Question

1. Cirrhosis - Mr. Garcia is a 43-year old male who presented to the ED complaining of nausea and vomiting x 3 days. The nurse notes a large, distended abdomen and yellowing of the patient’s skin and eyes. The patient reports a history of IV drug use and alcohol use.

1. What initial nursing assessment should be performed?
2. What diagnostic studies might you anticipate for Mr. Garcia?

Mr. Garcia’s vitals are stable, BP 100/58, bowel sounds are active but distant, and the nurse notes a positive fluid wave test on his abdomen. The patient denies itching but is constantly scratching at his chest. He is oriented to person only and his brother at the bedside reports he has not been himself today. He keeps trying to get out of bed.

3. Which finding is most concerning and needs to be reported to the provider? Explain your response.
4. What further diagnostic and lab studies should be ordered to determine Mr. Garcia’s priority problem?

The provider places orders for the following:

Keep SpO₂ > 92%

Keep HOB > 30 degrees

Insert 2 large bore PIV’s

500 mL NS IV bolus STAT

100 mL/hr NS IV continuous infusion

Hydrocodone/Acetaminophen 5-500 mg 1 tabs q4h PRN for moderate pain

Hydrocodone/Acetaminophen 5-500 mg 2 tabs q4h PRN for severe pain

Diphenhydramine 25 mg PO q8h PRN itching

Ondansetron 4 mg IV q6h PRN nausea

Lactulose 20 mg PO q6h

Mr. Garcia’s LFT’s and Ammonia level are elevated. He is extremely confused, agitated and appears somewhat short of breath. The patient’s current vital signs are as follows:

                             HR 82                 RR 22

BP 94/56           SpO₂93%

                             Temp 98.9°F

5. Which order should be implemented first? Why?
6. Which order should be questioned? Why?
7. Why is Mr. Garcia so confused and agitated? Explain the pathophysiology of your answer.

The provider calls to tells you he wants to perform a paracentesis on Mr. Garcia. He will be gathering the supplies and will be at the bedside in 10 minutes.

8. Is it safe for Mr. Garcia to get a paracentesis currently?
9. What medication will help with Mr. Garcia’s confusion? What is the mechanism of action for this medication?
10. List 3 nursing diagnoses which are appropriate for Mr. Garcia

In two days, Mr. Garcia’s condition has improved. His wife is at the hospital and is inquiring about how to care for him at home.

11. What nutritional teaching should be included in the discharge teaching for Mr. Garcia?

1. Pancreatitis

Mrs. Miller presented to the emergency room with complaints of epigastric pain of 10/10 with nausea and vomiting. She is obese, a heavy smoker, and drinks alcohol. Mrs. Miller is being admitted with a diagnosis of acute pancreatitis.

1. Briefly explain acute pancreatitis and discuss its incidence.
2. What are the major causes acute pancreatitis?
3. Can a person have chronic pancreatitis? If so, what is the incidence, and how would you define chronic pancreatitis?
4. Discuss the common clinical manifestations of acute pancreatitis
5. Briefly discuss the diagnostic tests which help confirm the diagnosis of pancreatitis

Mrs. Miller is scheduled for a KUB asks “What is the test I am having done today?”

6. How would the nurse describe a KUB to Mrs. Miller?
7. Briefly discuss the treatment options for pancreatitis and explain why Mrs. Miller has an NG tube to low wall suction.
8. Discuss the complications which can arise if pancreatitis is not treated.

Identify 3 priority nursing diagnoses for a patient with acute pancreatitis

Answer 1

1 [A] Accumulation of fluid is the most common complication of cirrhosis and is a frequent cause of seeking attention, either in emergency room or in day care settings. Fluid accumulates in the extracellular space, particularly the peritoneal and pleural cavities and interstitial tissue of the legs, causing ascites, pleural effusion, and leg edema, respectively.  The intensity of symptoms is related to the severity of fluid retention. Ascites may cause abdominal discomfort, pleural effusion may lead to dyspnea, and leg edema may impair walking capacity because of “heavy legs.” Actually, leg edema is one of the most important factors in the impairment of health‐related quality of life in patients with cirrhosis.The main roles of nurses in the assessment of patients with cirrhosis and ascites/edema are to evaluate patients’ history, check current status of ascites and edema, and plan future care to prevent recurrence.

[B}

Laboratory findings and imaging studies that are characteristic of cirrhosis include:

• Liver scan. Liver scan shows abnormal thickening and a liver mass.
• Liver biopsy. Liver biopsy is the definitive test for cirrhosis as it detects destruction and fibrosis of the hepatic tissue.
• Liver imaging. Computed tomography scan, ultrasound, and magnetic resonance imaging may confirm the diagnosis of cirrhosis through visualization of masses, abnormal growths, metastases, ans venous malformations.
• Cholecystography and cholangiography. These two visualize the gallbladder and the biliary duct system.
• Splenoportal venography. Splenoportal venography visualizes the portal venous system.
• Percutaneous transhepatic cholangiography. This test differentiates intrahepatic from extrahepatic obstructive jaundice and discloses hepatic pathology and the presence of gallstones.
• Complete blood count. There is decreased white blood cell count, hemoglobin level and hematocrit, albumin, or platelets.
• [C]
• The finding is most concerning and needs to be reported to the provider is that abdominal distention.
• .3 Signs and symptoms of decompensated cirrhosis include abdominal swelling, jaundice, and gastrointestinal bleeding. Sensitivity of these findings varies from 31 to 96 percent.4 Findings on physical examination include a contracted, nodular liver; splenomegaly; ascites; dilated abdominal wall veins; spider angiomata; palmar erythema; peripheral edema; and asterixis.
• Patients may be diagnosed incidentally through laboratory findings. Elevated hepatic transaminase levels (e.g., alanine transaminase, aspartate transaminase) are suggestive of ongoing hepatocyte injury; however, these may be normal with advanced liver disease. Elevation of serum prothrombin time or International Normalized Ratio (INR) may indicate a decreased ability of the liver to synthesize clotting factors. Thrombocytopenia may indicate splenic sequestration. The total bilirubin level may also be elevated.
• [A]500 mL NS IV bolus STAT shold be given first ,because he is extremely confused, agitated and appears somewhat short of breath, also his BP is low.
• Hydrocodone/Acetaminophen 5-500 mg 2 tabs q4h PRN for severe pain.Most cases of liver injury are associated with the use of acetaminophen at doses exceeding 4 g per day and often involve the use of more than 1 acetaminophen-containing product.
• He is so agitated and confused because of the development of Hepatic Encephalopathy.

  

[A] yes. Paracentesis may help alleviate ascites.

[B]Lactulose 20 mg PO q6h. It helps to reduce Amonia level.

• [C] Chronic pain and discomfort related to enlarged liver and ascites.
• Disturbed thought processes and potential for mental deterioration related to abnormal liver function and increased serum ammonia level.
• Fluid volume excess related ascites and edema formation.
• Encourage rest and probably a change in lifestyle (adequate,well-balanced diet and elimination of alcohol).

[A[Acute pancreatitis is sudden inflammation of the pancreas that may be mild or life threatening but usually subsides. Gallstones and alcohol abuse are the main causes of acute pancreatitis.

[B]

• Abdominal surgery.
• Alcoholism.
• Certain medications.
• Cystic fibrosis.
• Gallstones.
• High calcium levels in the blood (hypercalcemia), which may be caused by an overactive parathyroid gland (hyperparathyroidism)
• High triglyceride levels in the blood (hypertriglyceridemia).
• Chronic pancreatitis is defined as a continuing inflammatory disease of the pancreas characterized by irreversible morphologic changes that typically cause pain and/or permanent loss of function in the revised diagnostic criteria for chronic pancreatitis.

• Acute pancreatitis signs and symptoms include:

• Upper abdominal pain.
• Abdominal pain that radiates to your back.
• Abdominal pain that feels worse after eating.
• Fever.
• Rapid pulse.
• Nausea.
• Vomiting.
• Tenderness when touching the abdomen.

• Diagnosis

• Blood tests to look for elevated levels of pancreatic enzymes.
• Stool tests in chronic pancreatitis to measure levels of fat that could suggest your digestive system isn't absorbing nutrients adequately.
• Computerized tomography (CT) scan to look for gallstones and assess the extent of pancreas inflammation.
• A kidney, ureter, and bladder (KUB) X-ray may be performed to assess the abdominal area for causes of abdominal pain, or to assess the organs and structures of the urinary and/or gastrointestinal (GI) system. A KUB X-ray may be the first diagnostic procedure used to assess the urinary system.
• a hospital stay to treat dehydration with intravenous (IV) fluids and, if you can swallow them, fluids by mouth.
• pain medicine, and antibiotics by mouth or through an IV if you have an infection in your pancreas.
• a low-fat diet, or nutrition by feeding tube or IV if you can't eat.