. - It will be breakdown into glucose when energy is needed - the process is called glycogenolysis - Gluconeogenesis - converting protein and fats into glucose such as amino acids Protein - absorbed by the intestine in the form of amino acids and it can be converted into glucose. Excess amino acids will be excreted in the liver and will be converted into ammonia to urea and be excreted in urine. Bilirubin (RBC) - reticuloendothelial cells will pick up the old rbc by macrophagesbreakdown into heme and globin - Heme is both an iron and bilirubin - Bile - Globin is a protein that will undergo erythropoiesis to form new RBC Base product - goal ni liver is to dispose Unconjugated bilirubin- lipid soluble Glucuronidation - from unconjugated to conjugated - water soluble Fat emulsifier Conjugated bilirubin - colon large intestine may bacteria when exposed bilirubin will become urobilinogen - yellow urine Aroma of urine is because of the urea Fats - can also be converted into glucose when amino acids are used already - Ketones - sumasama sa blood circulation - Toxins (brain barrier) Jaundice - Yellowish color of the skin if there is problem in the liver - Assess the sclera or hands and the hard palate - Hemolytic jaundice - increase destruction of RBC - Hepatocellular jaundice caused by the liver cells Portal vein- decrease circulation will lead to portal hypertension when there is an obstruction- increased pressure Aldosterone- control the fluids and electrolytes - Osmotic pressure wala- magleak si fluid which will lead to ascites or ascitis - Albumin Paracentesis - removal of fluids in ascites Hepatoencelopathy - Toxins napunta sa brain Chapter 1 METABOLISM - Sum expenditure of all chemical reactions engaged in energy production and expenditure Catabolism - Think digestion. This process takes larger structures like proteins, fats or tissues and breaks them down into smaller units such as cells or fatty acids. Anabolism - The opposite of catabolism; it’s the mechanism that takes smaller units like nutrients, cells, or amino acids and bonds them together to create bigger structures. - One example of anabolism in action is when your body is trying to heal a cut. It adds tissue and structures around that wound; it is also the process involved in a child’s growth and in building stronger muscles. LIVER - The largest gland of the body, can be considered a chemical factory that manufactures, stores, and processes a large number of substances involved in metabolism - The liver is located in the upper right hand portion of the abdominal cavity, beneath the diaphragm, and on top of the stomach, right kidney, and intestine. Function of the Liver - Glucose metabolism - Ammonia conversion Protein metabolism Fat metabolism Vitamin and iron storage Bile formation Bilirubin excretion Drug metabolism Assessment ● Health History - If the liver function test results are abnormal, the patient is evaluated for liver diseases - Focuses on previous exposure of the patient to hepatotoxic substances or infectious agents - History of alcohol and drug use - Medications including acetaminophen (tylenol), ketoconazole (nizoral), and valproic acid (depakene) - Lifestyle behaviors, alcohol consumption - Men who consume 60 to 80G/day of alcohol (approximately 4 glasses of beer, wine, or mixed drinks - Women whose alcohol intake is 40 to 60 g/day ● Physical Assessment - Pallor often seen with chronic illness and jaundice, skin, mucosa, and sclerae are inspected for jaundice, atrophy, edema, and skin excoriation secondary to scratching. - Petechiae or ecchymotic areas (bruises), spider - ● angiomas, and palmar erythema Unilateral or bilateral gynecomastia and testicular atrophy due to hormonal changes. Diagnostic evaluation - Serum glutamic oxaloacetic transaminase (SGOT) - Serum glutamic pyruvic transaminase (SGPT) - Ultrasonography - Computed tomography - Magnetic resonance imaging - A radioisotope liver scan may be performed to assess liver size and hepatic blood flow, and obstruction - Biopsy for cancer cases Manifestations of hepatic dysfunction - Jaundice - a medical condition with yellowing of the skin or whites of the eyes Hemolytic Jaundice - Result of increased destruction of the red blood cells - The effect of which is to flood the plasma with bilirubin so rapidly that the liver, although functioning normally, cannot excrete the bilirubin as quickly as it is formed - Hemolytic transfusion reactions and other hemolytic disorders Hepatocellular Jaundice - Caused by the inability of damaged liver cells to clear normal amounts of bilirubin from the blood - Cellular damage may be caused by hepatitis viruses, other viruses that affect the liver, medications or chemical toxins, or alcohol - - Serum bilirubin concentration and the urine urobilinogen level may be elevated AST and ALT levels - increased Obstructive jaundice - Resulting from extrahepatic obstruction may be caused by occlusion of the bile duct from a gallstone, an inflammatory process, a tumor or pressure from an enlarged organ (liver, gallbladder) Portal Hypertension - Increased pressure throughout the portal venous system that results from obstruction of blood flow through the damaged liver - Main symptoms: ● Ascites ● Increased abdominal girth and rapid weight gain are common ● The patient may be short of breath and uncomfortable from the enlarged abdomen, and striae and distended veins may be visible over the abdominal wall ● Umbilical hernias also occur frequently in those patients with cirrhosis ● Fluid and electrolyte imbalances are common Medical Management - Dietary modification - Negative sodium balance to reduce fluid retention - Diuretics - Spironolactone (aldactone), an aldosterone-blocking agent - Ammonium chloride and acetazolamide (diamox) are - - - contraindicated because of the possibility hepatic coma Daily weight loss should not exceed 1 -2 kg (2.2-4.4 lb) ascites and peripheral edema 0.5-0.75 kg (1.1 -1.65lb) in patients without edema Possible diuretic therapy complications include fluid and electrolyte disturbances (hypovolemia, hypokalemia, hyponatremia), and encephalopathy Bed rest Upright posture Paracentesis - Removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions - Ultrasound guidance - Diagnostic examination of ascitic fluid - Skills laboratory for guidelines for assisting with paracentesis Nursing measure include - Assessment and documentation of intake and output - Abdominal girth - Daily weight to assess fluid status - Monitors serum ammonia - Electrolyte levels to determine electrolyte balance - Response to therapy, and indicators of encephalopathy HEPATIC ENCEPHALOPATHY AND COMA - A decline in brain function that occurs as a result of severe liver disease. - The liver CANNOT adequately remove toxins from your blood. - buildup of toxins in your bloodstream, which can lead to brain damage - minor mental changes and motor disturbances alterations in mood and sleep patterns disoriented with respect to time and place. With further progression, the patient lapses into frank coma and may have seizures. Asterixis (flapping tremor of the hands) Inability to reproduce a simple figure constructional apraxia. S/S - - Asterixis or “liver flap” may occur in hepatic encephalopathy. - Effects of constructional apraxia. Deterioration of handwriting and inability to draw a simple star figure occurs with progressive hepatic encephalopathy Clinical Manifestation - deep tendon reflexes are hyperactive - with worsening of the encephalopathy, these reflexes disappear, and the extremities may become flaccid. - fetor hepaticus, a sweet, slightly fecal odor to the breath FROM intestinal origin - *freshly mowed grass, acetone, or old wine Assessment and Diagnostic Findings - electroencephalogram (EEG) shows generalized slowing, increased amplitude of brain waves Medical Management - eliminating the precipitating cause, - initiating ammonia-lowering therapy - minimizing potential medical complications of cirrhosis and depressed consciousness, and reversing the underlying liver disease - Correction of the possible reasons for the deterioration such as bleeding, electrolyte abnormalities, sedation, or azotemia - Lactulose is administered to reduce serum ammonia levels. Nursing Alert - The patient receiving lactulose is monitored closely for the development of watery diarrheal stools because they indicate a medication overdose. Nursing Management - Neurologic status is assessed frequently. - Mental status is monitored by keeping a daily record of handwriting and arithmetic performance. - Fluid intake and output, and body weight are recorded each day. - Vital signs are measured and recorded every 4 hours. - Potential sites of infection (peritoneum, lungs) are assessed frequently, and abnormal findings are reported promptly. - Serum ammonia level is monitored daily. - Patients and families are advised about foods that are high in protein (meat, eggs), which may need to be eliminated from the diet for the short term to reduce ammonia production. - maintain a safe environment to prevent injury, bleeding, and infection prescribed treatments and monitors the patient for the numerous potential complications. deep breathing and position changes to prevent the development of atelectasis, pneumonia, and other respiratory complications. - - Hepatitis HEPATO = LIVER ITIS = INFLAMMATION VIRUS = AN INFECTIVE AGENT THAT TYPICALLY CONSISTS OF A NUCLEIC ACID MOLECULE IN A PROTEIN COAT, AND IS ABLE TO MULTIPLY ONLY WITHIN THE LIVING CELLS OF A HOST Incubation Period: the number of days between when you're infected with something and when you might see symptoms. Immunoglobulin G (IgG): This is the most common antibody. It's in blood and other body fluids, and protects against bacterial and viral infections. IgG can take time to form after an infection or immunization Immunoglobulin M (IgM): Found mainly in blood and lymph fluid, this is the first antibody the body makes when it fights a new infection. - - Nausea Swelling in your legs, feet or ankles (edema) Weight loss Itchy skin Yellow discoloration in the skin and eyes (jaundice) Fluid accumulation in your abdomen (ascites) Spiderlike blood vessels on your skin (spider angiomas) Redness in the palms of the hands For women, absent or loss of periods not related to menopause For men, loss of sex drive, breast enlargement (gynecomastia) or testicular atrophy Confusion, drowsiness and slurred speech (hepatic encephalopathy) Esophageal varices - HEPATIC CIRRHOSIS Where liver cells became severely damaged & are replaced with fibrous connective tissues. Scarring Causes - Viral infection - Alcohol consumption - High fat collection in the liver. - Bile duct problems - Autoimmune - Fatigue Easily bleeding or bruising Loss of appetite S/S Esophageal varices are enlarged veins in the esophagus. They're often due to obstructed blood flow through the portal vein, which carries blood from the intestine, pancreas and spleen to the liver. Esophageal varices are abnormal, enlarged veins in the tube that connects the throat and stomach (esophagus). Dx tests - Endoscopic exam. A procedure called upper gastrointestinal endoscopy is the preferred method of screening for esophageal varices. Your doctor inserts a thin, flexible, lighted tube (endoscope) through your mouth and into your esophagus, stomach and the beginning of your small intestine (duodenum). - Imaging tests. Both abdominal CT scans and Doppler ultrasounds Balloon Tamponade- To control hemorrhage in certain patients, balloon tamponade may be used. In this procedure, the pressure is exerted on the cardia (upper orifice of the stomach) and against the bleeding varices by a double-balloon tamponade (Sengstaken-Blakemore tube). Diabetes Mellitus - Diabetes mellitus is a group of metabolic diseases characterized by increased levels of glucose in the blood (hyperglycemia) resulting from defects in insulin secretion, insulin action, or both (American Diabetes Association [ADA], 2009a). erminologies: Glucose: “Sugar” Fuels cells in your body. Body needs it to survive. But it can not enter the cells without the help of insulin. Insulin: Blood sugar. Secreted by beta cells of pancreas. Glucagon: Blood sugar. It causes the liver to turn glycogen to glucose. Secreted by pancreas. What happen in DM: Body cannot access to the glucose you are eating. DM type I: - known as juvenile diabetes or insulin-dependent diabetes, is a chronic condition in which the pancreas produces little or no insulin. - Not related to lifestyle Genetic Auto immune Virus - Patients look thin, young. Ketones in the urine Type II diabetes: - cells quit responding to insulin. Insulin resistant. Related to life style Patients are obese, adult aged and rare to have ketones in urine Treatment: diet, exercise and oral medications S/S 3 Ps Polyuria:Excessive urination Polydipsia: extreme thirstiness. Polyphagia:excessive or extreme hunger. Slow wound healing Blurry vision Glycosuria Acetone Breath (DM 1) Rashes in skin Repeated yeast vaginal infection. DKA Diabetic ketoacidosis is a serious complication of diabetes that occurs when your body produces high levels of blood acids called ketones.- common in DM1 S/S: Hyperglycemia, Extreme Thirst, Kussmaul Breathing, fruity breath (Acetone Breath) Hyperosmolar hyperglycemic syndrome (HHS) is a serious complication of diabetes mellitus. HHS occurs when a person’s blood glucose (sugar) levels are too high for a long period, leading to severe dehydration (extreme thirst) and confusion.-common in DM2 S/S: Dehydration, thirsty, hyperglycrmia, mental status changes Medications DM1: Insulin injection Administer subcutaneously Rotate sites of injection, Do not use same site or more than once in period of 2-3 weeks. This can cause Lipodystrophy (LD), a disorder of adipose tissue, is one of the most common complications of subcutaneous insulin injections Remember when mixing insulins “CLEAR (REGULAR INSULIN)-CLOUDY(NPH)” DM2: Oral medications Sulfonylureas : Glipizide, Tolazmide, Glimepiride, Diabenase (NO alcohol, can cause extreme hypo glycemia) Meglitinides Biguanides Alpha-glucosidase inhibitors: Precose, Glyset Thiazolidinediones (also called glitazones) Hypoglycemia- Blood glucose > 60 mg/dl -Sweating, Clammy, confused, light headed, dizzy, double vision -Give simple Carbs ( Hard Candy, Fruit Juice, Graham Cracker, honey) -If unconscious, give IVF D50 -Patients who require insulin should be taught to eat a 15-g carbohydrate snack (a fruit exchange) or a snack of complex carbohydrates with a protein before engaging in moderate exercise to prevent unexpected hypoglycemia.
