Term
| the pancreas consists of what two kinds of major cells |
|
Definition
- exocrine: 80% of the pancreas are composed of acinar cells which produce digestive enzymes
- endocrine: which have islets of Langerhans ; alpha cells: make glucagon, beta cells make: insulin |
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Term
| what are the three digestive enzymes made by acinar cells? |
|
Definition
lipase- digests fats
trypsin- digests proteins
amylase- digests carbohydrates |
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Term
| what is the cause of acute pancreatitis |
|
Definition
pancreatic enzymes destroy ductal tissue and pancreatic cells this leads to autodigestion and fibrosis because the enzymes are activated before they even reach duodenum. This creates toxic injury to the cells.
- it can be life threatening
- The pancreas can turn into necrotizing hemorrhagic pancreatitis ( a dying and bleeding pancreas)--> 20% is bleeding. Trypsin backs up into the the pancreas and chews up the pancreas instead of going into the duodenum this makes it bleed. |
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Term
| what is acute pancreatic due to |
|
Definition
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Term
| what are the four major physiological processes of acute pancreatitis |
|
Definition
1. Lipolysis- lipase releases fatty acids and combine with intrinsic calcium which causes hypocalcemia. Trypsin also spits proteins into smaller polypeptides causing clots to form in the pancreas which could lead to blockage and gangrene
2. Necrosis of the blood vessels: elastase dissolve elastic fibers of the blood vessels and ducts causing the pancreas to bleed.
3. Kallikrein releases bradykinin and kinin which are vasoactive peptides they increase vasdiolation (decrease BP), increase permeability.
4. Inflammation: leukocytes form around bleeding and necrotic areas this causes pus and abcess formation. If walled off this could lead them rupturing |
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Term
| why does enzyme activation occur in acute pancreatitis? (2 main causes) |
|
Definition
bile reflux which causes obstruction of the cystic duct.
- hypersecretion- obstruction theory: ( think about it too much fluid getting being secreted but cant go anywhere) will cause the pancreas to bust.
- alcohol causes hydrochloric acid and secretin to be released this leads to digestive enzymes being released causing edema of the duodenum and ampulla of vater--> edema leads to obstruction to flow and causes the sphincter of Oddi to be floppy (it looses tone) which leads to duodenal reflux .
Basically: bile reflux, obstruction of flow, edema in duedonum obstructing flow. |
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Term
| Other causes of why enzyme activation occurs besides alcohol ingestion and biliary disorders is because? (7) |
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Definition
1. Trauma : blunt or surgical (whipple/ERCP)
2. Pancreatic obstructions: tumors
3. metabolic disturbances: hyperlipidemia, hyperthyroidism
4. renal failure or transplant
5. ulcers that lead to peritonitis
6. coxsackievirus B infections
7. Drug toxicity: steroids, thiazide diuretics, BC pills, opiods |
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Term
| What are the 8 complications of acute pancreatitis? |
|
Definition
- pancreatic infection (can swell and cut off blood flow to the gut)
- peritonitis
- hypovolemia
- hemmorage
- ARF
- paralytic ileus ( paralyses the ileum, peritonitis causes pressure on the guy which causes everything to stay still and obstructed, sometimes the NG tube is used to decompress the gut)
- septic shock
- DIABETES |
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|
Term
what are the symptoms of acute pancreatitis?
1. predominant symptoms
2. where it is
3. when is it worse |
|
Definition
1. really intense pain
2. It is pain in the center of the gut radiating to the back
3. it is worse when you are laying down on your back.
- jaundice
- Cullen's sign: tumors causing severe bruising related too trypsin, it leaks out of the pancreas and starts to chew up tissue bruising seen on the center
- Turner's sign- same thing but bruises seen on the side
- bowel sounds may be decreased or absent
- abdominal tenderness
- watch for signs of shock
- pain radiates to left shoulder
- watch for SOB, respiratory effusions
- access for excess alcohol intake
- labs: amylase and lipase increased
- |
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|
Term
laboratory evaluation
1. elevated in the serum
2. what are the major enzymes elevated in the serum
3. what enzymes are decreased in the serum? |
|
Definition
1. trypsin
- glucose
-bilirubin
-alanine aminotransferase
- leukocyte count
- elastase
2. amylase, lipase
3. magnesium and calcium |
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Term
| diagnoses for acute pancreatitis? |
|
Definition
acute pain
risk for infection
nausea- due to trypsin breaking down protein creates ammonia
- fluid volume defeceit
- ineffective breathing pattern
- activity and sleep disturbances |
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Term
| what does acute pancreatitis have a risk of turning into to ? |
|
Definition
hypovolemic
septic shock ( decrease oxygen due to infection in the blood)
Acute respiratory distress syndrome
paralytic ileus
multi organ system failure |
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Term
| What is the primary method to relieve pain, other than medication with acute pancreatitis. (5) |
|
Definition
1.rest the organs by getting them not to work; place the pt on an NPO diet for 7-10 days.
2. IV fluids for hydration
3. replacement of Ca and Mg
4. Ng drainage and suction ( for blood and standstill food not getting digested), maybe put them on a TPN diet
5. Assess for return of bowel sounds and pain control |
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Term
| Pain control for acute pancreatitis (medications) |
|
Definition
1. opiods : IV and PCA
2. Demerol: for the relief of spasms at the sphincter of oddi, Demerol is rarely used now has problems with being broken down.
3. fentanyl patch
4. epidural morphine with bupivacaine
5. pain may last 7-10 days |
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Term
| What are the other side drugs we can use for pain management |
|
Definition
-anticholinergics:( slows down the gut, parasympathetic system slowed down)
- atropine
-glucagon ( replacement)
- calcitonin ( replacement)
- histamine receptor agonist (zantac): alcohol related they give this to help with acid reflux
- protease inhibitors ( stop trysin: a enzyme that breaks down protein)
- antibiotics: Ceftazidime, cefuroxime, imipenem (primaxin)
- |
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Term
| Surgery for acute pancreatitis? |
|
Definition
yes,
- ERCP: endoscopic retrograde cholangiopancreatography, this is used to open sphincters
- pseudocystojejunostomy or pseudocystogastrotomy; they are done to drain abcess or pseudocyst: JP drains or sump tubes may be used/ left in for excess drainage. |
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Term
| What are the four main drugs that can cause acute pancreatitis? |
|
Definition
Opiods
steroids
thiazide diuretics
estrogen pills ( birth control) |
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Term
| what happens to your vitals with acute pancreatitis |
|
Definition
increase HR and respirations
decrease BP
and increase temperature |
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Term
| what nursing interventions are done for a acute pancreatitis: imbalanced nutrition; less than body requirements |
|
Definition
- remain NPO , may have NG tube
- may not eat for 7-10 days
- receive nutritional support through TRN or low fat low protein diet
- diet teaching and signs of chronic progression should be stressed with the patient |
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|
Term
| what do acute pancreatitis receive nutritional support through; aka what food is good to take in and what is not |
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Definition
| low fat low protein diet; carbs are good no alcohol and no spicy food. |
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Term
| when does chronic pancreatitis usually occur ? |
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Definition
| after repeated episodes of acute pancreatitis. |
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Term
| what is the most common cause of chronic pancreatitis? |
|
Definition
| they usually don't change their diet after having acute pancreatitis attacks. Still remain a high fat and high protein diet, they still probably have am increased alcohol intake as well. eventually trypsin breaks down pancreas |
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Term
| what are the two types of chronic pancreatitis? |
|
Definition
chronic calcifying pancreatitis
&
chronic obstructive pancreatitis |
|
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Term
| what is chronic calcifying pancreatitis |
|
Definition
| alcohol induced, proteins plug the ducts this leads to atrophy and dilation of the cells which eventually leads to ulceration and inflammation. This leads to fibrosis. Intraductal calcification and cystic sacs develop. eventually it becomes hard, firm, and not functioning, dump enzymes into the abdomen--> you can not digest food no inulin |
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Term
| what is chronic obstructive pancreatitis |
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Definition
| inflammation, spasms and obstruction of the sphincter of oddi--> inflammation and sclerotic lesions occur at the head of the pancreas--> obstruction and back flow of secretions occur. |
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Term
| pancreatitis implants and transplants are available for people with --- and not for people with --- |
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Definition
kidney failure and diabetes
not for alcoholics and someone with a fatty pancreas |
|
|
Term
| what do pancreas normally secrete to neutralize acid in the duodenum? |
|
Definition
|
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Term
| what are the results of having chronic pancreatitis |
|
Definition
1. you have loss exocrine function:
- no bicarbonate released to neutralize acid in the stomach =ulcers
2. pancreatic enzymes are blocked off can not digest food, they are reduced by 80 % = you have to go to the bathroom right after you eat. Steatorrhea white fatty floating stool. Urine is a tea color.
3. fat metabolism = weight loss and muscle wasting
4. edema r/t decreased albumin = belly gets really big. |
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|
Term
| pancreatic endocrine function causes what? |
|
Definition
|
|
Term
| will you have pulmonary problems with chronic pancreatitis? |
|
Definition
| yes from edema, and pancreatic acites, acute respiratory distress syndrome might develope |
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|
Term
| chronic pancreatitis is a major risk factor for |
|
Definition
|
|
Term
| what are some symptoms of chronic pancreatitis |
|
Definition
1. intense abdominal pain and tenderness
2. ascites- edema in the belly from protein loss
3. steatorrhea- white fatty stool; tea urine
4. respiratory compromise
5. wt loss
6. jaundice: from bilirubin in bile
7. signs of diabetes
8. elevates amylase and lipase
9. elevated bilirubin
10. elevated alkaline phosphatase and glucose |
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|
Term
| what are signs of pancreatic cancer? |
|
Definition
elevated bilirubin, alkaline phosphatase, and glucose
calcification on biopsy |
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|
Term
| what is a definitive dx of chronic pancreatitis |
|
Definition
| by biopsy to look for calcification |
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|
Term
| how do you manage pain with C. pancreatitis |
|
Definition
| opiods but if liver involvement they cant |
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Term
| nursing management for C. Pancreatitis |
|
Definition
opiods if liver is not involved
- enzyme replacement - dietary supplements, amount they take depends on how many stools they are having the more diarrhea you have the more you have to take. take with your meal not before or after. pancrease, viokase, cotazyme, donnazyme. wipe your lips off so trypsin don't cause mouth ulcers.
- insulin therapy
- NPO or TPN for days then low fat low protein diet
- histamine receptor blockers to decrease acid
- Octreotide (sandostatin) like somatostatin may be used for diarrhea to slow motiltiy |
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|
Term
|
Definition
| like somatostatin may be used for diarrhea to slow motility in chronic pancreatitis |
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|
Term
| enzyme therapy medication for chronic pancreatitis to take WITH meals |
|
Definition
pancrease
viokase
cotazyme
donnazyme
TAKE WITH FOOD AND WITH WATER ONLY |
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|
Term
| what is the major difference between acute and chronic pancreatitis |
|
Definition
| chronic you have to take enzyme replacement therapy |
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|
Term
| is surgery an option for chronic pancreatitis? |
|
Definition
| No, unless there is a cyst, obstruction or possible transplant for diabetes |
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|
Term
| health teaching for chronic pancreatitis (3) |
|
Definition
diet and alcohol avoidance is stressed
medication compliance with insulin and pancreatic enzymes
skin care for irritation r/t steatorrhea |
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Term
| what should you tell your patient to monitor for with chronic pancre. |
|
Definition
1. # of stools, diarrhea --> they need more enzymes
2. weight
3. blood suger - could be developing diabetes
4. irritation from fatty stool |
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Term
| 44 year old female admitted with abdominal pain, nausea and vomiting. She states that she has a lot of gas that wakes her up at night. What do you suspect? |
|
Definition
abdominal pain radiates to right shoulder
- gas and nausea from not digesting fats
( bile is in your gallbladder CCK makes gallbladder contract to push bile out to digest food.
- she is FAT, FERTILE, FEMALE, FORTY= gallbladder problem |
|
|
Term
| FAT FERTILE FEMALE AND FORTY |
|
Definition
|
|
Term
| what are the symptoms of gallbladder disease |
|
Definition
abdominal pain Right shoulder
gas and nausea |
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|
Term
| what can precipitate GB disease |
|
Definition
| high fatty diet, November through December is common because of the holidays |
|
|
Term
| what is the treatment for GB disease |
|
Definition
removal or
-if they can control their diet( decrease fats and proteins and alcohol) they can take actigal and urosdial to help it takes 6 months |
|
|
Term
| what are the two medications for gallbladder disease |
|
Definition
|
|
Term
| how can you prepare for GB surgery? |
|
Definition
general anesthesia
breathing tube
oral gastric tube
30-60 minutes |
|
|
Term
| how do you decide between laparoscopic and open GB surgery? |
|
Definition
| open cholesectomy - if the bile continues to build up it will rupture they have to open you up completely and clean you out. You know it ruptured if you had a bunch of pain and then it goes away all of a sudden, but your temp and WBC count increases |
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|
Term
| after GB surgery what does the post- op nurse need to do? |
|
Definition
walk them because they have a lot of gas
- pain medication
- NPO till bowel sounds return ( iff you are giving PO pain meds of a patient who is NPO they might become nauseated because there is no food in their belly)--> liquid diet then soft diet, then mechanical
- most leave after 24 hours |
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|
Term
|
Definition
|
|
Term
| how do you know it is a problem with your gallbladder? |
|
Definition
RUQ pain from GB stones blocking bile
nausea, vomiting, gas, fever |
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Term
| The patient undergoes a laparoscopic cholecystectomy, why is a T-tube inserted? |
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Definition
| a t-tube is used for gallbladder drainage. Bile should be green and slimy with no blood. If there is blood that means there is a leak. DO NOT IRRIGATE, DO NOT ASPIRATE, DO NOT CLAMP, sterile. without a doctors order |
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|
Term
| interventions for taking care of a GB T-tube at hom |
|
Definition
do not irrigate
do not aspirate
do not clamp
without a doctors order
make sure it is sterile |
|
|
Term
| what type of diet should they be on at home after GB surgery? |
|
Definition
| some people can tolerate fat, you will find it will irritate your stomach if it is too much fat. SO a lower fat diet that you can tolerate |
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|
Term
| Your patient is ready for discharge after gallbladder surgery what type of teaching Is necessary |
|
Definition
t-tube & diet
DO NOT IRRIGATE , ASPIRATE OR CLAMP T -tube without a doctors order |
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|
Term
what is a cholecystectomy?
Can it be done open or laproscopic?
signs that is needs to be removed?
risk factors for GB disease |
|
Definition
removal of the gallbladder
both
nausea, vomiting, fever, abdominal pain
forty, female, fertile, fat |
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|
Term
| what kind of pain meds do GB patients get post- op |
|
Definition
|
|
Term
| can GB patients eat right after surgery? |
|
Definition
| no they are NPO until bowel sounds return, then a clear liquid diet--> soft--> mechanical to DAT |
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|
Term
T-tube may remain in for how long?
what Is the normal T-tube drainage per day? |
|
Definition
1-6 weeks
monitor drainage should be bile color no blood
1000 ml/ day |
|
|
Term
| what is the largest organ in the body located in the RUQ |
|
Definition
| liver; it has a large right lobe and a smaller left lobe |
|
|
Term
| what is the liver made up of? |
|
Definition
|
|
Term
| where is bile made and secreted into |
|
Definition
| hepatocytes and secreted into bile canaliculi |
|
|
Term
| how much blood does the liver receive per minute |
|
Definition
|
|
Term
| how many different functions does the liver have |
|
Definition
|
|
Term
| what type of vitamins and minerals does the liver store? |
|
Definition
vitamin A- vision
Vitamin D- bone growth
Vitamin E- wound healing, without this vitamin you would be prone to infection
vitamin K- clot factors without this you would bleed
Vitamin B- thyamine, B1, B2, folic acid ( creates iron which is needed for RBC production or otherwise anemic) - neurotransmitters in the brain |
|
|
Term
| what are the only 3 main functions of the liver we are focusing on |
|
Definition
storage
protection
metabolism |
|
|
Term
| what protective cells are in the liver |
|
Definition
kupfer cells
phagocytic destroy bacteria and anemic red blood cells
- it also detoxifies chemicals and medicine ( Tylenol which is highly toxic to your liver). |
|
|
Term
| how many grams of Tylenol are you supposed to have per day |
|
Definition
4g/day MAX
found in midol, niquil, loritabs |
|
|
Term
| Metabolism of the liver makes protein in the form of what |
|
Definition
|
|
Term
| globulin forms antibodies without difficulty to fight infection |
|
Definition
|
|
Term
| increased ammonia--> can lead to |
|
Definition
|
|
Term
| normally there is more albumin than globulin but with sickness there is more globulin than ammonia |
|
Definition
|
|
Term
| what are the metabolism functions of the liver? |
|
Definition
- makes proteins ( albumin and globulin)
- breaks down amino acids to remove ammonia--> converted to nitrogen wastes
- synthesizes plasma proteins, albumin, prothrombin, and fibrinogen
- stores and releases glycogen
- breaks down / stores fatty acids and triglycerides
- forms and secretes bile |
|
|
Term
| what are the two main ways that liver failure patients die? |
|
Definition
bleeding to death due to livers inability to produce prothrombin, fibrinogen, and plasma proteins. You can not stop the bleeding.
- massive encephalopathy - due to massive protein break down--> increase ammonia levels cause this |
|
|
Term
| what are the two main liver disorders |
|
Definition
cirrhosis/ liver failure
hepatits |
|
|
Term
| a 55 year old male was admitted to the ED with abdominal pain , nausea and vomiting, weight loss. His abdomen is large and tender. His skin is light yellow. He has a fruity odor to his breath what do you suspect? |
|
Definition
liver failure
- abdominal pain, nausea and vomiting from big liver
- skin is light yellow from bilirubin build up
- abdomen is large and tender from ascites--> portal HTN pushed albumin out causing fluid to flow into 3rd space
- fruity odor breath: from ammonia in the blood it isn't excreted in the urine |
|
|
Term
| What lab work would be done for a patient with cirrhosis? |
|
Definition
ALT
AST
LDH
bilirubin
glucose
ammonia
DECREASED:
Mg
Ca
INR and PT ( the time it takes to clot): will be increased the liver stops producing clotting factors : vitamin K so blood is thin |
|
|
Term
| what if the patient becomes belligerent after a few hours and wants to leave? |
|
Definition
| Try and convince them to stay for treatment |
|
|
Term
| What radiology studies may be done for a patient with liver failure? |
|
Definition
- CT of abdomen
- ultrasound of liver |
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|
Term
| You have a liver failure pt whose liver enzymes are extremely elevated and he is becoming confused. What symptoms are you likely to see in this patient |
|
Definition
| - nausea, vomiting, abdominal pain, ascites, portal HTN, weight loss, jaundice, encephalopathy, esophageal varices, hemmroids, vomiting or pooping blood |
|
|
Term
| The liver failure pt starts to vomit blood , what does this mean and what may be done? what mecation might they give |
|
Definition
| portal HTN caused esophageal varices ( too much pressure on veins cause them to bust), or hemmroids blood in the poop. You can attempt to put in a NG tube to aspirate blood, if that doesn't work try a Blakemore tube. give vitamin K and packed RBC, albumin |
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|
Term
| The liver failure pt is ready for discharge and has improved what teaching would you give him? |
|
Definition
take vitamins
30 day rehab
low fat
no alcohol |
|
|
Term
|
Definition
| scaring of the liver, caused by chronic inflammation and sclerosis. This is irreversable |
|
|
Term
| what is the number 1, number 2, and number 3 cause of cirrhosis? |
|
Definition
#1 : alcoholism but it takes 20 years of drinking
#2 : hepatitis
#3 : NASH, fatty liver |
|
|
Term
| how does cirrhosis happen? |
|
Definition
| something happens to the hepatocytes where the become hard and they block bile duct and blood flow to the liver--> liver enlarges and then shrinks, it is hard and firm. |
|
|
Term
| what is the main type of liver failure |
|
Definition
|
|
Term
| what are the 8 things that may go along with cirrosis |
|
Definition
1. portal hypertension- due to cirrhosis of the liver blood vessels more resistance = harder to push blood 50 ml of blood back up in the systematic system- no blood to kidneys ( kidney failure)
2. ascites- portal HTN pushes albumin out into the abdomen fluid follows
3. coagulation defects- spenomegaly from portal HTN causes spleen to break platlets, low vitamin K production
4. Bacterial peritonitis- portal HTN pressure pushed bacteria out of bowel into peritonitis
5. |
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