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Acute Liver Failure

Acute Liver Failure and Pancreatitis

What are the criteria for acute liver failure? Evidence of coagulation abnormality (INR > 1.5), any degree of mental alteration (encephalopathy), Illness of < 26 weeks.
Typically acute liver failure patients do not have a history of: Hepatitis or Cirrhosis
What are the leading causes of acute liver failure? Acetaminophen toxicity, suicide attempts, the rest is unintentional, idiosyncratic drug reactions, infections, Hepatitis A or B, CMV - Cytomegalovirus, Ischemia, and other diseases.
Diagnostic findings in acute liver failure (ALF). Increased ALT and AST, lesser increases in alkalotics, near complete necrosis when enzymes return to normal but PT, INR, and bilirubin increase.
Why shouldn't we be fooled if the ALT and AST are normal? If the liver is so damaged that it is necrotic, it cannot secrete ALT or AST to let you know there is damage.
When the enzymes return to normal in ALF, what do we see? We see COMPLETE necrosis, but the PT, INR and bilirubin increase.
What does a ELAD do? It performs a lot of filtration function s and a lot of detoxifying that the liver does.
What is an ELAD? Wcternal Liver Assistant Device
What do we do to manage ALF? Nursing care related to the complications, liver assist devices, ELAD, liver dialysis, and possible transplant.
When providing nursing care in ALF, we provide care related to what complications? PSE (encephalopathy), varices, nutrition, bleeding tendencies, safety, prevention of sepsis.
If nursing care and liver assist devices aren't effective in managing ALF what is our next option? Liver Transplant
Sometimes Acute Liver Failure is referred to as: Fulminant Hepatic Failure - meaning that it just sort of rushes in like a storm!
What does liver disease do to the patient's nutrition? There is an alteration in nutrition because the liver stores and metabolizes all your nutrients.
How are calorie needs affected in liver disease? The calorie needs are increased because ascites has a hypermetabolic effect. Protein stores are also broken down because of protein in their ascitic fluid.
What will the patient with liver failure look like physically. Thin arms, thin legs, muscle atrophy, cachexic appearance.
What are the hypermetabolic effects of a paracentesis if the patient has liver disease? If a paracentesis is done, you are going to pull out all those proteins, this causes hypermetabolism.
Normally we get 80% of our energy from glycolysis and 20% from protein and fats. So when you need carbs, what does your liver do? It breaks down your glycogen stores.
A person with liver disease gets 30% of their energy from glycolysis andx 70% of their energy from protein and fats, what does this cause to happen to the patient? The patient literally melts away as muscle and fat breakdown. They have a cachexic appearance.
What kind of things might effect intake of patients with liver disease. Taste preferences change, ascites impact, anoreixia, intake can vay depending on encephalopathy, and effects of Interferon can effect appetite.
How do taste preferences change in people with liver disease? They can have an aversion to meat, they are not fond of sweets, they crave fruits, and thery do like fat!
How would intake vary depending on encephalopathy? There may be less encephalopathy in the morning, therefore they may be more alert, and have more of an appetite.
How would ascites impact the diet in patients with liver failure? Ascites will decrease the stomach volume. they will want to avoid gas forming foods and carbonated beverages.
What would you do for a patient with anorexia due to liver disease? You would give them Megace to stimulate the appetite, make the food look attractive, and consider the patients likes and dislikes.
What would you do for a patient who has lost their appetite because of Interferon drug therapy? Make sure they drink lots of fluids throughout the day.
What do the pancreas do? The pancreas secret digestive enzymes that go into the duodenum and aid in digestion.
What do the Alpha cells of the pancreas do? They secrete glucagon which tells your liver to breakdown glycogen.
What do the Beta cells of the pancreas do? They secrete insulin and insulin decreases blood sugar by allowing blood sugar to enter the cell.
What are the digestive enzymes of the pancreas? Amylase, lipase, tripsin, and pepsinogen.
Why do you see autodigestion with acute pancreatitis? The inflammation in the pancreas causes the duct to close off so that the digestive enzymes can't get out, they then start gobbling up the pancreas.
What causese acute pancreatitis? They aren't sure, but no matter what causes it, the digestive enzymes can't get out and therefore they start gobbling up the pancreas.
The two leading causes of pancreatitis are: Gallbladder disease and alcoholism.
Who is most likely to experience gallbladder disease? The four F's: Fat, Female, Forty and Fair.
Gallbladder disease is more common in: women
Why is alcoholism a leading cause of pancreatitis? Alcohol is a toxin to the liver and because of its proximity, it causes a lot of damage to the pancreas as well.
What are some additional causes of pancreatitis? Abdominal trauma, perforated ulcers, certain drugs , infections, heredity.
What kinds of drugs can cause pancreatitis? Steroids, long term use of birth control pills, thiazide diuretics.
What are the signs and symptoms of pancreatitis? Pain, mild jaundice,discoloratin of the abdomen and flank, absent or decreased bowel sounds, s/s shock, LOc changes, hyperglycemia, neuromuscular irritability, and associated disorders.
Why do patients with acute pancreatitis curl up in the fetal postion when they are experiencing pain? Because the fetal position takes the pressure off of the Retroperitoneal Nerve and helps to relieve the pain.
Why do patients with acute pancreatitis have mild jaundice. Because the pancreas swells and puts pressue on the common bile duct. This impedes the flow of bilirubin.
What causes the discoloration of the abdomen and the flank in patients with pancreatitis? It is an accumulation of the enzymes that eventually leak out into the tissue. It is just enzymes under the skin.
Why would the bowel sounds be absent or decreased in a patient with pancreatitis? Becaue pancreatitis can lead to peritonitis or acute bowel obstruction.
What types of shock would you watch for signs and symptoms of as a nurse caring for a patient with pancreatitis? Hypovolemic or hemorrhagic shock caused by hemorrhages or within the pancreas or fluid shifts, and septic shock caused by the inflammation.
What causes LOC changes in the patient with pancreatitis? With pancreatitis, there is some respiratory involvement because the pancreas is putting pressure on the diaphragm. This could cause the patient to go into hypoxia. Sepsis could also effect LOC in this patient.
Why does the patient with pancreatitis get hyperglycemia? Becaue the pancreas is unable to secrete enough insulin to the blood sugar will be elevated.
What causes the neuromuscular irritability in patients with pancreatitis? The end up with low calcium and when you have low calcium, it can cause tetany, and twitching.
Why do we need to carefully monitor lung sounds in a patient with pancreatitis? Lung aeration is not very good in these patients. They can have dyspnea and pleural effusion.
These patients can develop clotting abnormalities like DIC, and this disease can be fatal. Patients with pancreatitis.
What is Cullen's sign? Bluish discoloration around the abdomen.
What is Turner's sign? Bluish discoloratio in the flanks.
What do we consider the key to identifying acute pancreatitis? Labs - elevated amylase and lipase
This enzyme would be the most reliable for 24 hours after the onset of symptoms of acute pancreatitis. Amylase
This enzyme begins to elevate 3-6 hours after onset of symptoms, its peak is at 20-24 hours. Amylase
This enzyme increases after the amylase and it can stay elevated much longer. Serum Lipase
Typically if it is after a day of symptoms of acute pancreatitis, we start to look to see if what is elevated? Lipase
This enzyme can stay elevated up to 14 days longer than amylase. Lipase
What abnormal lab is the most reliable for the first 24 hours? Amylase
How does pregnancy effect amylase values? It can cause moderte increases, and women who take oral contraceptives have slightly decreased amylase levels.
Why is amylase not detectable in newborns? The stimulation for amylaseis food in the belly, so if they are newborn, no food in the belly and no stimulation for amylase.
Would an older patient have higher or lower amylase values? Higher
Why is bilirubin be increased in pancreatitis? The pressure of the common bile duct , the bilirubin cant get through so it is going to back up and you will have elevated bilirubin.
Why is alkaline phosophate increased in patients with pancreatitis? Alkaline phosophate is an enzyme coming form the cells lining the common bile duct. They are released to send out a message that tthe common bile duct is not happy.
Why would serum calcium, potassium, and magnesium be decreased in a patient with pancreatitis? There are a lot of electrolyte shifts to compensate. Calcium gets trapped in the pancreas.
Why is albumin decreased in patients with pancreatitis? Because we are not going to absorb any nutrients.
What causes the increase of WBC's in patients with pancratitis? The inflammation causes the increase in WBC's.
What is the #1 nursing priority in patients with pancreatitis? PAIN
What is the medication of choice for managing pain caused by pancreatitis? Morphine is the best.
What effect do all opioids have on the common bile duct? They increase pressure in the common bile duct.
Aside from causing pressure in the common bile duct, what other effect does morphine have here? It can also cause spasms in the common bile duct.
What could we give a patient that is having smooth muscle spasms in the common bile duct from administration of morphine? We can counteract it with smooth muscle relaxants such as nitroglycerine 0.6mg sublingually or amyl nitrate (inhaled). This will relax the coronay arteries, and relax the GI
If you administer Narcan/Naloxone to help relieve pain being caused by pancreatitis, what do you need to make sure you do? You have to give a real small amount because if you give too much of that you totally reverse the effect.
Why will a patient with pancreatitis be NPO? Becaue we don't want any stimulation for the ancreas. Anything in the stomach can stimulate the pancreas to produce enzymes.
Why may a patient with pancreatitis require respiratory therapy? Because they are at a greater risk for pleural effusions.
What is a pseudocyst? A fluid filled pocket.
What are some potential complications of pancratitis? Inflamed gallbladder, hemorrhage, abscess, pseudocyst, and fistula.
What could the complication of a fistula cause? Fistulas or tracking could develop into the pleural cavity or pelvis o another loop of the bowel.
Why would a CT or an ultrasound be used when a patient has pancreatitis? To detect if the patient has any pseudocysts ro fistulas.
As a patient is diagnosed and treated for acute pancreatitis, as they respond to treatment, you would expect their lipase levels to do what. To go down.
If the patient is responding to treatment for acute pancreatitis and their lipase levels remain elevated, they probably have: A psudocyst developing. A CT or an untrasound may done to determine this.
What is it important to make sure the patient with acute pancreatitis understands? The patient needs to understand any kinds of restrictions, and the importance of taking pancreatic enzymes if needed.
What is viokase? A pancreatic enzyme.
When do you administer pancrease? 1/2 hour befor meals and that will assist them in digestion.
What is pancrease? The digestive enzymes tha the pancreas can't normally produce.
Almost always, alcohol is involved in this type of pancreatitis Chronic Pancreatitis
What are the signs and symptoms of chronic pancreatitis? Greasy, oily, foul smelling stools that are clay colored. These patient also exhibit the s/s of diabetes including polyuria, polydipsia, and polyphagia.
Why is the urine a dark tea color in patients with chronic pancreatitis? Because the bilirubin cant get through to the intestine, and it instead goes into the urine.
How does a patient manage chronic pancreatitis? They have to stop drinking because of how much damage the alcohol is causing to the pancreas. Enzyme replacements need to be taken, and blood sugar may have to be treated if it is elevated.
What are the risk factors for pancreatic cancer? Cigarette smoking, diets high in fat and meat, and a history of peptic ulcer disease, diabetes mellitus, chronic pancreatitis, environmental toxins, industrial chemicals.
What kind of pancreatitis is a risk factor for pancreatic cancer? Chronic Pancreatitis
What activity is a MAJOR risk factor for pancreatic cancer? Smoking
What kind of a diet is a risk factor for pancreatic cancer? A diet high in fat and meat.
How could industrial chemicals become a risk factor for pancreatic cancer? Some chemicals are buried in barrels and ground water gets contaminated. This could be an issue.
Pancreatic cancer is more prevelant in: Males and African Americans
The 5 year survival for patients with pancreatic cancer is what percentage? 3%
What is the 4th leading cause of cancer deaths? Pancreatic Cancer
Most of the time people who are diagnosed with pancreatic cancer are diagnosed: At later stages.
What are the symptoms of pancreatic cancer? They are very vague. Weight loss, abdominal pain, jaundice, itching (pruitis).
What is the screening test for pancreatic cancer? There is no screening test for pancreatic cancer.
An X-ray of the common bile duct. Dye is used with this x-ray. Cholandiography
This procedure is done if a patient has jaundice and they can't figure out why they have jaundice. ERCP
This procedure can take a sample of tissue and then determine whether or not there is a malignancy there. ERCP
If a patient has abdominal pain, is jaundiced and they can't figure out what is going on and the labs are coming back inconclusive, what diagnostic test will be done? ERCP
This test is a multi-purpose test, it can remove gallstones, do biopsies, and insert stent's in the common bile duct. ERCP
What is CEA? Carcino-Embryonic Antigen that is elevated when someone has cancer.
Most of the time, where in the pancreas is pancreatic cancer located? In the head of the pancreas.
Three months is enough time for pancreatic cancer to: SPREAD
Most will die from pancreatic cancer within: 3-6 months
9 out of 10 patients with pancreatic cancer have no: Family History
A surgery that includes removing or resecting part of the pancreas. Whipple operation
What is immunotherapy for pancreatic cancer? A treatment in which they remove cancer cells from a patient and reinject those cells in a vaccine into the same patient to stimulate their immune system to fight the cancer.
How is pancreatic cancer treated? Chemotherapy, radiation, and surgical (whipple procedure).
What is a pancreatoduodenectomy? A procedure where they remove a good portion of the pancreas, a portion of the lower stomach, the whole duodenum and then they pullup the jejunum and anastamose it to the common bile duct.
In this procedure, there are two anastomosis sites. One connecting the pancreas to the jejunum and the other connecting the stomach to the jejunum. Whipple Procedure
As a nurse it is important to know that you cannot lie the patient flat after a whipple procedure. Why? You could pull out the anastamoses, and keepin the patient in semi-fowlers position also promotes better lung expansion.
Post op whipple procedure patients will usually be in ICU for how long? 24 Hours
Why don't we forcibly irrigate the NG tube and why do we NEVER repositon the NG tube? Because we could easily stick it right through the anastamoses site and rip it right open.
If the patient who has had a whipple procedure is in pain all of a sudden what might this mean? The anastamosis are disrupted or there can be some leakage from the anastamosis sites.
How often should we have the patient who has had a whipple procedure change positions? Q 1-2 hours
What complications would we monitor for in a patient who has had a whipple procedure? Hypovolemic shock, hemorrhage, hepatorenal failure.
Why would hepatorenal failure be a complication we need to watch for after a whipple procedure? Because the blood gets shunded to the major organs, so it would go to the heart, lungs and the brain, NOT the kidneys or liver.
Why would a patient have blood sugar issues following a whipple procedure? Because they have had a big part of their pancreas removed.
Just like pancreatitis, patients who have had the whipple procedure will have issues related to digestive enzymes, so they will have to take: Pancrease or viokase enzymes before they eat.
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