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Major fxn of gall bladder
to concentrate and store bile....constantly filling and emptying
What causes obstruction of the gall bladder?
stones migrating and lodging in the neck of the gall bladder, cystic duct or common bile duct
any condition in which the flow of bile from the liver is slowed or blocked.
- S/S-clay or white colored stools
- dark urine
- cant digest certain foods
- PAIN in right upper abdomen
- YELLOW skin or eyes
Result of bile not being able to flow....
bile is an irritant, causes inflammation and this inflammation can spread to other organs...pancrease=pancreatitis
What causes peritonitis?
bile and impaired circulation from swelling causes ischemia, leading to abscess formation and then necrosis of the GB wall and gangrene
Perforation then occurrs and you have peritonitis
infection of the common bile duct by bacteria from other parts of the body....got there by lymph channels
Stone formation in gallbladder
Inflammation of the gallbladder, may be acute or chronic
Stasis or lack of movement of bile
Sudden mid epigastric, very sever pain, which spread to the RUQ, radiates thru the back and under the scapula to the right shoulder
Obstruction of the common bile duct, R/T stones
What's the livers job?
inflammation of liver cells
What's Toxic Hepatitis
it is caused by drugs, alcohol, industrial toxins, medications and plan poisons
What's viral hepatitis
There are 6 types...ABCDEG
Patho of Hepatitis
- Virus replicates and attacks hepatocytes
- liver becomes enlarged and congested with inflammatory cells, lymphocytes and edema
- Swelling causes obstruction to the portal circulation with interference to the blood flow in to the hepatic lobules
- edema of liver bile channels results in intrahepatic obstructive jaundice
Why does the livers normal lobular pattern become distored?
Increasing inflammation, necrosis and regneration of cells causes this
How do you know that the liver is in recovery phase from hepatitis?
- active phagocytosis
- removal of damaged liver cells
- regeneration of liver cells
Takes 2-3 months
What will happen if liver cells dont regenerate with ongoing necrosis?
Hepatitis A Antigen (HAV)
How do you get it?
Causes acute Hepatitis
From fecal oral route....must be ingested, but NOT caused by kissing or sharing utensils
Common sources of contamination for HAV
- 1. water, especially during epidemics
- 2. From hands not being washed by food preparers
Incubation of HAV
High risk groups for HAV
- day care worker
- travelers in developing countries
- long term care facility workers
When do you get jaundice with HAV?
Beauty of HAV?
99% recover and it confers life long immunity
Hepatitis B Antigen (HBV)
How do you get it?
- Primarily a STD, but passed via skin thru:
- mucous membrane
- parenteral routes
- contact with infected blood or serous fluid
blood, semen, saliva, NG secretions
Dont want a break in your skin or mucous membrane!!
How can you tell if a person has HAV?
later confirmed by presence of HAV-IgM antibodies in the blood
How can you tell somebody has HBV?
What are the antibodies that appear later?
- presence of HbsAg(surface ag) and HbcAg(core ag) in the blood
- later the anti-HBcIgM antibodies appear
Bad part about HBV
carriers can harbor this virus in their bodies without manifesting symptoms and can distrubute the infection
How do you know if you are a carrier after HBV infection?
have HbsAg after 6 months
How can you tell if a person is going to develope chronic disease from HBV?
Presence of HbeAg
Random ways HBV is spread
- kissing(low risk)
- sharing tooth brush or water picks
- razor blades
- contaminated tattoing/body piercing
- acupuncture equip
- NAIL CLIPPERS!
- tampons/sanitary napkins or dressings
Blood and HBV
- dried blood on skin and clothing can infect you as a FOMITE!
- Rarely trnasmitted by blood transfusion
Incubation period for HBV
2-3 months after exposure
How can you tell if a person is in the recovery period and is now immune of HBV?
presence of antibodies HbsAg
High risk group for HBV
- Iv drug users (parenteral)
- fetuses of infected moms
- sexual partners with
- Permiscuous or anal sex
- male prisoners
- healthcare workers with frequent blood contact
Complications of HBV....
Cirrhosis and Hepatocellular Cancer (HCC)
What is the only hope for survival from end stage liver disease?
liver transplant....but only extends life by a max of 5 years
What causes untintentional liver damage?
What is given to people to fight HBV?
How do you know you have HCV?
- presence of HCV antibody
- increased ALT (ALT is supposed to be in the liver, not the blood)
Incidence of HCV
- Most common chronic blood borne infection in the US
- Typical in males 29-49
NEEDLES AND COKE
HCV...acute or chronic?
It is both....
acute can go chronic, but chronic doesnt necessarily start as acute
Incubation period for HCV
Usually 50 days
Symptoms of acute HCV
High risk groups for HCV
- frequent blood transfusion prior to 1992
- veterans injured
- IV drug users
- Been in bar fights
What the risk of a mom giving her unborn child HCV?
HCV becomes chronic in ....
75-85% of people....but can have it for 10-40 years before you know.
Growing concern with baby boomers.
Will show up with increase in liver enzymes in your physical
Hepatitis D Antigen HDV....found in what kind of people?
- Seen in Mediterranean basin
- Middle East
- Central Africa
- Amazonian basin
Detail about HDV
It is only active in the presence of HBV...so get HBV vaccine, and you cant get it
High risk groups for HDV
- same as HBV
- but most common in drug addict and those receiving blood transfusions
Whats the reality of a co infection?
high risk for hepatic failure!
Hepatitis E-HEV....how is it spread?
Acute or chronic?
- spread by fecal oral route
- acute infection
Hepatitis G HGV....hows it transmitted?
- transmitted through blood
- co infection with B or C
G is Benign....but B and C will kill you!!
Viruses that can cause hepatitis as a part of their own systemic infection
- yellow fever
- Systemic Herpes simplex
Difference between HAV and all other Hepatitis viruses?
"A" has a very sudden onset
Three stages of Hepatitis
- Pre-icteric Phase/Prodromal Phase
- Icteric Phase
- Post Icteric Phase
Prodromal/Pre Icteric Phase S/S:
ANOREXIA & FATIGUE
Starts when and lasts?
starts in 2 weeks and lasts 4-6 weeks
Worsening of anorexia, nausea, starts vomiting, weakness and maliaise, liver tenderness NOW JAUNDICE
What causes jaundice?
Increased amt of bilirubin in serum
when the liver's bile channels are obstructed, the concentration of bilirubin in the blood becomes abnormally high, excess bilirubin collects in the dermis and epidermis and in the connective tissue of the sclera creating yellow of jaundice
S/S of jaundice:
- yellow sclera and skin
- elevated total bilirubin in serum
- dark amber, foamy urine
- light brown to clay colored stools
- pruritis and burning skin
What causes pruritis
irritation of bile salts on the skin
How can you tell if there is liver damage?
- Liver function tests.....look at:
- Elevated ALT and AST enzymes
- Elevated Alkaline Phosphate
Why does alkaline phosphate elevate with liver problems
it is made in the bones, kidney, liver and intestines and is excreted thru the biliary tract. When it is blocked, levels rise
What does liver damage to do PT and PTT?
will prolong PT first and cause clotting time to increase.
PTT will increase with severe liver damage
Clotting factors are synthesized in the liver and will be decreased with liver damage causing few clotting factors therefore prolonged clotting times and high risk bleeding
What does liver damage do to albumin?
it is made in the liver too...so will have decreased levels of this which means a potential for drug problems
When will direct (conjugated-in water soluble form) bilirubin levels be elevated?
during any condition that obstructs blood flow.
- Such as:
- Anything that damages liver cells
When will indirect bilirubin increase?
Only when the person is having a problem with destruction of RBC's. Like in Anemia or Rh problems in newborn.
NOT with Hepatitis
When a person has Hepatitis A, B, C and D....what serologic test will be abnormal?
How long does it last?
What is it?
Lasts several weeks to months and is when complications of Hepatitis occurs....cuz it is when chronic forms develop
What is Chronic Persistent Hepatitis?
- Liver inflammation that lasts longer than 6 months.
- Mile or no symptoms, no further destruction after initial insult
- HBV 1-10% adults or 15-80% in newborns
- HCV 75-85% chance of all cases to become chronic
Why would a person with HBV or HCV become chronic?
- increased physical exertion
- Alcohol intake
Chronic Active Hepatitis B,C,D
is liver damage that can lead to hepatic necrosis and cirrhosis (fibrotic liver disease)
What does Cirrhosis (Fibrotic liver disease) cause?
- Fulminant Hepatitis-it is the failure of liver cells to regenerate
- Progressive necrosis and damage leads to liver failure.
- Fatal form is rate....but once develop fatal form-1 yr to live
S&S of liver failure
- rapid weight gain from fluid collection with ascites
- dark urine
- scleral icterus
- hepaic encephalopathy-mental status change
- edema in legs
- cardiac damage
accumulation of fluid in peritoneal cavity
Why dont ascites get drained very often?
cuz the fluid has lots of albumin in it....will drain it if they cant breathe.
Push on beer belly, get a fluid wave...ascites
Which hepatisis is linked to Primary liver carcinoma (Hepaticellular carcinoma)
Hepatitis B and C
How does liver failure cause hepatic encephalopathy
toxins in the blood go to the brain....
- Activity intolerance
- Risk for fluid volume imbalance
- Risk for injury: bleeding (no clotting)
- Imbalanced nutrition
- Risk for impairment of skin integrity(pruritis)
- Risk for social isolation (Hep A....cant work in restaurant)
What do you do to treat Hepatitis?
- No cure!!
- Fluid and elctrolyte replacement
- Vitamin K-for clotting
Alpha Interferon treats what?
- Hepatitis B and C
- by stopping viral replication
antiviral drug used to treat HBV
Used in conjunction with Interferon
Stops replication, which decreases viral load which decreases liver damage
prego test done before
Nursing interventions for Hepatitis
- REST with BRP only
- comfort measures for pruritis
- Maintenance of food and fluids
- Daily wt (watch for ascites)
- Prevent Injury...especially if PT is prolonged
- use soft tooth brushes
- Vit K
How much food and drink should a person with Hepatitis eat per day during acute phase
- 3000 calories/day
- 3000 mL/day of fluid
Special diet for person with Hepatitis
No special diet....just smaller and frequent meals. Lots of them!!
Where do you monitor for S/S of bleeding in a person with Hepatitis?
- skin for petachie
Because people with hepatitis have bleeding problems what limitations are put on them?
- use electric razors
- soft toothbrush
- no contact sports
- no subcutaneous or IM injections
If have to give Subcutaneous or IM injection...apply pressure for 5 minutes
Patient teaching for a person with hepatitis
Watch OTC's that are known to cause liver damage
- medications with alcohol (cough meds)
- Must avoid for 3-12 months
NO ALCOHOL EVER IF HAVE CHRONIC HEPATITIS
Prevention of the spread of Hepatitis A and E
- Standard Precautions and Contact Isolation
- Wear gloves/gown
- Private toilet with daily cleaning
- Bag, label and clean contaminated linens
- Isolation of tools (thermometers)
- Careful handwashing
Prevention of the spread of Hepatitis B,C,D & G
- Standard precautions
- Careful disposal of needles and items exposed to patients blood or body fluids
- Avoidance of contamination of open cuts and mucous membranes (MINE)
- Teach pt. to avoid sex until liver fxn test is normal...then USE A CONDOM
- Dont share razors or tooth brushes
- DONT donate blood, plasma, organs, tissues or semen!!
Prophylaxis for Hepatitis A
Havris-provides immunization for 1 year old and above
Initial dose followed by a booster 6-12 months later
Post exposure for persons who have contact with a person with HAV
- HIG must be given within 7-14 days of exposure
- 48 hours from the first exposure is best
Hepatitis B vaccine
- admin in deltoid, may cause flu like symptoms
- requires a series of 3 shots with 2nd and 3rd dose being given 1 and 6 months after the initial dose
Latest thoughts on Recombivax HB
have an antibody titer drawn 1-2 months after the 3rd injection. If ok you are protected for life, if not, booster is needed
Post exposure to Hepatitis B...what do you do?
HBIG within 7 days then get Recombivax series
Pediatrics guildelines for infants and Hepatitis B vaccines
1st and 2nd doses should be separated by at least 1 month and final dose 24 weeks
If a child is born to infected Hepatitis B mom what do you do?
- HBIG given at 1 and 6 months
- 4 doses of combo vaccine
- Test pt for HBsAg and antibody to Hepatitis B surface antigen at 12 and 15 months of age to see if have antibodies
Since what year have hepatitis B vaccines been required for middle schoolers?
Vaccine for CDE and G
- Stops viral replication
- Is better cuz has a longer 1/2 life and so it is given less often
Which Hepatitis cause cancer?