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.
what lab test would be elevated w/ [hepatic] encephalopathy [brain damage caused by liver disease & ammonia intoxication]?
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.
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.
PT/PTT will be _________ w/ liver disease?
what CBC result is expected w/ liver disease?
low Hgb & Hct (will show petechiae & bruising at umbilical area & flanks due to bleeding).
SITUATION: a pt. who has jaundice will be c/o what?
- bile salts coming through skin.
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.
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.
SITUATION: pt. is in liver failure, what lab test will be decreased & why?
albumin leve b/c it's not being absorbed by liver.
w/ pancreatitis, which lab tests are elevated?
- serum/urine amylase.
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]
normal levels of serum ammonia:
- 36-65 mg/dL (Saunders textbook)
- 15-110 mg/dL (ATI textbook)
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.
SITUATION: chirrotic pt. has ascites [obvious large abd]. what is the primary concern?
what is a parecentesis & why is it done?
procedure in which needle is inserted into abd to drain excess fluid.
what should pt. do prior to a parecentesis?
void to prevent puncturing bladder.
what are nursing considerations after parecentesis?
- 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.
what should happen to pt.'s abd after parecentesis?
size of girth will be smaller.
how often should size of girth be checked?
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).
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.
vitamin K deficiency can lead to what & results in?
bleeding tendencies (results in ecchymosis [bruising] & purpura).
what color of urine & stool be for pt. who has hepatic disease?
tea-colored urine & clay-colored stools.
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.
portal hypotension causes what?
- JVD [jugular venous distention].
- pedal edema.
- varicose veins develop.
- blood clots in portal system.
what is the best explanation for developing esophageal varices?
most often a consequence of portal hypertension [pressure building up in portal system].
what is the name of tube used to exert pressure on outside for pt. who has esophageal varices?
sengstaken-blakemore tube [esophageal balloon].
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).
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?
after any surgery, what should you help pt. w/?
- leg exercises (for early ambulation).
- provide incentive spirometer every 2hrs.
what should be checked & monitored after any surgery?
VS & bleeding.
SITUATION: pt. has alcoholic cirrhosis (laennec's cirrhosis) & serum ammonia level is low. what diet should pt. be on?
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.
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?
SITUATION: female pt. c/o sudden onset of flu-like symptoms & blood work is done [AST & ALT markedly elevated]. tests are sign of?
what precautions are used for pt. w/ hepatitis A?
use of gloves & gowns when touching soiled linen.
how is hepatitis A transmitted?
oral fecal route, contamination associated w/ flood waters/contaminated food (shellfish).
how is hepatitis B transmitted?
blood/body fluid contact.
what do we screen for w/ hepatitis B?
blood/organ transplant donors.
how do healthcare workers come in contact w/ hepatitis B?
[accidental] needle sticks.
which people are more suceptible to hepatitits B?
- [IV] drug addicts.
- clients undergoing long-term hemodialysis.
- healthcare personnel (nurses & Dr.).
- people having unprotected sex.
which viral hepatitis is most associated w/ blood transfusion?
hepatitis C--transmitted same as HBV; primarily through blood.
which viral hepatitis are blood-borne transmitted?
hepatitis B, C, D, & G.
what are early s/s of kidney disease [viral hepatitis]?
nausea, vomiting, malaise, & anorexia.
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.
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.
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?
icteric [yellow] pt. would have what color of urine/stool?
- tea-colored urine.
- clay-colored stool.
SITUATION: pt. has severe pain in RUQ [of abd]. which organs are involved?
liver, gallbladder, & pancreas.
if pt.'s amylase leve is elevated, what would that indicate?
if pt.'s AST & LDH is elevated, what does that indicate?
pt. Dx w/ acute pancreatitis has abd pain, fever, distention, & weight loss. which complaint is highest priority?
[relieve] abd pain.
why is that any disorder of bili area trea is cautioned not to be treated w/ morphine?
causes spasms in sphincter of odi.
what kind of diet should pt. be on w/ pancreatitis?
why would pt. w/ pancreatitis be NPO initially?
pt. has no gastric juices therefore, no stimulation in liver, gallbladder, & pancreas.
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].
which statement relates to concerns of pt. w/ pancreatitis who dreads going to bed?
pain is aggravated in recumbent position.
if pt. is prescribed aveeno baths, it would be for what?
pruritus (anything involving liver, gallbladder, & pancreas).
what is a whipple procedure?
removal of the head of pancreas & enastimose duodenum to remaining part.
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.
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.