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what blood test is helpful to determine extent of liver disease?
- AST (aspartate aminotransferase)--5-40 units/L.
- ALT (alanine aminotransferase)--8-20 units/L; 3-35 IU/L [most definative assessment of liver tissue damage].
- LDH (lactic dehydrogenase)--100190 U/L.
- ALP (alkaline phosphatase)--42-128 units/L; 30-85 IU/L.
- [serum] bilirubin.
- [serum protein] albumin.
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what lab test would be elevated w/ [hepatic] encephalopathy [brain damage caused by liver disease & ammonia intoxication]?
ammonia level.
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SITUATION: pt. is going for an ERCP [endoscopic retrogade cholangiopancreatography]--involves insertion of cannula into pancreatic & common bile ducts during endoscopy using fiberoptic duodenoscope. what lab test is checked & what should be monitored?
- bilirubin--test not performed if result is > 3-4 mg/dL.
- monitor for pancreatitis post-procedure.
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SITUATION: pt. comes in w/ anorexia, ascites, weight loss, decreased AST/ALT/LDH/total bilirubin. what should you suspect & what s/s would be present?
- liver disease [cancer].
- s/s of jaundice.
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PT/PTT will be _________ w/ liver disease?
prolonged.
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what CBC result is expected w/ liver disease?
low Hgb & Hct (will show petechiae & bruising at umbilical area & flanks due to bleeding).
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SITUATION: a pt. who has jaundice will be c/o what?
- itching.
- bile salts coming through skin.
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SITUATION: pt. comes in for [needle] liver biopsy:
- invasive procedure requiring informed consent.
- monitor clotting time, bleeding time, PT & INR prior to procedure.
- -void before procedure.
- -conscious sedation.
- position pt. supine w/ right arem over head during procedure.
- have pt. exhale & not breath while needle is inserted--raises diaphragm.
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what nursing considerations are done after [needle] liver biopsy?
- position on right side for 2 hrs/more w/ pillow under ribs.
- monitor for pneumothorax, peritonitis, & [tamponade] bleeding.
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SITUATION: pt. is in liver failure, what lab test will be decreased & why?
albumin leve b/c it's not being absorbed by liver.
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w/ pancreatitis, which lab tests are elevated?
- serum/urine amylase.
- lipase.
- bilirubin.
- WBC.
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normal levels of serum bilirubin:
direct bilirubin [____________]
indirect bilirubin [____________]
total bilirubin [____________]
- direct bilirubin [0.1-0.3 mg/dL]
- indirect bilirubin [0.2-0.8 mg/dL]
- total bilirubin [0.1-1.0 mg/dL]
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normal levels of serum ammonia:
- 36-65 mg/dL (Saunders textbook)
- 15-110 mg/dL (ATI textbook)
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what condition would pt. be in if their total bilirubin, serum ammonia, & PT is prolonged?
pt. would be jaundiced, have bleeding, & if serum ammonia level is high, pt. will be confused.
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SITUATION: chirrotic pt. has ascites [obvious large abd]. what is the primary concern?
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what is a parecentesis & why is it done?
procedure in which needle is inserted into abd to drain excess fluid.
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what should pt. do prior to a parecentesis?
void to prevent puncturing bladder.
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what are nursing considerations after parecentesis?
- monitor:
- VS [elevated temp. of 101.4], redness, & swelling.
- labs [may have coagulation studies to check for
bleeding].- drainage output.
- position pt. in semi-Fowler's to facilitate drainage.
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what should happen to pt.'s abd after parecentesis?
size of girth will be smaller.
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how often should size of girth be checked?
daily.
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what should pt. do if size of girth increases in size again?
notify Dr. (procedure will be done again if pt. can no longer breathe properly).
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what are risk factors for cirrhosis?
- malnutrition: low to no protein (if impending liver failure); fluid & sodium restriction (ascites & portal hypertension).
- alcoholism: teach pt. to stop drinking.
- hepatitis.
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vitamin K deficiency can lead to what & results in?
bleeding tendencies (results in ecchymosis [bruising] & purpura).
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what color of urine & stool be for pt. who has hepatic disease?
tea-colored urine & clay-colored stools.
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SITUATION: pt. w/ liver disease has portal hypotension [increase in BP w/in system of veins called portal venous system], where is pressure going to be felt/transmitted?
if vessels in liver are blocked, hard for blood to flow causing high pressure in portal system resulting in ascites & esophageal & rectal varices.
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portal hypotension causes what?
- JVD [jugular venous distention].
- pedal edema.
- varicose veins develop.
- cirrhosis.
- blood clots in portal system.
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what is the best explanation for developing esophageal varices?
most often a consequence of portal hypertension [pressure building up in portal system].
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what is the name of tube used to exert pressure on outside for pt. who has esophageal varices?
sengstaken-blakemore tube [esophageal balloon].
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pt. w/ cirrhosis has prolonged PT time. what would be pt.'s priority assessment?
assess for bleeding (client may have esophageal varices & bleeding tendencies due to decreased clotting factors).
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SITUATION: pt. w/ esophageal varices had portacava shunt [tube from portal to superior/inferior vena cava to relieve pressure] put in by Dr. pt. should be monitored for what after procedure?
bleeding.
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after any surgery, what should you help pt. w/?
- turn.
- cough.
- leg exercises (for early ambulation).
- provide incentive spirometer every 2hrs.
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what should be checked & monitored after any surgery?
VS & bleeding.
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SITUATION: pt. has alcoholic cirrhosis (laennec's cirrhosis) & serum ammonia level is low. what diet should pt. be on?
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how would you assess for asterixis [s/s of hepatic encephalopathy]?
- pt.'s wrists & fingers are observed to "flap" b/c of brief, rapid relaxation of wrist dorsiflexion.
- *"flapping" indicates pt. is about to go into coma.
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s/s of sever liver disease: pruritus, jaundice, ecchymotic areas all over body, terribly confused, & can no longer write their name. what is the most serious prob?
terribly confused.
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SITUATION: female pt. c/o sudden onset of flu-like symptoms & blood work is done [AST & ALT markedly elevated]. tests are sign of?
hepatitis.
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what precautions are used for pt. w/ hepatitis A?
use of gloves & gowns when touching soiled linen.
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how is hepatitis A transmitted?
oral fecal route, contamination associated w/ flood waters/contaminated food (shellfish).
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how is hepatitis B transmitted?
blood/body fluid contact.
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what do we screen for w/ hepatitis B?
blood/organ transplant donors.
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how do healthcare workers come in contact w/ hepatitis B?
[accidental] needle sticks.
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which people are more suceptible to hepatitits B?
- [IV] drug addicts.
- clients undergoing long-term hemodialysis.
- healthcare personnel (nurses & Dr.).
- people having unprotected sex.
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which viral hepatitis is most associated w/ blood transfusion?
hepatitis C--transmitted same as HBV; primarily through blood.
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which viral hepatitis are blood-borne transmitted?
hepatitis B, C, D, & G.
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what are early s/s of kidney disease [viral hepatitis]?
nausea, vomiting, malaise, & anorexia.
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what nursing considerations are done for pt. w/ hepatitis A?
- strict handwashing, stool & needle precautions, standard precautions.
- [teach] pt. must not prepare food for others.
- [provide] vaccination/immunoglobulin for those exposed/traveling.
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if pt. doesn't have signs of liver failure, what diet should pt. be on?
- regular diet: high-protein/carbs.
- *w/ pt. showing signs of liver failure--regular diet: low-protein & high-carbs.
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SITUATION: pt. who has cholelithiasis [gallstones] is taking lithotripsy to break up gallstones has a stone lodged in common bile duct, what color would their urine be?
yellow [icteric].
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icteric [yellow] pt. would have what color of urine/stool?
- tea-colored urine.
- clay-colored stool.
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SITUATION: pt. has severe pain in RUQ [of abd]. which organs are involved?
liver, gallbladder, & pancreas.
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if pt.'s amylase leve is elevated, what would that indicate?
pancreatitis.
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if pt.'s AST & LDH is elevated, what does that indicate?
liver [disease/failure].
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pt. Dx w/ acute pancreatitis has abd pain, fever, distention, & weight loss. which complaint is highest priority?
[relieve] abd pain.
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why is that any disorder of bili area trea is cautioned not to be treated w/ morphine?
causes spasms in sphincter of odi.
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what kind of diet should pt. be on w/ pancreatitis?
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why would pt. w/ pancreatitis be NPO initially?
pt. has no gastric juices therefore, no stimulation in liver, gallbladder, & pancreas.
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what is done for pt. c/o nausea & vomiting?
- NGT is inserted placed on low-intermittent suctioning [to prevent suctioning everything out & from sticking on sides of stomach].
- *loses electrolytes [potassium].
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which statement relates to concerns of pt. w/ pancreatitis who dreads going to bed?
pain is aggravated in recumbent position.
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if pt. is prescribed aveeno baths, it would be for what?
pruritus (anything involving liver, gallbladder, & pancreas).
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what is a whipple procedure?
removal of the head of pancreas & enastimose duodenum to remaining part.
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pt. has had a pancreatectomy [removal of pancreas] & spleenectomy [removal of spleen] for cancer of pancreas. post-surgically, pt. is sleepy but can answer questions appropriately & VS are WNL. what is highest priority before leaving?
pt.'s safety: side rails up.
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pt. who had operation on gallbladder/liver/pancreas is at high risk for pnuemonia b/c?
they're not breathing deeply due to pain from incision.
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