1. Interventions for clients with liver, galdbladder and pancreas disorders. Clients with malnutrition and obesity..

2. Liver disorders Hepatitis  1.Definition: inflammation of the liver due to virus, exposure to alcohol, drugs, toxins; may be acute or chronic in nature  2.Pathophysiology: metabolic functions and bile elimination functions of the liver are disrupted by the inflammation of the liver.

3. Hepatitis  Widespread viral inflammation of liver cells  Hepatitis A  Hepatitis B  Hepatitis C  Hepatitis D  Hepatitis E  Hepatitis F and G are uncommon

4. Hepatitis Viral Hepatitis  1.Types (causative agents) a. Hepatitis A virus (HAV) Infectious hepatitis  1. Transmission: fecal-oral route, often contaminated foods, water or direct contact, blood transfusions, contaminated equipment  2. Contagious through stool up to 2 weeks before symptoms occur; abrupt onset  3. Benign, self limited; symptoms last up to 2 months

5. Hepatitis  Prevention of Hepatitis A  Good handwashing  Good personal hygiene  Control and screening of food handlers  Passive immunization  Incubation period :20-50 days (short incubation period)

6. Hepatitis  Incidence  More common in fall and winter months  Usually found in children and young adults  Infectious for 3 weeks prior and 1 week after developing jaundice  Clinical recovery 3-16 weeks

7. Hepatitis Hepatitis B virus (HBV)  1.Transmission:  infected blood and body fluids,  parenteral route with infusion  ingestion or inhalation of the blood of an infected person  Contaminated needles, syringes, dental instruments  Oral or sexual contact  High risk individuals include homosexual, IV drug abusers, persons with multiple sexual partners, medical workers  2.Liver cells damaged by immune response; increased risk for primary liver cancer; causes acute and chronic hepatitis, fulminant hepatitis and carrier state

8. Hepatitis Hepatitis C virus (HCV)  1.Transmission: infected blood and body fluids; injection drug use is primary factor  2.Initial manifestations are mild, nonspecific  3.Primary worldwide cause of chronic hepatitis, cirrhosis, liver cancer  4. Usual incubation period 7-8 weeks

9. Hepatitis Hepatitis E virus (HEV)  1.Transmission: fecal-oral route, contaminated water supplies in developing nations; rare in U.S.  2.Affects young adults; fulminant in pregnant women

10. Clinical Manifestations  Abdominal pain  Changes in skin or eye color  Arthralgia (joint pain)  Myalgia (muscle pain)  Diarrhea/constipation  Fever  Lethargy  Malaise  Nausea/vomiting  Pruritus

11. Nonsurgical Management  Physical rest  Psychological rest  Diet therapy  Drug therapy includes:  Antiemetics  Antiviral medications  Immunomodulators

12. Fatty Liver (Steatohepatitis)  Fatty liver is caused by the accumulation of fats in and around the hepatic cells.  Causes include:  Diabetes mellitus  Obesity  Elevated lipid profile  Many clients are asymptomatic

13. Hepatic Abscess  Liver invaded by bacteria or protozoa causing abscess  Pyrogenic liver abscess; amebic hepatic abscess  Treatment usually involves:  Drainage with ultrasound guidance  Antibiotic therapy

15. Liver Trauma  The liver is the most common organ injured in clients with penetrating trauma of the abdomen, such as gunshot wounds and stab wounds.  Clinical manifestations include abdominal tenderness, distention, guarding, rigidity.  Treatment involves surgery, multiple blood products.

16. Cirrhosis  Cirrhosis is extensive scarring of the liver, usually caused by a chronic irreversible reaction to hepatic inflammation and necrosis.  Complications depend on the amount of damage sustained by the liver.  In compensated cirrhosis, liver has significant scarring but performs essential functions without causing significant symptoms.

18. Complications  Portal hypertension  Ascites  Bleeding esophageal varices  Coagulation defects  Jaundice  Portal-systemic encephalopathy with hepatic coma  Hepatorenal syndrome  Spontaneous bacterial peritonitis

19. Etiology  Known causes of liver disease include:  Alcohol  Viral hepatitis  Autoimmune hepatitis  Steatohepatitis  Drugs and toxins  Biliary disease  Metabolic/genetic causes  Cardiovascular disease

20. Clinical Manifestations  In early stages, signs of liver disease include:  Fatigue  Significant change in weight  Gastrointestinal symptoms  Abdominal pain and liver tenderness  Pruritus

21. Clinical Manifestations  In late stages, the signs vary:  Jaundice and icterus  Dry skin  Rashes  Petechiae, or ecchymoses (lesions)  Warm, bright red palms of the hands  Spider angiomas  Peripheral dependent edema of the extremities and sacrum

22. Abdominal Assessment  Massive ascites  Umbilicus protrusion  Caput medusae (dilated abdominal veins)  Hepatomegaly (liver enlargement

24. Other Physical Assessments  Assess nasogastric drainage, vomitus, and stool for presence of blood  Fetor hepaticus (breath odor)  Amenorrhea  Gynecomastia, testicular atrophy, impotence  Bruising, petechiae, enlarged spleen  Neurologic changes  Asterixis

26. Laboratory Assessment  Aminotransferase serum levels and lactate dehydrogenase may be elevated.  Alkaline phosphatase levels may increase.  Total serum bilirubin and urobilinogen levels may rise.  Total serum protein and albumin levels decrease.

27. Laboratory Assessment (Continued)  Prothrombin time prolonged; platelet count low  Decreased hemoglobin and hematocrit values and white blood cell count  Elevated ammonia levels  Serum creatinine level possibly elevated

28. Surgical Interventions  Peritoneovenous shunt  Portocaval shunt  Transjugular intrahepatic portosystemic shunt

29. Cancer of the Liver  One of the most common tumors in the world  Most common complaint: abdominal discomfort  Treatment includes:  Chemotherapy  Surgery

31. Liver Transplantation  Used in the treatment of end-stage liver disease, primary malignant neoplasm of the liver  Donor livers obtained primarily from trauma victims who have not had liver damage  Donor liver transported to the surgery center in a cooled saline solution that preserves the organ for up to 8 hours

33. Complications  Acute, chronic graft rejection  Infection  Hemorrhage  Hepatic artery thrombosis  Fluid and electrolyte imbalances  Pulmonary atelectasis  Acute renal failure  Psychological maladjustment

34. Acute Cholecystitis  Acute cholecystitis is the inflammation of the gallbladder.  Cholelithiasis (gallstones) usually accompanies cholecystitis.  Acalculous cholecystitis inflammation can occur in the absence of gallstones.  Calculous cholecystitis is the obstruction of the cystic duct by a stone, which creates an inflammatory response.

35. Chronic Cholecystitis  Repeated episodes of cystic duct obstruction result in chronic inflammation  Pancreatitis, cholangitis  Jaundice  Icterus  Obstructive jaundice  Pruritus

36. Clinical Manifestations  Flatulence, dyspepsia, eructation, anorexia, nausea and vomiting, abdominal pain  Biliary colic  Murphy’s sign  Blumberg’s sign  Rebound tenderness  Steatorrhea

38. Nonsurgical Management  Diet therapy: low-fat diet, fat-soluble vitamins, bile salts  Drug therapy: opioid analgesia with meperidine hydrochloride, antispasmodic or anticholinergic drugs, antiemetic  Percutaneous transhepatic biliary catheter insertion

39. Surgical Management  Laparoscopic cholecystectomy  Standard preoperative care  Operative procedure  Postoperative care  Free air pain result of carbon dioxide retention in the abdomen  Ambulation  Return to activities in 1 to 3 weeks

40. Traditional Cholecystectomy  Standard preoperative care  Operative procedure  Postoperative care  Meperidine hydrochloride via patient-controlled analgesia pump  Antiemetics  Wound care  Care of the T-tube  Nothing by mouth  Diet therapy

41. Cancer of the Gallbladder  Anorexia, weight loss, nausea, vomiting, general malaise, jaundice, hepatosplenomegaly, chronic, progressively severe epigastric or right upper quadrant pain  Poor prognosis  Surgery, radiation, chemotherapy

42. Acute Pancreatitis  Serious and possibly life-threatening inflammatory process of the pancreas  Necrotizing hemorrhagic pancreatitis  Lipolysis  Proteolysis  Necrosis of blood vessels  Inflammation  Theories of enzyme activation

44. Complications of Acute Pancreatitis  Hypovolemia  Hemorrhage  Acute renal failure  Paralytic ileus  Hypovolemic or septic shock  Pleural effusion, respiratory distress syndrome,pneumonia  Multisystem organ failure  Disseminated intravascular coagulation  Diabetes mellitus

45. Clinical Manifestations  Generalized jaundice  Cullen’s sign  Turner’s sign  Bowel sounds  Abdominal tenderness, rigidity, guarding  Pancreatic ascites  Significant changes in vital signs

46. Surgical Management  Preoperative care: NG tube may be inserted  Operative procedures  Postoperative care  Monitor drainage tubes and record output from drain.  Provide meticulous skin care and dressing changes.  Maintain skin integrity.

47. Chronic Pancreatitis  Progressive destructive disease of the pancreas, characterized by remissions and exacerbations  Nonsurgical management includes:  Drug therapy  Analgesic administration  Enzyme replacement  Insulin therapy  Diet therapy

48. Pancreatic Abscess  Most serious complication of pancreatitis; always fatal if untreated  High fever  Blood cultures  Drainage via the percutaneous method or laparoscopy  Antibiotic treatment alone does not resolve abscess

49. Pancreatic Carcinoma  Nonsurgical management  Drug therapy  Radiation therapy  Biliary stent insertion

50. Surgical Management  Preoperative care  NG tube may be inserted  TPN typically begun  Operative procedure may include Whipple procedure  Postoperative care  Observe for complications  Gastrointestinal drainage monitoring  Positioning  Fluid and electrolyte assessment  Glucose monitoring

51. Nutritional Standards to Promote Health  Dietary recommendations, food guide pyramids for adequate nutrition  Nutritional assessment includes:  Diet history  Anthropometric measurements  Measurement of height and weight  Assessment of body fat (body mass index)

52. Malnutrition  Protein-calorie malnutrition  Marasmus calorie malnutrition, in which body fat and protein are wasted, serum proteins are often preserved  Kwashiorkor  Marasmic-kwashiorkor

54. Laboratory Assessment  Hematology  Protein studies  Serum cholesterol  Other laboratory tests

55. Imbalanced Nutrition: Less Than Body Requirements  Interventions include:  Drug therapy  Partial enteral nutrition  Total enteral nutrition  Candidates for total enteral nutrition

56. Enteral Nutrition  Types of enteral products for nutrients  Methods of administration of total enteral nutrition  Types of tubes  Types of feedings  Complications of total enteral nutrition:  Aspiration, fluid excess, increased osmolarity, dehydration, electrolyte imbalances

57. Parenteral Nutrition  Partial parenteral nutrition  Total parenteral nutrition  Complications include:  Fluid imbalances  Electrolyte imbalances  Glucose imbalances  Infection

58. Obesity  Overweight: increase in body weight for height compared to standard  Obesity: at least 20% above upper limit of normal range for ideal body weight  Morbid obesity: severe negative effect on health

60. Obesity Complications  Diabetes mellitus  Hypertension  Hyperlipidemia  CAD  Obstructive sleep apnea  Obesity hypoventilation syndrome  Depression and other mental health/behavioral health problems

61. Obesity Complications  Urinary incontinence  Cholelithiasis  Chronic back pain  Early osteoarthritis  Decreased wound healing  Increased susceptibility to infection

62. Obesity and Health Promotion  Health promotion/illness prevention  Teach the potential consequences and complications.  Teach the importance of eating a healthy diet.  Teach that foods eaten away from home tend to be higher in fat, cholesterol, and salt, and lower in calcium.  Reinforce need for regular moderate activity for at least 30 min per day.  Educate regarding diet and activity for children and adolescents, and continuing throughout adulthood.

63. Nonsurgical Management  Fasting  Very low-calorie diets of 200 to 800 calories per day  Balanced and unbalanced low-energy diets  Novelty diets  Diet therapy  Exercise program  Drug therapy  Complementary and alternative therapies and treatments

64. Surgical Management  Liposuction  Panniculectomy  Bariatric surgery  Preoperative care  Operative procedures  Vertical banded gastroplasty  Circumgastric banding  Gastric bypass  Roux-en-Y gastric bypass

65. Postoperative Care  Analgesia  Skin care  Nasogastric tube placement  Diet  Prevention of postoperative complications  Observe dumping syndrome signs such as tachycardia, nausea, diarrhea, and abdominal cramping