Pharm Exam 4

What does the gallbladder store?

bile from the liver

What is cholelithiasis?

stones in the gallbladder

What is cholecystitis?

inflammation of the gallbladder

If the gallbladder becomes infected, what should you do?

it needs to come out

What subjective assessments could be seen in a patient with gallbladder disease?

higher RUQ abdominal pain and n/v

What objective assessments could be seen in a patient with gallbladder disease?

fever, jaundice/pruritus, pale/clay-colored stool, labs, ultrasound, and ECRP

What labs are important with gallbladder disease?

CBC --> high WBCs, PT/INR/PTT --> clotting factors, AST, and ALT

What is the best way to tell whether the issue is the gallbladder or the liver since they have similar symptoms?

ultrasound

What do you need to monitor for after an ERCP?

it can be dangerous, uses fluoroscopy/CT dye, and need to monitor for pancreatitis since the pancreas duct is right next to the bile duct

What can cause pruritus in a patient with gallbladder disease?

the bile salts get backed up and the salt crystals can form on the skin

What diagnoses can you see with Gallbladder Disease?

pain, risk for infection, nausea, and imbalanced nutrition

What non-pharmacological implementations can we do for gallbladder disease?

nutritional support, IV fluids, NPO for acute episodes, low fat diet, NG tube, weight control, stop smoking, and exercise

Why is a low fat diet helpful for a patient with gallbladder disease?

bile is released with fat so a clear liquid diet full of carbs/sugars is best

Why is smoking cessation important for a patient with gallbladder disease?

it can cause the gallbladder to have spasms

What do you need for prep for an ECRP (endoscopic retrograde cholangiopancreatography)?

consent and don't want blood too thin so need to check coag factors like PT/INR/PTT

What is an ERCP (endoscopic retrograde cholangiopancreatography)?

A scope is put down the throat and a catheter is put into the bile duct, a wire is put into the duct further to see what's going on. If there's a gallstone, they can put in a balloon that goes up past the stone is inflated and pulls the stone out after a little cut is made at the edge of the duct and it will come out with feces

What surgical implementations can be done for gallbladder disease?

laparoscopic cholecystectomy, transhepatic biliary catheter, and lithotripsy

What can happen after a laparoscopic cholecystectomy?

the body won't have bile stored and it can lead to diarrhea

What is a transhepatic biliary catheter?

Aka a T-tube. It is inserted into the common bile duct above the stone to ensure patency of the duct to allow excess bile to drain into a drainage bag.

Where does the bag for bile drainage need to be located?

lower so the gravity can drain the bile

What do you need to make sure of with a biliary catheter?

there are no kinks/loops and you're seeing the bile come out

What do you need to do with a transhepatic biliary catheter when the patient eats?

you need to occlude it when they're eating so that the bile can go into the stomach; should only keep clamped for an hour

Why can hyperparathyroidism cause gallstones?

high calcium can cause calcium gallstones

What do you need to manage after a cholecystectomy?

carbon dioxide to inflate abdomen, fiberoptic scope with camera, removed through abdominal incision, may require a drain - T tube or JP drain, monitor for peritonitis/infection, sense of fullness after procedure, and right shoulder pain bc of CO2

What postop surgical nursing care can you do after gallbladder surgery?

ABCs, pain, n/v, vital signs, bowel sounds, incision care, and activity

What is pancreatitis?

inflammation of the pancreas

What is often the cause of pancreatitis?

cholelithiasis - if there's a stone where the pancreatic duct and bile duct meet, pancreatic juices can back up and severe alcohol abuse

What is interstitial pancreatitis (mild)?

may they don't drink for a while and it goes away and then comes back

What is necrotizing pancreatitis (severe)?

tissue of the pancreas starts to die

Is pancreatitis or gallbladder disease more serious?

you can die with pancreatitis

What subjective information should you assess for pancreatitis?

alcohol use, worst pain ever - can give ketorolac and pain meds, and pmh of cholelithiasis or weight loss

What objective information should you assess for pancreatitis?

jaundice, ecchymosis of flank area, umbilicus bruising, vital signs, CBC/BMP, amylase, lipase, really dark urine, ultrasound, and CT

What are the main labs for pancreatitis?

amylase and lipase

What electrolyte can be off with pancreatitis?

hypocalcemia which can cause Chvostek's and Trousseau's so we can give calcium IV

What is causing the bruising of the flank area and umbilicus?

blood vessels are breaking and leaking and the blood is leaking out

What diagnoses can you see with pancreatitis?

pain r/t irritation, imbalanced nutrition, deficient fluid volume r/t n/v/restricted oral intake, and risk for impaired gas exchange

What can cause impaired gas exchange in a patient with pancreatitis?

they're in so much pain they can barely move so they aren't taking deep breaths so if you treat the pain, you treat the gas exchange

What non-pharmacological treatments can you do for pancreatitis?

get alcohol under control (ETOH), hanging over/sitting up to get pressure off pancreas, accuchecks, STRICT NPO, NG to LIS, TPN, and surgery

Why do patients with pancreatitis need accuchecks?

the amylase can't break down carbs and the pancreas isn't producing insulin well

If a patient has Necrotizing pancreatitis or pancreatic cancer, what surgery should you do?

Pancreaticojejunostomy; want to remove the common bile duct and attach the pancreas to the jejunum

What do you need to monitor for after a Pancreaticojejunostomy?

peritonitis/infection because of all the stitches

What electrolytes may need replaced with pancreatitis?

calcium and magnesium

What increases the risk for pancreatic cancer?

smoking and alcohol

Why is metastasis likely with pancreatic cancer?

the pancreas is closely attached to multiple organs

Why is pancreatic cancer so deadly?

they usually do not seek medical attention until later stages or think it's heartburn and don't get it checked out

What nursing management can you do for a patient with pancreatic cancer?

pain control and nutrition through TPN or a PEJ tube is going home

What is the most common cause of liver failure?

viral hepatitis

Why is the liver so resilient?

2 blood supplies: Hepatic/portal vein = nutrients and hepatic artery = oxygen so it's getting fresh oxygen and nutrients

What happens if the liver is damaged?

blood and nutrients can't penetrate the liver

What does the liver make?

albumin

What can occur in the integumentary system from liver damage?

pruritus, jaundice, spider angioma/veins, petechiae, and easy bruising

What can occur in the endocrine system from liver damage?

glycogen is stored in the liver and isn't being produced so hypoglycemia, unable to metabolize estrogen and testosterone so loss of hair, testicular atrophy, impotence, loss of libido, and amenorrhea

What can occur hematologically from liver damage?

anemia, thrombocytopenia, coagulation disorders, and splenomegaly

What can occur metabolically from liver damage?

hypokalemia, hyponatremia, and hypoalbuminemia

What can occur in the cardiovascular system from liver damage?

fluid retention, peripheral edema, and ascites

What can occur in the GI system from liver damage?

diarrhea/constipation, esophageal varices, hemorrhoidal varices, hematemesis, and n/v

What can occur neurologically from liver damage?

hepatic encephalopathy and asterixis

What is hepatic encephalopathy?

when a patient has protein, protein is broken down to ammonia in the liver and then is broken down to uria and you pee it out - microbiota in your gut also make ammonia; if someone's liver isn't working, their ammonia levels can get high in the brain which causes the neurons to swell and the patient will be out of their mind

What is asterixis?

high ammonia causes the patient's hands to flap up and down uncontrollably/tremors

If a patient with liver damage starts vomiting blood or having bloody stools, what should you do?

notify the provider

What are the main ways to diagnose liver damage?

AST, ALT, GGT, look for an underlying cause with virology testing or biopsy, and ultrasound

What labs would you see with liver disease?

elevated everything but albumin

What are some diagnoses you would have for liver disease?

imbalanced nutrition, impaired skin integrity, excess fluid volume, decreased cardiac output, and acute/chronic confusion

What implementations can you do for imbalanced nutrition?

high carb, high protein, low sodium diet - may need to fo enteral feedings if having trouble eating

When wouldn't you want to do a high protein diet for someone with liver disease?

if they have high ammonia levels

Why do you want to decrease fat intake with liver disease?

no bile is being made so fat can't be broken up

Why do you want a low sodium diet with liver disease?

lots of sodium in the body being retained that's diluted because of lots of water so want to minimize intake; can give salt substitutes like Mrs. Dash but they can be high in potassium so watch it

Why would a patient with liver disease need vitamin supplements?

folate, iron, and thiamine are made in liver so at risk for anemia (iron) and confusion/Wernicke's (thiamine)

What do you need to educate your patient on for their diet?

they need to upkeep the low sodium, high carb, and high protein diet at home or their symptoms won't go away

How much sodium can someone on a low sodium diet have?

less than 500 mg/day

What implementations can you do for impaired skin integrity?

lotion, keep nails short, padded gloves if necessary, medications, and meticulous skin care - roho cushion, specialty mattresses, repositioning, and mobility

what areas of the skin are more prone to skin breakdown?

edematous areas

What are the cells in the liver that protect you from infection and protect the GI system (5 second rule)?

Kupffer cells - decreased in liver disease so more risk for infection

What can you implement for excess fluid with liver disease?

fluid/sodium restriction, diuretics, and treating ascites

What do you need to do if you give your patient diuretics?

need a urinal/bedside commode by the bed or make sure they have the call light if they need to go

What can you do to alleviate ascites in a patient with liver disease?

paracentesis, TIPS, positioning, electrolyte replacement, and give albumin

If a patient has never had a paracentesis done, what should you do?

take a sample of fluid and send it in

Do you need a consent form for paracentesis and TIPS?

yes

What do you need to be careful of when doing a Transjugular intrahepatic portosystemic shunt (TIPS)?

they need to have functioning kidneys before the fluoroscopy or a bicarb buffer if they don't

What is the best indicator for fluid volume?

weight

What is a TIPS procedure?

inject dye and put a stent in between the portal and hepatic vein to reroute everything from the GI to the body directly; issue = meds wouldn't be metabolized so get a larger dose, not extracting vitamin K so your clotting factors aren't working

What position is best for ascites?

sitting in recliner or chair; laying down puts pressure on diaphragm

Is it normal for electrolytes to burn when given through IV?

yes but can mix lidocaine into it

What can decreased cardiac output be caused by?

esophageal/gastric varices or ascites

What implementations can you do for esophageal/gastric varices?

IV fluids, blood transfusions, CBC/BMP/clotting factors, foley catheter/strict I/Os, balloon tamponade, endoscopic sclerotherapy/variceal ligation banding, TIPS, and pharmacological therapy

What are clotting factors?

PT, PTT, INR; if low you may want to give vitamin K

What is the balloon tamponade?

If a patient has ruptured esophageal varices, they will put a tube down with balloons and inflate it so that there is pressure on the bleeding; will stay in until the patient is stabilized and then they can do an endoscopy and find the bleeding to cauterize them/fix the bleeds

What is endoscopic sclerotherapy?

medications that they can go in and put on that solidifies and helps stop the bleeding

What is variceal ligation banding?

Putting bands around the varices to cut off blood flow

If a patient has low blood pressure, what should you do to try to treat it?

give albumin first but if that doesn't work give IV fluids

What implementations can we do for ascites with liver disease?

give lots of albumin to raise BP and increase urine output

What implementations can you do for confusion with liver disease?

ammonia-lowering agents, vitamins, and safety

What vitamins can you give for confusion with liver disease?

thiamine, folic acid, A, B, D, and E

What safety issues do you need to watch for with hepatic encephalopathy?

at risk for falling, may need a sitter, video monitoring, bed alarm, etc

What can you do to prevent liver disease?

vaccines - hep B, safe sex practice - hep C, diet and exercise - low fat, and avoid substance abuse/drinking

What can the patient monitor for early identification of liver issues?

GI bleed symptoms, swelling - ascites or lower extremities, and changes in urine, skin, or stool - jaundice, dark urine, or pale/fatty stool

Can you get a liver transplant as an alcoholic?

not likely; need to be alcohol free for about 6 months

What score is used to determine transplant priority?

MELD score

Do they replace the whole liver?

no, just a small piece since the liver regenerates

If the case worker doesn't think the patient will take the anti-rejection meds, will they get the transplant?

no