Gallstones and Cholecystitis

Gallstones/Cholelithiasis

• Cholesterol crystals aggregate to form a stone.
• Bile secretions become saturated with cholesterol, leading to gallstone formation.
• Bile stasis/slow bile secretion causes bile to stay in the gallbladder longer than normal.
• Conditions associated with cholesterol gallstone formation include spinal cord injuries, TPN, rapid weight loss, and pregnancy.
• Symptoms include severe RUQ pain, fever, biliary colic, especially after high-fat food consumption.
• Labs show leukocytosis, increased bilirubin, and elevated ALT.
• Diagnosis is via ultrasound.
• Treatment options include ERCP and lithotripsy.

Cholecystitis

• Cholecystitis is inflammation of the gallbladder wall, which can be acute or chronic.
• Acute cholecystitis presents with elevated temperature, severe RUQ pain, and leukocytosis.
• Chronic cholecystitis is often asymptomatic.
• Diagnostic testing includes MRI, CT, and ultrasound.
• Dietary interventions include low-fat intake, increased protein and avoiding gas-forming foods and alcohol.
• Endoscopic retrograde cholangiopancreatography (ERCP) is a treatment option, monitor for fever as a complication.
• Cholecystectomy involves post-operative monitoring and teaching.
• Call the surgeon if febrile after cholecystectomy.
• Avoid fatty foods for 4-6 weeks post-cholecystectomy.
• Walking helps to relieve pain due to gas after surgery.

Portal Hypertension/Liver Disease

• Portal hypertension involves GI congestion and enlargement of the portal vein.
• A complication of advanced liver disease.
• Portal hypertension manifests as ascites and esophageal varices.
• Liver failure signs include jaundice, hypoalbuminemia, and splenomegaly.
• Use mild soaps for bathing.
• Monitor Prothrombin Time (will be elevated).
• Avoid ETOH, Tylenol, and hepatotoxic substances.

Hepatitis A (HVA)

• Caused by an RNA virus due to a lack of safe water and poor sanitation.
• Incubation period is 2-7 weeks.
• Anti-hepatitis virus A Immunoglobulin G (IgG) indicates immunity to HVA.

Hepatitis B (HBV)

• Caused by a double-stranded DNA virus.
• The incubation period is 2-6 months.
• Risk factors include IV drug use and transmission via blood and body fluids.
• Clinical manifestations include anorexia, fever, jaundice, and serum sickness.
• Surface antigen (HBsAg) indicates early/active and chronic infection.
• Surface antibody (HbsAb) indicates resolution and immunity.
• Core antigen (HBcAg) appears first in active infection.
• Core antibody (HBcAb) indicates seroconversion.
• Hepatitis B antigen (HBeAg) indicates viral replication and infectivity.
• Avoid hepatotoxic substances and alcohol.
• Diet should be high in carbs and low in fat.
• Avoid sexual activity until HVB testing is negative.

Hepatitis C (HVC)

• Caused by a single-stranded RNA virus.
• Clinical manifestations are similar to Hep B.
• Chronic HVC can lead to peripheral edema, ascites, and changes in mental status.
• HVCRNA and anti-HVC (antibodies to the virus) are diagnostic markers.
• Antiviral treatment is prescribed.

Hepatitis E (HVE)

• Caused by a fecal-oral virus from contaminated food/water.
• Often contracted by international travelers.
• Clinical manifestations are the same as Hep A.
• Education includes no drinking or Tylenol, and wash hands to prevent spread.

Non-Viral Hepatitis

• Nonalcoholic Steatohepatitis (NASH): Risk factors include diabetes type 1 and high cholesterol.
• Alcoholic Hepatitis: Inflammation of the centrilobular region of the liver causes necrosis of the liver cells.
• Clinical Manifestations: Portal HTN, Encephalopathy, Fever, and Hepatomegaly.
• Avoid ETOH and hepatotoxic medications.
• Prednisolone, N-acetylcysteine, and statin meds for cholesterol are tx.
• Isoniazid is LIVER TOXIC.
• Symptom management with Zofran, Toradol, and docusate.

Thyroid Gland

• Calcitonin, secreted by thyroid cells, increases bone formation, inhibits breakdown, and decreases blood levels of Ca+.
• T3 and T4 are secreted by the thyroid and need iodine to form.
• Iodine increased or decreased the chance of goiter.
• Thyroid hormone increases metabolic rate and is essential for normal growth/ development.
• Beta Blockers (LOL), Lasix (furosemide), and Aspirin interfere with thyroid levels.
• Monitor for Hypothyroid and monitor parathyroid (hypo/hyper); this means monitor calcium!!
• If spasm with BP check à Trousseau Sign
• immediately administer IV Calcium gluconate.

Parathyroid Gland

• Monitor Parathyroid hormone and calcium.
• Place the patient on ECG (think calcium à QT Interval)
• Hyper-parathyroid: increased PTH = increased calcium.
• Hyperparathyroidism is likely due to a tumor.
• Clinical manifestations may be asymptomatic, discomfort to flank area à needs attention as it could be related to kidney failure.

Hypothyroidism

• Primary Hypothyroidism: thyroid gland not working for many reasons.
• Secondary Hypothyroidism: Cancer, Brain infection, neurosurgery, caused by severe head trauma.
• Complication: Myxedema Coma: generalized edema, AMS, low temp.
• Females will have heavy menstruation.
• Muscle cramping, fatigue, anxiety, depression
• Prolonged QT interval.
• Treatment includes Levothyroxine.
• Call PCP if chest pain occurs with Levothyroxine.
• Monitor TSH periodically.
• Take HR à if greater than 100 then hold med.
• Myxedema Coma: Having suction at the bedside is a priority.

Hyperthyroidism

• Patho: Thyroid is hypersecreting.
• Graves Disease: High levels of TSH autoantibodies, sun/ light can cause head pain
• Thyroid cell destruction: Hashimoto thyroiditis.
• Complication: Thyroid Storm
• Elevated temp, Diarrhea, High HR
• If the patient begins experiencing Delirium, further increases in temp, increased peripheral pulses, and crackles in lungs, this patient needs the most attention!!
• If received radioactive iodine monitor for signs of worsening hyperthyroid à increased temp (THYROID STORM).
• The patient will need a cardiac monitor placed for the potential of dysrhythmia.

Addison’s Disease

• Adrenocortical insufficiency.
• Primary Cause: The patient cannot produce cortisol causing adrenal insufficiency.
• Secondary cause: Corticosteroid Therapy.
• Adrenocorticotropic Hormone (ACTH) provocation test à pt will fail to produce cortisol.
• Meds: Hydrocortisone.
• Education: Keep emergency steroid kit readily available
• Avoid strenuous activity, especially in hot weather.
• Diet: HIGHSALT, high carb, and high protein.

Cushing’s Disease

• Increased/ elevated cortisol.
• Manifestations include hyperglycemia, hypokalemia, and hypertension.
• Test for ACTH to differentiate between primary and secondary conditions.
• Dexamethasone Suppression Test: 1mg of dexamethasone given PO at night and then serum cortisol level obtained in AM.
• normal result à decreased cortisol level
• If it is high then this could mean tumor (adrenal or pituitary) or hypersecretion of cortisol.

Systemic Lupus Erythematosus (SLE)

• Auto-antibody production occurs in women.
• Resulting from an abnormal immune and phagocytic system that decreases tolerance to self.
• Glomerulonephritis indicates kidney involvement is systemic.
• Clinical manifestations: Malar rash, cardiac/ respiratory inflammation.
• Dx: ANA, LE Cell Test.
• Call the doctor if the patient reports chest pain with breathing/ movement.
• Educate on wearing sunscreen (exacerbates malar rash).

Rheumatoid Arthritis

• Autoimmune inflammatory response, causing immune cells to aggregate in small joints.
• Bilateral-Symmetrical polyarthritis, Bone deformities, and Fatigue.
• Diagnosis via labs and x-rays.
• Medication education is important.
• Encourage activity with rest periods.
• Use adaptive equipment.
• Monitor Glucose levels as treatment can be with corticosteroids.

Scleroderma

• Collagenous tissue deposits in connective tissues of the body.
• Genetic and triggered by infection.
• Can affect the skin or present systemically/ diffuse with internal organ involvement.
• CREST (calcinosis, Raynaud's, esophageal dysfunction, sclerodactyly, telangiectasias).

Hypersensitivity

• Hypersensitivity 1- anaphylaxis
• Hypersensitivity 2- tissue-specific IGG/ IGM (blood transfusion or medication transfusion)
• Hypersensitivity 3- antigen-antibody immune complex (Strep leading to glomerulonephritis)
• Hypersensitivity 4- contact reaction
• TBDxTesting: Mantoux skin test: if positive this is a hypersensitivity reaction

Pneumocystitis jirovecii Pneumonia

• A fungal infection in the lungs.
• Can be seen with those with weakened immune systems (HIV/ Cancer).
• Clinical Manifestations include hypoxemia.

Human Immunodeficiency Virus (HIV)

• Caused by a viral infection that affects CD4, lymphocytes, and macrophages.
• Causes a RNA retrovirus and must convert to DNA to replicate and infect other cells.
• Transcriptase, integrase, and protease are needed for viral replication.
• The primary site of replication is the GI tract.
• Risk Factors: being a healthcare worker/phlebotomist, unprotected sex.
• Concurrent STIs or genital lesions increase HIV infection risk.
• Being born to a mother who has HIV à can occur intrauterine, during delivery, or breastfeeding.
• Initially asymptomatic.
• Females: vaginal itching with discharge.
• HIV has advanced to AIDS: Difficulty swallowing, SOB, Productive Cough, weight loss, Chest pain, Night sweats, and LOW CD4.
• Wasting syndrome àmonitor electrolytes.
• Allow the patient to rest/ nap before meals.
• Immunosuppression: Someone else needs to clean the litterbox.
• Raw foods need to be cleaned and cooked thoroughly before eating.
• Disinfect surfaces.
• Monitor temperatures.

Chronic Myeloid Leukemia (CML)

• Gradual Onset.
• Age 40-50.
• Prognosis is poor due to poor response to chemo.
• Manifestations: Fatigue, weight loss, bleeding, discomfort, and sweating.
• High granulocyte count.
• Diagnosis is via Bone marrow aspiration and CBC with a differential.
• Treatment includes Tyrosine kinase inhibitor (PO).
• It is important for the nurse to educate on what will happen and how to take meds.

Acute Myeloid Leukemia (AML)

• Acute Onset.
• Median age 64.
• Problem with chromosomes that cause blast cell proliferation/ mutation.
• Assorted chromosomal translocations or inversions cause the disease to present in many ways.
• Responds well to treatment.
• Clinical Manifestations: Splenomegaly, Bone pain, Anemia, and Thrombocytopenia
• Diagnosis via Bone marrow aspiration, CBC, and blood smear.
• Treatment: Aggressive chemotherapy that starts with induction therapy.

Multiple Myeloma

• Patho: antibody-secreting B Lymphocytes (Plasma) disorder
• Antibodies are destroying healthy cells.
• Clinical Manifestations: Bone lesions/ issues, hypercalcemia.
• Complications: Spinal fracture and risk for spinal cord compression.
• Diagnosis via Bone Marrow Biopsy
• Urinalysis: the presence of Bence-Jones Protein.
• Treatment: Steroids, chemo, stem cell, and radiation
• Increased daily water intake and maintain high UOP.

Acute Lymphoblastic Leukemia (ALL)

• Childhood cancer.
• Malignant transformation of B (lymphoblast) Cells.
• Abrupt onset of symptoms (fever, infection, anorexia), Severe headache, and Vomiting
• Increased number of immature WBC
• Diagnosis: Bone Marrow Aspiration, CBC, Blood Smear.
• Treatment and Interventions: Chemo and Steroids
• High remission rates
• Normal Expected labs after treatment.
• platelet: 150,000-400,000
• WBC: 5,000-10,000
• Encourage slow weight gain (1lb a week).

Lymphoma

• Lymphoid neoplasms that start in lymph nodes then spread to tissues and organs
• Hodgkin’s: Lymphadenopathy (cervical, supraclavicular, mediastinal), B Symptoms (systemicàfever, sweating, weight loss), Pruritus, Jaundice, and Herpes Zoster.
• Dx: Biopsy showingàReed-Sternberg Cells.
• Platelets- normal .
• Treatment/Interventions: Chemo, stem cell transplant, and radiation.
• Educate on avoiding soaps/ lotions that dry out skin.
• Wear cotton clothing.
• Use an electric razor instead of a straight edge blade.
• Non-Hodgkin’s: Lymphadenopathy (abd, chest, neck), Fever, sweating, and weight loss/ anorexia.
• Can present with spinal cord compression.
• Diagnosis at the latest stage as less aggressive.
• Treatment/Interventions: Chemo, antibiotics, antifungals, antivirals, and pain.
• Educate on exercise x 30 min 5x a week

Metastatic Cancer

• The pattern is related to circulatory flow.
• Cell survival is not guaranteed after entering circulation.
• Grading/ staging should be done for all tumors.

Chemotherapy

• Monitor WBC daily.
• If WBC drops below normal (critical levels) this can be a complication.
• Chemo helps shrink and destroy all cells.
• Should be given via a central venous access device.
• Chemo can be by mouth, IV, or directly into the spinal fluid.

Labs

• WBC: 5,000-10,000
• PLT: 150,000-400,000
• Prothrombin Time: 11-12.5
• HCT Male: 42-52, Female: 37-47
• BUN: 10-20
• Potassium: 3.5-5
• Sodium: 135-145