199 terms

Adult 3 - oral, colon,pancreas, gastritis cancer - RR

Define oral cancer
Cancers involving any part of the mouth, tongue, gums, pharynx, lips
--curable if found early (most of the time not found early)
Most common sites for oral cancer
Lips - lateral tongue - floor of mouth
Risk factors for oral cancer
Smokeless tobacco - smoking - excessive etoh - over 50 - AA man
--combined use of tobacco and etoh due to synergistic carcinogen effect
Type of oral cancers
Mostly SCC
also BCC
Oral SCC
Surface of epithelium
-slow growing dysplasia - non painful - crusted/scaly lesions that won't heal
Oral BCC
Primarily on lips
-ulcer with raised pearly border
-non healing/masses/bleed easy
--lesion that is nonhealing for 2 weeks to mth = need to see dr
S/S of oral SCC
-crusted scaly area on skin w/ red inflammed base
-persistent non healing ulcerated bump or thickened skin on lower lip
-wart like growth or plaque
-red scaly patches or bumps
S/S of oral BCC
-slow growing
-raised border
-can have ulceration
-bleed when disturbed
-depression in the center and can ooze
Dx of oral ca
Oral exam
Cervical LN assessment
CT head/neck
Bx any lesion that doesn't heal in 2 weeks
Standard tx of oral ca
-Surgery to remove and clear margins
-Radiation - to shrink - sometimes preop to make margins easier to clear w/o deforming (sometimes implanted into tongue)
Oral tumors that are > 4 cm =
will come back
What is a radical neck dissection
Removal of all cervical LN
-from mandible to clavicle & removal of sternocleidomastoid muscle, internal jugular vein, & spinal accessory nerve
Complications of radical neck dissection
Shoulder drop - poor cosmetic (visible neck depression)
Modified radical neck dissection
Preserves one or more of the nonlymph structures
-used more often
-selective neck dissection
-preserves 1 or more LN groups, internal jugular, muscle and nerves
Reconstruction for neck dissections
With flap & vasculature
-cutaneous flap with skin & subq tissue
-myocutaneous flap with subq tissue, mucle & skin - more freq used
What is used for large skin grafts in reconstruction for neck dissection
Microvascular free flap
-involves transfer of muscle, skin, or bone w/ artery or vein
Complications s/p neck dissection
-risk for swelling of posterior pharynx
--temporary trach
-chyle fistula
-nerve depression
-impaired airway
What is the #1 concern s/p neck dissection
Patent airway
#2 = hemorrhage
RN interventions s/p neck dissection
-Put in fowlers or high fowlers - to facilitate breathing and drainage of lymph fluid and blood, swallowing
(never flat = blood can pool/clot)
-call light in reach
-pain control
-wound/flap care
-assess for nerve injury
What are the s/s of hemorrhage s/p neck dissection
S/S shock (hypoTN, tachycardia)
-saturated dressings
What is a chyle fistula
Damage or cutting of lymph duct system in the neck during dissection
-damage to thoracic duct in surgery
S/S of chyle fistula
Drainage of "milky white" or clear fluid
- Drainage ranges from low output (< 500 mL/day) to more than 3 L /day
-excess drainage that has a 3% fat content and sp gravity of 1.012 or more
What can peristent chyle fistula lead to
Elyte disturbance, hypovolemia, hypoalbuminemia, coagulopathy, immunosuppression, chylothorax, and peripheral edema, wound infection and local skin breakdown.
---Prolonged chyle leak can lead to mortality
why are drains used in neck dissections
To prevent collection of fluid subq
-between 80-120 mL of serosanguineous may drain for 1st 24H
--excess drainage could mean hemorrhage or chyle fistula
Assessing incision s/p neck dissection for infection
Grafts should be pale pink and warm to the touch
-watch incisions for pus and malodorous drainage
-aseptic technique to clean around incision
Avoiding hemorrhage s/p neck dissection
-VS Q 1-2 H - then Q4H after stabilized
-avoid valsalva
-high epigastric pain = impending rupture signs
-assess dressings for excessive bleeding
Nerve injury s/p neck dissection
Can occur if cervical plexus or spinal accessory nerve is severed
--can cause lower facial paralysis
-if laryngeal nerve is severed = problems swallowing
How to assess for nerve injury s/p neck dissection
-have pt smile, frown, move jaw
-can they swallow?
What are lower jaw fx?
Mandibular fractures -- wired shut
-if nausea = fix asap! (risk of aspiration)
**take wire cutters everywhere w/ pt and have bedside always
-eating thru straw
-exposed wires - put wax on ends or bend wire
-oral suction if needed
What is gastric cancer
Occurs anywhere in the stomach
--pylorus (40%)
--Body (40%)
--Cardia (15%)
--Multiple (10%)
--tumors can infiltrate surrounding areas
What is the most common kind of gastric ca
--86% occur in stomach lining
Early s/s of gastric cancer
-usually asymptomatic
-pain releived w/ antacids
Risk factors for gastric ca
-diet high in smoked meat, pickled & salted food
-men and > 55 years old
-porr drinking
Late s/s of gastric ca
-early satiety (full earlier) b/c tumor taking up space
-wt loss
-abd pain above umbilicus
**anemia = late s/s
Assess & dx of gastric cancer
EGD w/ bx & cytology (**study of choice)
Stools for occult blood
CBC - ck for anemia
--gastric tumors not palpable until advanced stages
--monitor for CEA's for recurrence Q6m forever
Problems associated w/ gastric ca
-Pyloric obstruction
-Bleeding and *anemia*+
-Severe pain
-Gastric perforation
Medical mgmt for gastric ca
Surgery (total gastrectomy)
Tumor resection
Dx laparoscopy
Palliative care
What is a total gastrectomy
Removal of entire stomach, duodenum, LN & mesentary, lower part of esophagus
-connect esophagus to jejunum
Problems of gastrectomy
Without stomach - there is no secretion of intrinsic factor
-intrinsic needed for absorption of V B12 to prevent pernicious anemia
What will a pt w/ total gastrectomy need for the rest of their life
Vitamin B12 injections
What is a diagnostic laparoscopy
Evaluate gastric tumor and take tissue bx and look for mets
Palliative care for gastric cancer
No successfult tx other than removal of tumor
-if unable to remove tumor = do chemo
What are 2 other types of surgery for gastric cancer
*Biliroth I - pylorus is removed and the proximal stomach is connected to the duodenum
*Biliroth II - (gastrojejunostomy) - the greater curvature of the stomach is connected to the jejunum in a side-to-side manner.
Biliroth 1 is better for what?
Stomach function
Biliroth 2 is better for what?
Decrease recurrence
Indications for gastric surgery
-life threaten hemorrhage
-gastric cancer
-ulcerations that are not responsive to meds or EGD tx
Complications of gastric surgery
**Short term
-anastomosis leak - blood clots - bowel obstruction
**Long term
-B12 deficient - esophagitis (constant GERD) - osteoporosis - dumping syndrome
Nutrition for s/p gastric surgery
-eat small freq meals
-avoid drinking fluids w/ meals
-low sugar intake
**high fat and protein for calories
obstacles to good nutrition s/p gastric surgery
dumping syndrome and reflux
What are the s/s of dumping syndrome
-full sensation - weak - faintness - dizzy - palpitations - sweating - cramping pains - diarrhea
--resolve after intestine has been evacuated
--later = rapid elevation of BS & increased insulin secretion = reactive hypoglycemia
When do vasomotor s/s of dumping syndrome occur
10-90 minutes after eating
--pallor, sweat, palpitations, HA, warmth, dizzy, drowsy
--could also eventually cause steatorrhea (prevents adequate mixing of panc & biliary secretions)
Goals for nursing s/p gastric surgery
Reduce anxiety
Maintain weight
Relieve pain
Prevent infection
Palliative care for gastric surgery
Decrease pain
Radiation - for pt w/ obstruction r/t tumor, GI bleeding, severe pain
Surgery - bypass the tumor
What are the risk factors for pancreatic cancer
-Increasing age (peaks 70-80)
-Chemical exposures
-Diet high in fat/or meat
-DM, chronic pancreatitis, hereditary
Where does 70% of pancreatic ca occur?
Head of the pancreas
What are the early s/s of pancreatic ca
-Vague - non specific
-Vague pain, epigastric may radiate to the back = increases w/ food
-rarely dx at this time
What are the late s/s of pancreatic ca
-Mets to other organs
-S/s of obstruction
**Pain, jaundice & weight loss are classic s/s
-ascites from cancer cells in the peritoneum
Dx of pancreatic cancer
CT (85-90% accurate)
Endoscopic US
Gi xray (just shows malformation)
CA 19-9, CEA, DU-PAN-tumor markers non specific for panc ca but used to mark progession
Treatment for pancreatic ca
Surgical resection / whipple or pancreaticoduodenectomy
What is pancreaticoduodenectomy
Used for resection of head of pancreas when thought to be only site of cancer
-GB removed, part of stomach, duodenum, proximal jejunum & head of panc & common bile duct are removed
-rest of panc connected to jejunum along w/ stomach
-allows bile to flow into jejunum
What will the patient have to manage s/p pancreaticoduodenectomy
Intake of fat and carbs post op
-may require panc enzymes added to their meds
How many lobes does the liver have
*What are the sources of perfusion to the liver
Hepatic artery
Portal vein
-terminal branches join to form the capillary beds
What is the portal vein
80% of the blood supply to the liver comes from the portal vein
--drains the GI tract
--rich in nutrients / lacks O2
What is the hepatic artery
20% blood supply to the liver
-rich in O2
What are the common capillary beds
Terminal branches of the hepatic artery and portal vein
-mixture of venous & arterial blood bathes the liver cells
Functions of the liver
Hepatic dysfunction occurs when?
Damage to hepatocytes / liver cells
What are the causes of hepatic dysfunction
Primary liver disease - acute/chronic cirrhosis
Obstruction of bile flow - gallstones
Derangements of hepatic circulation - portal hypertension
Common s/s of liver disease
-Hemolytic (RBC destruction)
-Hepatocellular (bili levels up due to damaged liver cells)
-Obstructive (gallstones, tumors, pressures from enlarged organs)
-Hereditary hyperbilirubinemia (increasing bili w/o liver damage)
What is jaundice caused by
Accumulation of bilirubin in the boold that the liver is unable to breakdown
What 2 things are directly linked to liver disease
Portal HTN
What is portal hypertension
Increased pressure thru the portal venous system
-caused by obstruction of blood flow thru the damaged liver
What are the 2 major consequences of portal HTN
Pathophys of ascites
Increased capillary pressure
Fluid shift into intraperitoneal space
S/S of ascites
-increased abdominal girth
-rapid weight gain
-flanks bulge when in supine position
-fluid wave
What is fluid wave
lay flat - hand at umbilical and tap rt or lt side - watch fluid "wave"
Assess for ascites
Abd girth measurements
Watch respirations - causes pressure on diaphragm
Vasodilation, H2O & Na+ retention
Medical mgmt of ascites
-Diet - decrease protein
-Diuretics - pull fluid off
-Paracentesis - to pull fluid off
-Transjugular intrahepatic portosystemic shunt (TIPS)
What is directly related to esophagus varices
Portal HTN
Nursing mgmt for liver disorders and ascites
-Abd girth measurement
-Daily weights
-Frequent rest periods
-Small freq meals
Portal HTN is a result of what
It is the increased pressure thru the portal venous system that results from obstruction of blood flow thru the damaged liver
What is the type of fluid of ascites
As a result of liver damage - large amounts of albumin-rich fluid, 15L or more, may accumulate in the peritoneal cavity as ascites
What are esophageal varices
Dilated tortuous veins found in the submucosa of lower esophagus
-develop from elevated pressure in the veins that drain into the portal system
-prone to rupture & source of massive GI bleed
Why should a pt w/ ascites be placed on bedrest
Upright posture is assoc w/ activation of renin-angiotensin-aldosterone system
-causes reduced glomerular filtration & Na+ excretion and decreased response to diuretics
What is the TIPS procedure
Treats ascites
-cannula threaded into portal vein by transjugular route
--to reduce portal HTN, stent is placed to serve as intrahepatic shunt between portal circulation & hepatic vein
-tx of choice for refractive ascites
--decreases Na+ retention & prevents recur of fluid accumulation
What causes esophageal varices
** almost always caused by portal HTN
--the worse the portal HTN, the higher it can go
-esophagus not designed to swell & shrink so stay swollen
**hemorrhage easy and quick
--if liver disorder and vomit = emergent b/c weakens vessel walls
S/S of esophageal varices (book)
*rapid decrease in mental / physical status
Often hx of etoh abuse
S/S of shock could be present
Dx of esophageal varices
*Immediate EGD
--identify cause and site of bleeding
*Portal system pressures
How are portal HTN measured
Palpable enlarged spleen and ascites may be present
-can be measured indirect or direct
Indirect measurement of portal HTN
Most common
-requires inserted cath w/ balloon into antecubital or femoral vein
-advance to hepatic vein
-fluid infused to inflate balloon
-wedge pressure taken by occluding blood flow and measure unoccluded vessel
Direct measurement of portal HTN
Needle into spleen during laparotomy
-manometer greater than 20mL is abnormal
-another method is to insert cath into portal vein or its branches
First line of tx for esophageal varices
-for people W/O CAD
-produces constriction of preportal splanchnic arterioles & decreases portal pressurs
Other medical mgmt for esophageal varices
Balloon tamponade
Endoscopy - sclerotherapy & variceal banding
What is balloon tamponade
To control hemorrhage in esophageal varices
-pressure is exerted on the cardia (upper orifice of stomach)
-tube has 4 openings for gastric aspiration, esophageal aspiration, gastric & esophageal balloon inflation
-compression of bleeding varices by inflation of balloon
-gastric & esophageal outlets allow nurse to aspirate secretions
Where should the pt getting balloon tamponade remain
ICU b/c of risk of complications
-monitor close and continuouss
-no more than 24 hrs
What is sclerotherapy
For esophageal varices
-sclerosing agent injected thru endoscope into bleeding varices to promote thrombosis & sclerosis
-treat acute GI bleed but NOT prevention and subsequent variceal bleeding
What is cirrhosis
CHRONIC disease characterized by replacement of normal liver tissue w/ diffuse fibrosis that disrupts structure & function of liver
---scarring of liver
Pathophys of cirrhosis
Liver cells necrose
Destroyed cells replaced by scar tissue
Eventually more scar tissue than functioning tissue
Hobnail appearance -
Why does cirrhosis cause hobnail appearance
Due to islands of normal tissue and regenerating liver tissue
Cirrhosis types
Alcoholic (Laennec's)
Post necrotic
Who is at higher risk for cirrhosis
Weomen who drink
age 40-60
What is the most common type of cirrhosis
--effects circulation & nutrients & O2 of portal area
What is alcoholic cirrhosis
Scar tissue normally surrounds the portal areas
-most frequently caused by chronic alcoholism
What is postnecrotic cirrhosis
Broad bands of scar tissue
-late result of a previous bout of acute viral hepatitis
What is biliary cirrhosis
Scarring occurs in liver around bile ducts
-results from chronic biliary obstruction & infection
--least common of the types of cirrhosis
Most common cause of cirrhosis
etoh consumption
-reduced protein intake contributes as well
What are the s/s of cirrhosis (child pugh scale)
The more of these s/s the poorer the outcome
-ascites (absent 1 - slight 2 - moderate 3)
-bilirubin (+ to or < 2 is a 1 - 2-3 is a 2 - moderate >3 is a 3)
-albumin (>3.5 is a 1 - 2.8-3.5 is a 2 - < 2.8 is a 3)
-pt (1-3 is a 1 - 4-6 is a 2 - >6 is a 3)
-encephalopathy (None is 1 - gradet 1-2 is a 2 - grade 3-4 is a 3)
What is compensated cirrhosis
-Less severe
-vague s/s
-early disease
-discovered secondary at a routine physical exam
What is decompensated cirrhosis
-Late disease
-Result from failure to synthesize proteins, clotting factors other manisfestations of portal HTN
S/S of compensated cirrhosis
-intermittent mild fever
-vascular spiders
-reddened palms (palmar erythema)
-unexplained epistaxis
-ankle edema
-vague morning indigestion
-flatulent dyspepsia
-abd pain
-firm, enlarged liver
-enlarged spleen
S/S of decompensated cirrhosis
-muscle wasting
-weight loss
-continuous mild fever
-clubbing of fingers
-purpura (b/c decreased platelet count)
-spontaneous bruising
-sparse body hair
-white nails
-gonadal atrophy
Dx tests for cirrhosis
radioisotope liver scan
liver bx
After liver bx, how should patient be positioned
Bedrest - lay on side of bx to seal
ck for bleeding
Medical mgmt of cirrhosis
Treat s/s and slow disease progress
-eliminate etoh
-Meds (PPI, H2 blockers, antacids)
-Nutrition (low protein, high calorie
Medical mgmt of ascites
*Potassium sparing diuretics (spironolactone)
-decrease ascites
-minimize fluid and elyte imbalances compared to other diuretics
*COLCHICINE (gout meds)
-may increase survival in mild-moderate cirrhosis
Nursing management for ascites and cirrhosis
Promote rest
Skin care
Decrease risk of injury
Monitor for potential complications (bleeding, hemorrhage, hepatic encephalopathy, fluid volume excess)
Why promote rest for cirrhosis
End state has fatigue, poor exercise tolerance - need rest periods
Improving nutrition for cirrhosis
Low protein - fruits - vegs - lean proteins - vitamins - small freq meals
Skin care for cirrhosis
Requires moisturizers and antipuritic agents (benadryl & atarax) - itchiness r/t ammonia
What is hepatic encephalopathy / portal systemic encephalopathy
Accumulation of ammonia & toxic metabolites in blood and brain
-portal hypertension
-poor marker for survival
Pathophys of hepatic encephalopathy
Liver cells unable to convert ammonia to urea
-causes brain dysfunction and damage
What is asterixis
flapping tremor, or liver flap - tremor of the hand when the wrist is extended, sometimes said to resemble a bird flapping its wings
--sign of hepatic encephalopathy due to high ammonia levels
Sources of ammonia
Absorption from GI tract
Kidney cells
Muscle cells
S/S of hepatic encephalopathy
Mood changes
Impaired sleep pattern
Dx of hepatic encephalopathy
Labs (ammonia level)
EEG - show generalized slowing
Fetor hepaticus - sweet slightly fecal odor to breath
Medical mgmt of hepatic encephalopathy
Supportive tx
-lactulose = promote excretion of ammonia - titrate so pt has 2-3 soft bowels/day
-neomycin = suppress GI bacteria that produces ammonia
-serum ammonia
-avoid sedatives, tranq, analgesics
-small freq meals and low protein diet
Main s/s of hypocalcemia
What is the gold standard to dx colon cancer
Risk factors for colon cancer
Increasing age - fam hx of colon ca or polyps - previous colon ca or adenomatous polyps - high etoh - smoking - obesity - hx of gastrectomy - history of IBD - high fat & protein and low fiber diet - genital cancers
Pathyphys of colon ca
95% are adenocarcinoma
-rising from lining of colon
-usually starts as polyp - transforms to malignancy - invades, destroys normal tissues
S/S of colon cancer
Change in bowel habits (#1) - blood in stools - unexplained anemia - anorexia - wt loss - fatigue
S/S of left sided colon lesions
Associated with obstruction
S/S of rectal lesions
Ineffective painful straining upon BM
Assess & dx of colon ca
Occult blood
Labs (CEA)
Complications of colon ca
Partial or complete obstruction
Hemorrhage (tumor invades surrounding vessels)
S/S of partial obstruction
Pain and thin pencil stools
S/S of full or complete bowel obstruction
Telescope bowels - death of bowel tissue
What should a stoma look like
Beefy red or hot pink
Medical mgmt of colon ca
Depends on stage
-surgery #1 choice
Nursing mgmt for colon ca surgery
Pre op = bowel prep
Post op = monitor for anastomosis leakage - prolapse stoma - perforation - stoma retraction - fecal impaction - skin irritation
Nutrition = TPN or IVF until bowel function returns - slow advance diet - healthy diet
How should you irrigate a colostomy
Helps schedule bowel movements
Supports body image
Monitor and manage complications
Procedure for irrigation of colostomy
-sit in chair by toilet
-500-1500mL tap water is hung 15-20 in above stoma (shoulder height)
-remove pouch
-apply sleeve to stoma - place end in commode - allow solution to flow thru tube & cath - lubricate irrigating cone and insert into stoma - allow water to flow slowly while advancing cath - replace dressin
Purpose of irrigating colostomy
-control odor and allow feces & H2O to flow into commode
-painful cramps caused by too rapid flow or too much solution
S/S of right sided colon lesion/ cancer
Dull abd pain
Melena stools
Ascending colon
S/S of left sided colon lesion/cancer
Abd pain
Ribbon stools
Feeling of incomplete evacuation
Constipation & abd distention
Blood in stool
Descending colong - near colorectal area
S/S of colorectal ca
Pain LLQ
Ineffective, painful straining due to obstruction
Tenesmus (constant feeling of need to pass stools)
Rectal pain
Feeling of incomplete evacuation
Alternate w/ diarrhea & constipation
Frank bloody stools
Esophageal varices (ATI)
Swollen, fragile blood vessels in esophagus
--medical emergency if hemorrhage
Primary risk factor for esophageal varices (ATI)
Portal hypertension
What is portal hypertension (ATI)
Elevated BP in veins that carry blood from intestines to liver
What causes portal HTN (ATI)
Impaired circulation of blood thru liver
--collateral circulation develops creating varices in upper stomach and esophagus
S/S of esophageal varices (ATI)
melena and hematemesis
Activities that precipitate bleeding of esophageal varices (ATI)
Valsalva - lifting heavy objects - coughing - sneezing - etoh
Objective data for bleeding esophageal varices (ATI)
Hgb & Hct (indicating anemia)
How do beta blockers treat esophageal varices (ATI)
Decrease heart trate and reduce hepatic venous pressure
-used prophylactically not for emergent hemorrhage
How do vasocontrictors tx esophageal varices (ATI)
Vasopressin & somatostatin
--most effective to increase portal inflow
---vasopression not for pt w/ CAD
Sclerotherapy and band ligation for esophageal varices (ATI)
-ligating bands or injected sclerotherapy for active bleeding ONLY
--sclerotherapy higher risk for hemorrhage
What is TIPS (ATI)
Under sedation - cath passed into liver via jugular vein
-stent placed btween portal & hepatic veins bypassing the liver
--portal HTN relieved
--monitor VS and elevate HOB
Balloon tamponade (ATI)
Tube / gastric balloons used to compress blood vessels
-traction applied after balloons inflated to desired pressure
-when bleeding stops - traction released - pressure in balloon reduced
--for pt w/ unsuccessful TIPS
Nurse admits pt w/ bleeding esophageal varices - she should anticipate Rx for what med (ATI)?
A propranolol (Inderal)
B Metoclopramide (Reglan)
C Rantidine (zantac)
D Terlipressin (vasopressin)

**D - constricts blood vessels
What is dumping syndrome (ATI)
Group of manifestations that occur after eating
-shift of fluid to abd is triggered by rapid gastric empty or HIGH CARB ingestion
Pathophys of dumping syndrome (ATI)
Response to sudden influx of hypertonic fluid - SI pulls fluid from EC space to convert hypertonic to isotonic fluid
--fluid shift causes decrease in circulating volume - resuls in vasomotor s/s
S/S of dumping syndrome (ATI)
Syncope - palpitations - dizzy - HA
What surgery poses greatest risk for dumping syndrome (ATI)
Gastrojejunostomy (billroth II)
--reduced stomach has less ability to control amount & rate of chyme that enters SI after meal
RN interventions for dumping syndrome (ATI)
-lie down when vasomotor manifestations occur
-bentyl (antispasmodic med)
-I&O - labs values - weight
--lie down after meal to slow movement of food - limit fluid ingested - no liquids w/ meals for 1 hr before and after meals - high protein, low fat, low fiber, low to moderate carb - avoid milk,sweets, or surgars - small freq meals
Pancreatitis (ATI)
Autodigestion of pancreas by panc digestive enzymes that activate prematurely before reaching the intestiness
--results in inflammation, necrosis, hemorrhage
Classic presentation of acute pancreatitis (ATI)
Severe - constant - knife like pain (LUQ, mid epigastric and /or radiating to back) - unrelieved by N/V
Acute pancreatitis (ATI)
Inflammatory process due to activated panc enyzmes autodigesting the pancreas
--severity varies but overall mortality is 10-20%
Chronic pancreatitis (ATI)
Progressive, destructive disease w/ development of calcifications & necrosis
-possible result in hemorrhage pancreatitis
-mortality as high as 50%
How to avoid pancreatitis (ATI)
Avoid etoh
Eat low fat diet
Risk factors for pancreatitis (ATI)
Etoh -- primary cause
GI surgery
Kidney failure
Meds / drug toxicity
Subjective s/s of pancreatitis (ATI)
-sudden onset of severe pain
-epigastric, radiating to back, left flank or shoulder pain
-worse when lying down or eating
-worse after etoh or high fat foods
-not releived w/ vomiting
-pain somewhat releived by fetal position
-N/V weight loss
Objective s/s of pancreatitis (ATI)
Seepage of blood exudates into tissue from panc enzyme actions
-ecchymoses on flanks (turners sign)
-bluish gray periumbilical discolor (cullens sign)
-absent or decreased BS - possible ileus
-warm, moist skin - fruity breath (hyperglycemia)
-increase WBC, bilirubin, glucose, amylase, enzymes
-decreased platelets, calcium, magnesium
Nursing care for pancreatitis (ATI)
Rest the pancreas
-NPO until pain free
-when diet resumed = bland, low fat, no stimulants, small freq meals
-NG for gastric decompression
-no etoh or smoking - limit stress - pain mgmt
-position for comfort - fetal, side lying, HOB elevated, sitting up or leaning forward)
Nurse is doing admission assessment of pt w/ acute pancreatitis. What is the priority to be reported to the dr (ATI)?
A - Hx of cholelithiasis
B - Amylase levels 3x greater than expected
C - Severe pain radiating to back rated at 8
D - Hand spasms when BP is checked

**D** indicative of hypocalcemia = risk for cardiac dysrhythmia
Nurse assessing pt w/ pancreatitis on admission. What is expected finding (ATI)?
A - Pain in RUQ radiating to right shoulder
B - Pain worse when sitting upright
C - Pain relieved w/ defecation
D - Epigastric pain radiating to left shoulder

Nurse teaching nutrition to pt w/ pancreatitis. What indicates pt needs further teaching (ATI)?
A - I will eat small, freq meals
B - I will eat easy to digest foods w/ limited spice
C - I will use skim milk when cooking
D - I will drink regular cola

*D*Caffeine free beverages are recommended
RN interventions after liver bx (ATI)
-pt to right side lying position for several hours
-monitor VS
-assess for abd pain
-assess for bleeding from puncture site
What is cirrhosis (ATI)
Extensive scarring of liver caused by necrotic injury or chronic reaction to inflammation over prolonged time
--normal liver tissue is replaced w/ fibrotic tissue that lacks function
What are the 3 types of cirrhosis (ATI)
--stay current on vaccines
--avoid etoh
What is postnecrotic cirrhosis (ATI)
Caused by viral hepatitis or certain meds or toxins
What is Laennec's cirrhosis (ATI)
Caused by chronic etoh
What is biliary cirrhosis (ATI)
Caused by biliary obstruction or autoimmune disease
Risk factors for cirrhosis (ATI)
Etoh - chronic hepatitis - autoimmune hepatitis - steatohepatitis (fatty liver disease causing chronic inflammation) - damage to liver by drugs, toxins, infections - chronic biliary cirrhosis - cardiac cirrhosis caused by rt side HF
Subjective data for cirrhosis (ATI)
Fatigue - wt loss - pruritus (severe itching) - confusion or difficult thinking - mental / personality changes
Why does cirrhosis cause difficult thinking or confusion (ATI)
Due to buildup of waste products in blood and brain that liver is unable to rid of
Objective data for cirrhosis (ATI)
Cognitive changes - altered sleep/wake pattern - depression, euphoria, lability - GI bleed - ascites - jaundice - petechiae - ecchymosis - nosebleeds - melena - hematemesis - palmar erythema - peripheral edema - asterixis - fetor hepaticus
Most definitive test for cirrhosis (ATI)
Liver bx
Meds for cirrhosis (ATI)
Diuretics - decrease fluid build up / ascites
Beta blocker - for pt w/ varices to prevent bleeding
Lactulose - to promote excretion of ammonia thru stool
Nursing care for cirrhosis (ATI)
Resp status
Skin integrity
Fluid balance
Neuro status
GI status
Pain status
Respiratory status for pt w/ cirrhosis (ATI)
-monitor O2 sats & distress
-position pt for easy respiration
-sit in chair or elevate HOB
Skin integrity for pt w/ cirrhosis (ATI)
-monitor for skin breakdown
-prevent pressure ulcers
-pruritus (assoc w/ jaundice) will cause itching - encourage washing w/ cold water & apply lotion
Fluid balance for pt w/ cirrhosis (ATI)
-monitor for fluid excess
-strict I&O
-daily weights
-assess ascites & edema
-restrict fluids and Na+ if needed
Neuro status monitoring for pt w/ cirrhosis (ATI)
-monitor for deteriorating mental status & dementia consistent w/ hepatic encephalopathy
--lactulose may be needed do decrease ammonia
Nutrition for pt w/ cirrhosis (ATI)
-High carb - high protein - moderate fat - low sodium
-vitamins supplement
GI status for pt w/ cirrhosis (ATI)
-abd girth measured daily if pt has ascites
-mark location w/ tape for consistency
What is portal systemic encephalopathy (ATI)
-pt unable to convert ammonia to urea
-those products are carried to the brain & cause neuro s/s
-treat w/ lactulose
-reduce protein intake if
What elyte should you monitor if giving pt lactulose (ATI)
-can cause hypokalemia w/ increased stools from lactulose`
S/S that hepatic encephalopathy is worsening (ATI)
Fecor hepaticus (liver breath)
Asterixis (flapping of hands)