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Liver, Biliary Tract,

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Liver, Biliary Tract, & Pancreas Problems Nur 302 Unit I Liver, Biliary Tract & Pancreas Problems Jaundice Hemolytic jaundice Hepatocellular Jaundice Obstructive ... – PowerPoint PPT presentation

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Title: Liver, Biliary Tract,


1
Liver, Biliary Tract, Pancreas Problems
  • Nur 302
  • Unit I

2
Liver, Biliary Tract Pancreas Problems
  • Jaundice
  • Hemolytic jaundice
  • Hepatocellular Jaundice
  • Obstructive jaundice

3
Viral Hepatitis
  • 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

4
Hepatitis 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

5
Hepatitis B
  • 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

6
Hepatitis C
  • Transmission- pericutaneous
  • At risk IV drugs, bld transfusion, hemodialysis,
    tattooing, hi risk sexual behavior, organ
    transplants, health care workers

7
Hepatitis D
  • 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

8
Hepatitis E
  • 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.

9
Hepatitis G
  • Recently discovered.
  • Found in blood donors transmitted by
    transfusion.
  • Co-exists with other hepatitis viruses.
  • Not associated with chronic hepatitis or
    cirrhosis.

10
Pathophysiology
  • Inflammation of liver -gt 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

11
Collaborative Care
  • 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

12
Nursing Care Hepatitis
  • Health Promotion
  • Assessment of jaundice
  • Adequate nutrition
  • Rest
  • Home Care

13
Toxic, Drug-induced Idiopathic Hepatitis
  • 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

14
Cirrhosis of the Liver
  • 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

15
Types of Cirrhosis
  • 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-gt decreased
    functioning of liver

16
Clinical Manifestations
  • 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 acid,
    thiamine, B-12.

17
Diagnostic Studies
  • 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

18
Peripheral Edema Ascites
  • Peripheral edema _at_ ankle presacral area - decr.
    albumin -gt decr colloidal osmotic pressure.
    Increased portalcaval pressure from portal
    hypertension.
  • Ascites- hypertension in liver-gtproteins move bld
    via capillaries to lymph-gtleak into peritoneal
    cavity-gt 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.

19
Collaborative Care
  • 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

20
Portal Hypertension Esophageal Varices
  • Compression, destruction of hepatic portal
    veins sinusoids-gt obstruction portal bld flow-gt
    portal hypertension.
  • Collateral circulation lower esophagus,
    parietal peritoneum, rectum-gt varices where
    collateral systemic circulation meet.
  • Esophageal varices, fragile, tolerate hi pressure
    poorly, tortuous, bleed easily. Life threatening
    complication.

21
Hepatic Encephalopathy
  • Ammonia in systemic circulation without liver
    detoxification.
  • Ammonia from metabolism of P shunted past liver
    or liver unable to convert ammonia to urea-gt lg
    amt ammonia-gt crosses blood-brain barrier-gtneuro
    s/s
  • S/S LOC changes from lethargy to coma,
    disorientation, asterixis, writing impairments,
    hyperventilation, hypothermia, grimacing,
    grasping, fetor hepaticus

22
Collaborative Care
  • Protein restriction
  • Neomycin po or enemas
  • Lactulose (Cephalac)
  • Control GI blding, remove bld from intestinal
    tract, treat lyte acid/base imbalance
  • Liver transplant

23
Nursing Care Encephalopathy
  • 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

24
Hepatorenal Syndrome
  • 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

25
Nursing Care Cirrhosis
  • 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

26
Home Care
  • 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

27
Liver Cancer
  • 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

28
Endoscopic Retrograde Cholangiopancreatography
  • 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???

29
ERCP 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

30
Cholecystitis Cholelithiasis
  • S/S cholecystitis indigestion, moderate-gt 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

31
Collaborative Care
  • 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

32
Nursing Care GB Disease
  • 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
    Simms position, prevent resp complications, care
    of T-tube

33
Cancer of the Gallbladder
  • 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

34
Chronic Pancreatitis
  • 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

35
Collaborative Care
  • 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

36
Pancreatic Cancer
  • Over 50 tumors _at_ head of pancreas-gt obstruction
    of common bile duct-gtjaundice
  • S/S pain, rapid wt loss, anorexia, nausea,
    jaundice
  • Dx CEA, CA19-9, ultrasound, CT, ERCP-gt samples
    for cytology biopsy
  • Rx Whipples procedure, radiation, chemo
  • Nursing Care supportive, comfort, help pt
    family grieve
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