Ill Unit 5 (liver, endocrine)

jaundice

-yellow discoloration from abnormal bilirubin metabolism or bile flow

—most bilirubin is formed from Hgb breakdown (this is unconjugated, organs cannot filter it)

—liver makes and excretes conjugated bilirubin

-types

—hemolytic jaundice: d/t increased RBC breakdownn (SCD & other anemias, blood transfusions)

—hepatocellular jaundice: d/t liver unable to excrete bilirubin (hepatitis, cirrhosis, liver CA)

—obstructive jaundice: bile flow is obstructed through liver or biliary system (tumors, hepatitis, cirrhosis, stones, strictures, pancreatic CA)

• causes clay-colored stools b/c no bile in intestine, dark urine b/c bilirubin ends up there

-best places to assess: sclera, palms, earlobes

hepatitis

-d/t virus, drugs (Tylenol, Tegretol, Zocor), ETOH, chemicals (arsenic, mercury), autoimmune

-reportable disease

-some people may only carry the virus w/o S/S

-5 types

—A & E are transmitted fecal-oral

—B, C, & D are transmitted percutaneous/parenteral (blood, intercourse, pregnancy)

-phases of S/S

—pre-icteric for 1-4 mo: no jaundice yet; anorexia, weight loss, HA, fever, nausea, RUQ pain, fatigue

—icteric for a few wks: jaundice, dark urine, clay-colored stools, malaise, fatigue, pruritis (from bile) GI S/S like pre-icteric

—post-icteric for 1-4 mo: no jaundice anymore

hepatitis care

-complications:

—A/E: none usually

—B/C/D: chroinc infection, liver CA, LF

-dx: Ab/Ag test (dx type), high bilirubin (serum & urine), high PT/INR/PTT (liver makes coagulation fx), high AST & ALT, high LDH

-vax for hep A and B (3 shots)

tx hepatitis

-acute tx:

—many meds must be avoided; also alcohol

—small frequent meals, high-carb, high-kcal, low-fat

—antiemetics

-chronic tx:

—antivirals to slow progression (Interferon: causes leukopenia)

—liver CA screen q6mo

—hepatitis Ab (IgG)

• given to pt exposed to hepatitis

-standard precautions, private room

cirrhosis

-insidious onset, chronic progressive liver destruction

—liver cells are replaced w/ fibrous CT

-early S/S: anorexia, dyspepsia, flatulence, N/V

-later S/S: jaundice, peripheral edema/anasarka, ascites (d/t low albumin → low OP)

-other S/S: weight gain (fluid), encephalopathy, neuropathy, splenomegaly, abdominal pain/distention, angiomas, palmar erythema, pupura/petechiae

-causes varices, hematemesis, amenorrhea, impotence, pancytopenia, low Na+/K+/albumin

portal HTN

-complication of cirrhosis

—causes enlarged swollen veins d/t compression from fibrosis

—causes esophageal and gastric varices from increased BP → bleed risk

• esp d/t low clotting fx

• tx: IV vasopressin, ligation, Sengstaken-Blakemore tube inserted into esophagus to sxn & tamponade

—nursing: pt should avoid alcohol, ASA, certain foods, coughing (prevent/tx URI), NSAIDs

hepatic encephalopathy

-complication of cirrhosis

—d/t high ammonia levels (liver cannot convert into urea for excretion)

—causes change in mental responsiveness and disorientation

—nursing: restrict protein to prevent ammonia formation

—tx: lactulose (also a laxative!)

• monitor mental status throughout day to assess med effectiveness

cirrhosis care

-dx: LFTs (AST, ALT, GGT), liver biopsy (bleed risk!), PT/INR/PTT, high albumin/bilirubin/ammonia

—EGD (esophageogastroduodenoscopy)

-tx: rest!

—pericentesis for ascites

• empty bladder first (lengthy procedure), have pt lay still

—peritoneovenous shunt for portal HTN and varices

—Na+ restriction and diuretics (Aldactone) for edema

-nursing: oral hygiene, soft toothbrush (bleed risk) small frequent meals, high-Fowler’s (ascites causes dyspnea), skin care (turn q2h), avoid straining for stool, elevate edematous limbs & scrotum

—assess I&O, daily weights, abdominal girth

—safety concerns d/t encephalopathy (neuro assessments q2h)

liver CA

-early S/S like cirrhosis

-dx: US, CT, MRI, angiography, percutaneous biopsy

—ERCP (endoscopic retrograde cholangiopancreatography) to visualize pancreatic and bile duct; pt must lay still

—AFP (elevated d/t primary liver CA)

-need palliative care (poor prognosis: death w/in 6-12 mo)

-if CA is only in liver and has normal LFTs and portal BP, partial hepatectomy may treat

acute pancreatitis

-pancreatic enzymes are activated w/in pancreas (instead of small intestine) and auto-digest → bleeding

-usually d/t gallbladder disease, or alcoholism

—also biliary tract disease, viral infections, penetrating duodenal ulcers, CF, meds, smoking

-S/S: severe, deep, piercing, continuous abdominal pain in LUQ radiating to back, worsened by eating; N/V, tachycardia, jaundice, decreased or absent bowel sounds

—Grey Turner’s spots & Cullen’s sign

-complications: hTN; respiratory complications like pleural effusion, pneumonia, ARDS; hypocalcemia (→ tingling, tetany, Chvostek & Trousseau)

care for acute pancreatitis

-dx: elevated amylase and lipase, abdominal US, CT

-tx: drain pseudocyst or abscess to prevent rupture

—place pt NPO & give IVF

—analgesics (IV morphine)

—antispasmodics (Bentyl)

—remove gallstones or gallbladder

chronic pancreatitis

-d/t alcoholism

—also gallstones, tumors, trauma, CF

—may or may not follow acute pancreatitis

-S/S: abdominal pain that comes and goes, weight loss, mild jaundice, dark urine, steatorrhea

—leads to DM

care for chronic pancreatitis

-dx:

—elevated: amylase, lipase, bili, ALP, ESR, WBC

—CT, MRI, ERCP, stool analysis

-tx: NPO, then low-fat bland diet; avoid alcohol, nicotine, caffeine; small frequent meals, DM meds

—meds: Pancrease (enzyme), antacids, H2-blockers, PPIs, antidepressants (for neuropathic pain)

—surgery to divert bile flow:

• via T-tube

• via bile duct anstomosis into jejunum

• via Roux-en-Y (panreatojejunostomy): pancreatic duct anastomosis into jejunum

pancreatic CA

-risk fx: smoking, chronic pancreatitis, DM, fam hx, high-fat diet, red meat

-S/S similar to pancreatitis: pain, jaundice, N/V, weight loss

-very poor prognosis (often metastasized at time of dx)

-tx: meds for N/V, opioids for pain, insulin, pancreatic enzymes; semi-Fowler’s

—chemo, radiation, surgery

pancreatic cancer surgery

Whipple’s operation / radical pancreaticoduodenectomy

-resection of proximal pancreas, duodenum, distal stomach and distal common bile duct

-anastomosis created between pancreatic duct, common bile duct, and stomach to jejunum

cholelithiasis and cholecystitis

-S/S: severe RUQ pain (worse after high fat meal)

-may lead to pancreatitis

-dx: US, ERCP, HIDA scan

-tx: low-fat high-fiber diet, clear liquid diet

—anticholinergics

—shock-wave lithotripsy

—laparoscopic or incisional cholecystectomy

levothyroxine / Synthroid / Levoxyl

-TH replacement

-100-400 mcg/day (start out 25-50 and gradually increase)

-usually oral, but can be IV for rapid replacement (1/2 dose)

-give 1 hr before breakfast or 2 hr after

-take for life

-nursing: monitor HR & BP, monitor for AEs and allergic reactions, monitor thyroid labs, check other meds

problems with levothyroxine

-AEs: irritability, insomnia, HA, tremors, tachycardia, arrythmias, N/V/D, appetite change, weight loss, hair loss

—report immediately: chest pain, palpitations, nervousness

-contra: maybe ASA allergy

goiter

-thyroid cells are hyper- or hypoactive

-d/t lack of iodine or TH

-dx: TSH, T4

-tx underlying cause

hyperthyroidism

-increase in T3 and T4 levels

-more common in women

-d/t pituitary problems, stress, autoimmune, excess iodine intake

-often d/t Grave’s disease

—autoimmune idiopathic: Ab created against TSH receptor sites → thyroid enlargement

-S/S: enlarged thyroid, heat intolerance, fine straight hair, exopthalmosis, facial flushing, tachycardia, high SBP, breast enlargement, weight loss, muscle wasting, local edema, clubbing, tremors, diarrhea, amenorrhea

hyperthyroidism care

-dx: low TSH, free T4, US, thyroid scan

—EKG (tachycardia, A-fib)

—RAIU: radioactive iodine uptake (rules out Graves)

• contra: pregnancy

-diet: high-kcal high-carb high-protein snacks, no caffeine

-meds: propylthiouracil, methimazole/Tapazole, iodine (SSKI), beta blockers

-tx: radioactive iodine therapy (RAI), thyroidectomy

RAI

-destroys thyroid tissue

-done for 2-3 months

-oral

-combine w/ meds

-may cause hypothyroidism

-pregnancy test before

thyroidectomy

-subtotal: 90% removed and 10% regenerated

-for goiter compression, pt unresponsive to antithyroid meds, thyroid CA

-post-op complications: hypothyroidism, hypoparathyroidism, hypocalcemia, hemorrhage, laryngeal nerve famage, infection, thyrotoxic crisis, airway obstruction

hypothyroidism

-causes everything in body to slow down

-d/t:

—primary: destruction of thyroid tissue or defective hormone synthesis

—seondary: pituitary disease decreases TSH, hypothalamus dysfunction decreases TRH

-S/S: cold intolerance, receding hairline and hair loss, facial and periorbital edema, dull-blank expression, extreme fatigue, thick tongue and slow speech, anorexia, brittle nails and hair, mentrual problems, lethargy, apathy, dry scaly skin, muscle aches and weakness, constipation

-late S/S: hypothermia, bradycardia, wieght gain, decreased LOC, thickened skin, heart problems

-*often S/S are similar to aging

myxedema coma

-complication of hypothyroidism

-medical emergency

-triggered by infectino, narcotics, trauma

-causes sudden onset of depressed body system processes

-decreased CO, hypothermia, hTN, respiratory depression, bradycardia, stupor

-tx: IV Synthroid, treat underlying cause

care for hypothyroidism

-dx: TSH, T4, EKG

-tx: lifelong levothyroxine, warm environment, skin care, prevent constipation, daily weights, avoid fatigue

Cushing Syndrome

-d/t prolonged steroid intake, ACTH-secreting pituitary tumor, cortisol-secreting neoplasm

-S/S: thin hair/skin/SQ, red cheeks, supraclavicular fat pad, muscle atrophy, acne, moon face, increased body hair, weight gain, purple striae, pendulous abdomen, easy bruising, slow wound healing

care for Cushing Syndrome

-dx: high cortisol, high Na+, low K+, high BGM

—CBC, 24-hr urine collection (cortisol)

—CT & MRI (adrenal atrophy; lesions on pituitary, adrenal, lung, GI, pancreas

-tx; reduce steroids gradually

-nursing: limit sodium, increase potassium and protein, I&O, daily weights (hypervolemia risk), prevent infections, exercise

tx for Cushing

—“medical adrenalectomy” (Mitotane to kill adrenals)

—adrenalectomy (→ infection risk)

• need UA QD to check cortisol

—transphenoidal hypophysectomy (remove pituitary adenoma)

• post-op: elevate HOB, oral care q2h, assess nasal drainage

adrenocortical insufficiency

-hypofunction of adrenal cortex

-d/t pituitary or hypothalamus issues, Addison’s disease (autoimmune)

-insidious onset

-S/S (late): fatigue, weakness, weight loss, hypovolemia

-Addison’s S/S: bronze skin, body hair distribution changes, GI problems, hypoglycemia, ohTN

complications of adrenocortical insufficiency

Addison’s crisis

-rapid onset life-threatening emergency

-triggered by trauma, dehydration, stress, infection, surgery, steroid withdrawal

-S/S: tachycardia, hTN, hyperkalemia, hyponatremia, fatigue, dehydration

—kidneys shut down, CVS collapses

-tx: IV hydrocortisone, IVF, Kayexalate

—monitor BP, VS, EKG carefully

care for Addison’s

-tx: lifelong corticosteroids (prednisone) and mineralcorticoids (Florinef)

—higher dose during stress

-sodium (during excess heat)

-teahcing: keep emergency IM hydrocortisone on hand, wear medical alert band

pheochromocytoma

-tumor of adrenal medulla that produces excess catecholamines

-dx: 24-hr urine collection (shows catecholamines and creatinin)

-tx: surgery

—pre-op: do NOT palpate abdomen; monitor HR, BP, EKG

—prevent BP and tachycardia

—need lifelong hormone replacement, glucocorticoids, mineralocorticoids