Exam 2

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liver’s functions

produces, detox, metabolizes, storage

Rheumatoid arthritis

Chronic, progressive systemic inflammation autoimmune disease that affects diarthradial (free-moving) joints

* can occur at any age

How are joints affected in R.A.?

Bilateral

7 S’s of RA

* Sunrise Stiffness
* Synovium (joints)
* Symmetrical
* Stages
* Systemic (fever, anemia, heart, lungs)
* Soft feeling (paresthesia)
* Swelling

Early Symptoms for R.A.

* Joint inflammation (hands fingers)
* Low grade fever
* General weakness
* Anorexia
* Paresthesia
* Upper extremities
* Morning stiffness + minimal pain
* Pain at rest

Late Symptoms for R.A.

* Morning stiffness + severe pain
* Subc. Nodules
* Pericarditis
* Fibrotic Lung disease
* Kidney Disease
* Osteoporosis
* Sjogren’s Syndrome

Sjogren’s Syndrome

Dry eyes and dry mouth (gritty)

Labs for R.A.

* Elevated ESR
* Elev. CRP
* (+) ANA
* Elev. WBC

Educate for R.A.

* Adhere to treatment plan
* Report S/S of infection
* Keep up to date w/ current vaccines
* Attend PT/OT

Treatment for R.A.

Based around decreasing inflammation and pain

* NSAIDS
* Steroids (bad side effects)
* COX-2 Enzyme Blockers (CELEBREX)

Long term treatment for R.A.

METHOTREXATE *Gold standard*

* DMARD: Blocks chemicals that cause inflammation by releasing adenosine

Methotrexate: what to remember as RN?

Monitor for hepatotoxicity (ast/alt)

* Take folic acids to prevent s.e. (oral ulcers)
* Avoid alcohol
* No pregnancy

Nursing Interventions for R.A.

* HEAT treats STIFFNESS
* COLD treats PAIN/INFLAMMATION
* ROM Exercises
* Low Impact Aerobics
* Biking
* Physical exercise (decr. fatigue, incr. muscle strength)
* Hot shower
* Schedule breaks and rest

What to watch out for R.A.?

* Obesity
* Anemia (give erythropoietin - folic acid, iron)
* R/F Bleeding (G.I.)

Systemic Lupus Erythematosus (SLE)

Chronic, progressive inflammatory disease that can affect any organ system

* Immune system attacks its own tissue by making immune complexes and depositing them into the tissue

SLE: Discoid

SKIN

* Alopecia
* Mouth Ulcers

Can be defined by…

* Butterfly rash on nose and cheeks
* Coin-like lesions/scars
* Self-limiting

SLE: Systemic

Organs

* Failure

\#3 Cause for Kidney Transplant
* Fatigue

SLE: Med-Induced

* Hydralazine: BP Med
* Procainamide: Antiarrhythmic
* Isoniazid: TB

Rash resolves when med is stopped

Labs for SLE

* Elev CRP and ESR
* + ANA
* Elev BUN and Crea
* Pancytopenia = decr blood cells

Triggers for SLE

* Illness = no vaccines
* Sunlight
* Meds
* Pregnancy
* Major Surg
* Allergies

SLE: Exposure to sunlight

Sunscreen

Hat

Wash with mild soap (dry well, lotion)

Reynaud’s Phenomenon (SLE)

Vasospasms in response to coldness

* Turns fingers and toes white

Treatment for SLE

Focused on new exacerbations

* NSAIDS - Decr. inflammation and pain
* Corticosteroids - Immunosuppression and dec. inflammation

Applied as cream
* Anti-malarial agents - HYDROXYCHLOROQUINE

suppresses synovitis, fatigue, fever
* Immunosuppressive - Methotrexate (no preg, take w folic)

Hydroxychloroquine (SLE): what should the RN know?

* Check eyes biannually

Exacerbation/FLARE UPs (SLE)

Fatigue

Low grade fever

Achy joints

Rashes

Edema (legs/hands)

Sickle Cell Anemia

* Genetic disorder of the hgb
* RBC goes through a morphological change when it is exposed to less O2 Tension
* RBC elongate, become stiff, loose flexibility
* CARRIES LESS O2 and BREAK APART EASILY

SCD: Vaso-occlusive

Most common

* Obstruction caused by hemolysed cells
* Hypoxia
* Pain

SCD: Aplastic

Bone marrow stops producing RBC

SCD: Sequestration

Sudden pooling of RBC in spleen

* Hypovol shock
* CV Failure

SCD: Hemolytic Crisis

Elev RBC Hemolysis

* Brings down HGB
* Elev Jaundice

SCD: S/S

* Tachycardia
* SOB
* Tachypnea
* Fatigue
* Pallor
* Jaundice
* Pain

SCD: Triggers

* Extreme temp
* Overexertion
* Stress
* Dehydration
* Environment - altitude
* Preg

SCD: Treatment (Nursing Interventions)

Focus on prevention of crisis/complications

* O2 administration
* Adeq Hydration
* Pain mgmt: EXCRUTIATING: Dilaudid \\ OPIOIDS
* Remove constrictive clothing
* Rest - extremities extended
* Warm room
* Check extr circulation q1h (pulses, cap refill)

SCD: Acute Chest Syndrome

Respiratory Infection | common cause of death

* Can lead to fat embolism
* Pulm debris
* Form SC

SCD: Acute Chest Syndrome S/S

* Pneumonia
* Cough
* Abn breath sounds
* Infiltrate x-ray
* Can have fever/not
* Chest Pain

SCD: At risk for long term

* Heart failure
* Pulm htn: trying to compensate
* CKD
* Damaged spleen
* Damaged liver
* Ulcers on low extremities

SCD: what do we prioritize first for this pt?

* O2
* FLUIDS
* PAIN

SCD: Hydroxyurea

Stimulates production of fetal hgb

Reduces number of sickling episodes

* S/E: Supresses bone marrow = myelo
* R/F Infection
* Drug tox
* Leukemia
* No preg bc teratogenic

SCD: Education

Avoid crowds

Routine blood tests

s/s toxicity

Vaccines

S/S Infection (fever, contact physician at first s/s of infection)

Hand hygiene/wear mask

Start drug early

Promote perfusion

Sickle Cell leads to…

sepsis

* MODS
* death

Thrombocytopenia

Decreased plt count

Normal plt count (150-450)

Other complications Sickle Cell leads to

CVA

Infection

Long term infection

Normal total cholesterol

Normal LDL

Normal HDL

>40-60

Normal triglycerides

Liver produces

Albumin

Bile

Coagulation factors

Albumin’s factors

1. Volume expander (attracts fluids into vascular spaces - h20)
2. Binds to calcium
3. Transports drugs in the body

What happens if there is no albumin?

drug toxicity

* edema
* ascites
* fluid overload

Normal Calcium Levels

8\.2-10.2

Bile’s function

BUS of your system

transports bilirubin (brkdwn of rbc)

Picks up excess cholesterol around body to excrete in stool

If liver fails, buildup of bilirubin results to?

Jaundice

Indications for internal bleeding

* Dark tarry stools
* Bleeding
* Coffee ground cough
* Brown pee

Normal PT Level

10-13

Normal PTT Level

25-35

Normal Hgb Level

11\.7-17.3

Normal HCT Level

36-52

Normal AST Level

15-40

Normal ALT Level

13-40

Normal albumin level

3\.4-5.4

Ammonia Level

15-60

Detox in Liver

First Pass: bioavailability a fraction of the administered dose if a majority of the medication is metabolized through the liver

First barrier for alcohol/pathogens that enter liver

Kupffer Cells

Buildup of trash

* Portal vein
* Hepatic artery

Storage in liver

glycogen for energy

at risk for hyper and hypoglycemia

What vitamins does liver store?

Vit A, B (thiamine), C, Folic Acid, K

Metabolism in liver: what is the protein byproduct?

Ammonia

this is then turned to urea and then sent to kidneys for excretion

Buildup of ammonia results to?

hepatic encephalopathy

Liver receives blood from?

hepatic artery

Liver vitamin deficiences: iron low, vit. k low, what to give?

Banana Bag

* vit k, folic acid, iron, minerals, thiamine, mag sulfate

If cholesterol is elevated, what do we administer?

statins

Steroids side effects

* Immunosuppression
* Weight gain
* Hyperglycemia
* Hypokalemia
* Skin changes/poor wound healing
* htn
* black tarry stools
* mood swings

Hepatic encephalopathy: signs and symptoms

* change in MS
* Asterixes
* Motor disturbances
* Increased ammonia levels

What to administer for hepatic encephalopathy?

Lactulose

How do you know lactulose is working?

* Pooping
* Increased LOC
* Ammonia level goes down

Normal mag level

1\.7-2.2

Esophageal varices: what is it?

enlarged veins/ulcers in the esophagus

What is esophageal varices from?

Portal htn (pressure inside portal vein)

How does patient present in esophageal varices?

vomiting blood

tarry stools

epistaxis

What color are patient’s with jaundice stool?

clay colored stools

Treatment for Esophageal varices

Fluids

Albumin/Blood products (Cross type)

Vasopressin

Octreotide

Propanolol

Banding

Bilirubin build up can lead to…

jaundice

gallstones

and pruritis (PREVENT INFECTION)

What is itching associated with jaundice?

PRURITIS

Prevent infection

Ascites: what is it?

Large amount of fluid collects in abd cavity (peritoneal cavity)

* can result from portal hypertension

With ascites, how do we want to position pt?

fluid pushes up on their diaphragm leading to SOB, so position them high fowlers, sitting up.

Interventions for a patient with ascites?

* Fluid restriction
* Low sodium diet
* Small, frequent meals
* Avoid hepatotoxic drugs

Treatment for ascites?

* diuretics (spironolactone)
* Low Na diet
* Bedrest
* Paracentesis
* Monitor for bleeding
* Monitor for bp and heart rate
* Have pt empty bladder before procedure

Signs and symptoms for ascites

• ↑ abdominal girth & weight gain

• shortness of breath

• Striae & distended veins on abdomen

• Abdominal discomfort and umbilical hernia

• Fluid & electrolyte inbalances

With liver patients, it is important to monitor?

* liver enzymes
* bgm

Cirrhosis: what is it?

Scarring of liver tissue

* Chronice disease process that replace normal tissue with diffuse connective tissue
* •Greatest incidence with chronic alcohol abuse.

•Insidious onset

•Can progress over 30 years

S/S of cirrhosis

•Liver enlargement

•Portal Obstruction & Ascites

•Infection &  Peritonitis

•G. I. Varices 

•Mental Deterioration

•Edema 

•Vitamin Deficiency

•Pruritis

•Fetor hepaticus

Liver nursing management

•Promoting rest, HOB ↑ for SOB

•Improving nutrition

•Skin care (puritis)

•Risk of injury (bleeding, confusion, etc.)

•Psychosocial support for client and family

•Monitor and manage potential complications

•Promote home and community based care

Improving nutrition for liver patients

• HIGH protein diet with cirrhosis ***IF*** no ascites, edema, or encephalopathy

• Vitamin supplements (B complex, A, C, K, folic acid, thiamine)

• Small, frequent meals if ascites is present

• Probiotics

• Low sodium diet

• Fluid restriction if indicated

Normal WBC Level

4\.5-11.1

Normal INR Level

0\.9-1.1

What to promote for liver patients

•Dietary education

•Avoid alcohol, refer to AA is appropriate

•Avoid hepatotoxic medication (Tylenol, etc.)

•Educate on bleeding risk

•Educate on infection prevention

• Counseling if difficulty coping

Home health eval is appropriate

H2 antagonists are?

to prevent stress uclers

(pepcid/protonix)

Liver third spaces, what is third spacing also called?

edema

What medication is for ascites treatment? (hint: a diuretic)

Spironolactone

Always give albumin __ minutes before a diuretic..

30

Give prophylactic antibiotics to prevent _____ in liver disease?

Peritonitis