Metabolic and Endocrine Function

1. Metabolic and Endocrine Function Larry Santiago, MSN, RN

3. Assessment and Management of Patients With Hepatic Disorders

4. Assessment • Health History • Exposure to hepatotoxins • Alcohol and drug use • Lifestyle behaviors • Physical Examination • Skin inspection • Abdominal assessment • Liver palpation

5. Diagnostic Evaluation • Liver Function Tests – page 1079 • Liver Biopsy -removal of a small amount of liver tissue through needle aspiration

6. Diagnostic Evaluation 2 • Ultrasonography • Computed Tomography

7. Diagnostic Evaluation 3 • Magnetic resonance imaging (MRI) • Laparoscopy

8. Hepatic Dysfunction • Jaundice- hemolytic, hepatocellular, obstructive, and hereditary hyperbilirubinemia

9. Hepatic Dysfunction 2 • Portal Hypertension • Ascites

11. Ascites • Pathophysiology • Clinical manifestations

12. Ascites 2 • Medical/Nursing management • Dietary Modification – strict sodium restriction • Diuretics

13. Ascites 3 • Bed Rest • Paracentesis

14. Esophageal Varices • - dilated, tortuous veins found in the submucosa of the esophagus or even the stomach

15. Hepatic Encephalopathy and Coma • Results from accumulation of ammonia and other toxic metabolites in the blood • Hepatic coma represents most advanced stage of hepatic encephalopathy • Clinical manifestations include: mental changes, motor disturbances, asterixis and constructional apraxia

16. Hepatic Encephalopathy • RN is responsible for maintaining a safe environment to prevent injury, bleeding, and infection • Assess neuro status frequently • Strict I & O • Assess for symptoms of infection • Monitor serum ammonia level and electrolytes

17. Management of Patients With Viral Hepatic Disorders • Viral Hepatitis • Systemic viral infection in which necrosis and inflammation of the liver cells produce a cluster of changes • Includes Hepatitis A,B,C,D, and E

18. Hepatitis A • Mode of transmission • fecal/oral Signs & Symptoms: Headache, malaise, fatigue, later on dark urine, jaundice, tender liver

20. Hepatitis B • Mode of transmission: • sex, either by intercourse or oral contact • Perinatal tranmission • Health care personnel • Long incubation period (70-80 days) • Signs/symptoms insidious and variable

21. Hepatitis B 2 • Active Immunization: Hepatitis B Vaccine • Passive Immunity: Hepatitis B Immune Globulin

22. Hepatitis B 3 • Medical/Nursing management • Antiviral agents – Epvir and Hepsera • Bed rest, activity restriction • Adequate nutrition

23. Hepatitis C • Mode of transmission: • Blood transfusion • Risk increased with STD Signs and Symptoms: Similar to HBV, but less severe and anicteric • Increased risk of chronic liver disease and hepatic cancer • Hepatitis G risk factors similar to HCV

24. Hepatitis D • Mode of transmission: • same as HBV Signs and Symptoms: Similar to HBV Outcome: Greater likelihood of carrier state, chronic active hepatitis, and cirrhosis

26. Hepatitis E Mode of transmission: Fecal-oral Signs and Symptoms: Similar to HAV Very severe in PG women Outcome: Similar to HAV except very severe in PG women

27. Management of Patients With Nonviral Hepatic Disorders • Toxic Hepatitis • Exposure to hepatotoxic chemicals or meds - Symptoms include vomiting, abnormal clotting, delirium, coma, seizures, death

28. Hepatic Cirrhosis • Types of cirrhosis: • Alcoholic cirrhosis – most common • Postnecrotic cirrhosis – broad bands of scar tissue from previous acute viral hepatitis • Biliary cirrhosis – result of chronic biliary obstruction and infection – much less common

29. Hepatic Cirrhosis 2 • Pathophysiology • Alcohol consumption major causative factor • Characterized by episodes of necrosis involving the liver cells • Destroyed liver cells are replaced by scar tissue

30. Hepatic Cirrhosis 3 • Clinical manifestations • Hepatomegaly • Portal Obstruction and Ascites • Infection and Peritonitis • Gastrointestinal varices • Edema • Vitamin deficiency and anemia • Mental deterioration

31. Hepatic Cirrhosis 4 • Assessment and Diagnostic Findings • Medical Management

32. Assessment and Management of Patients With Biliary Disorders

34. Diseases of the Gallbladder • Cholecystitis- acute inflammation, calculous cholecystitis • Cholelithiasis- gallstones

35. Cholelithiasis • Medical Management- lithotripsy, UDCA and CDCA, MTBE, ERCP

36. ERCP

37. Cholelithiasis 2 • Surgical Management- cholecystectomy

39. Cholelithiasis 3 • Nursing Management- relieve pain, promote biliary drainage, improve nutritional status

40. Diseases of the Pancreas • Acute Pancreatitis- mild, self- limiting to fatal, self-digestion of pancreas by proteolytic enzymes

41. Acute Pancreatitis Gerontologic considerations – mortality increases with advancing age

42. Acute Pancreatitis 2 • Pathophysiology • Caused by self-digestion of the pancreas • Long-term use of alcohol is commonly associated • Mortality rate is high (10%)

43. Acute Pancreatitis 3 • Clinical Manifestations • Severe abdominal pain • Nausea/vomiting • Hypotension • Respiratory distress • Tachycardia • Cyanosis

44. Acute Pancreatitis 4 • Medical Management directed at relief of symptoms, prevention and treatment of complications, and managing exocrine and endocrine insufficiency of pancreatitis

45. Chronic Pancreatitis • Characterized by progressive anatomic and functional destruction of the pancreas • End result is mechanical obstruction of the pancreatic and common bile ducts and the duodenum • Major causes are alcoholism and malnutrition

46. Chronic Pancreatitis 2 • Clinical Manifestations • Recurring attacks of severe abdominal and back pain • Vomiting • Opioids often do not provide relief • Weight loss • Steatorrhea

47. Chronic Pancreatitis 3 • Medical Management • Pain management • Diabetes Mellitus • Pancreatico- jejunostomy

49. Assessment and Management of Patients With Diabetes Mellitus

50. Diabetes Mellitus • Type 1- destruction of pancreatic beta cells • Combined genetic, immunologic, and environmental factors contribute to beta cell destruction