Cirrhosis of the Liver

by Laura Kowalk Rogge RN, BSN & Carlyn Husbands RN, BSN

Cirrhosis of the liver is a disease in which the hepatic cells become damaged and scarred. The two most common causes are excessive alcohol use and viral infections of the liver such as hepatitis. Other causes can be autoimmune disorders, disorders of the bile duct and obesity, uncontrolled hyperlipidemia and diabetes. 

The liver has a few very important functions: 1) metabolizes, 2) detoxifies, 3) stores and 4) produces. An interruption is any of these hepatic functions can cause the cells in the liver to die and become fibrous, leading to irreversible liver damage called cirrhosis. In addition, this fibrous scar tissue interferes with the blood flow of the liver resulting in portal hypertension. Portal hypertension is a serious complication of cirrhosis that can lead to splenomegaly and bleeding varices within the stomach, esophagus and/or rectum which can be potentially fatal.

During metabolism the liver will break down waste products and convert them into something that the body can use. An example of this is when the body metabolizes ammonia into urea. Ammonia, a by-product of protein metabolism, will go to the liver to be metabolized and is converted into urea which is then excreted via the kidneys as urine. In cirrhosis, the liver will be unable to convert the ammonia into urea leading to dangerous levels of elevated ammonia causing toxic hepatic encephalopathy.

The liver is responsible for detoxifying all substances we ingest, such as alcohol and medications, deciding what can pass through safely into our bloodstream and throughout our body. It does this with the help of the Kupffer cells.

Glycogen is an accumulation of glucose and is stored in the liver. When the body has an excess of glucose such as from eating a heavy meal, it will store all this extra glucose as glycogen. When the body requires energy, it will tap into this storage of glycogen and convert it to glucose for the body to use as energy. In cirrhosis, both of these storage functions can be impaired causing hyperglycemia when the liver is unable to take in and store the excess glucose. Hypoglycemia will occur when the liver is unable to convert the glycogen back to glucose when the body requires it. The liver also stores the vitamins A, C, E, D, K, B12 and iron. In cirrhosis, the liver is unable to absorb these necessary vitamins.  

Albumin, bile and coagulation factors are produced in the liver. Albumin is a necessary protein in that is attracts fluids and drugs and brings them into the vascular system. It also is bound to calcium and is important for bones. Bile is the substance that transports old red blood cells (bilirubin) to the spleen, and also transports cholesterol, flushing it out of our body via the stool. Coagulation factors such as PT, PTT, INR are produced in the liver and are responsible for the clotting of our blood.

When in the early-stages, cirrhosis symptoms can often go undetected. Frequently, cirrhosis is first discovered via routine blood work. To help substantiate the Dianosis, both lab and imaging tests are done. Liver function tests include enzymes that are found in the liver ALT AST ALP and bilirubin. Coagulation tests PT, and hepatitis antibodies are also used. An ultrasound, Ct, or MRI of abdomen may also be done. 

 Treatment for cirrhosis varies according to the cause and extent of the liver damage. The goals of treatment are to slow the progression of scarring by prevention or treating symptoms and problems cause by cirrhosis.

• If you have cirrhosis caused by excessive alcohol use, try to STOP drinking. Alcohol  in cirrhosis is toxic to the liver.

• Weight loss. People with cirrhosis caused by nonalcoholic fatty liver disease could become healthier if they lose weight and control their blood sugar levels.

• Medications may limit further damage to liver cells caused by hepatitis B or C via specific Tx.  of the viruses.

Staff, M. C. (2018, December 07). Cirrhosis. Retrieved from mayoclinic.org: https://www.mayoclinic.org/diseases-conditions/cirrhosis/symptoms-causes/syc-20351487

Edited by Shirley Comer DNP, RN, JD, CNE, ACNS-BC, APN

Irritable Bowel Syndrome by Artria Alexander RN BSN

Irritable bowel Syndrome (IBS) is a common gastrointestinal disorder characterized by a cluster of signs and symptoms that effects the process of digestion in the large intestine. The process of food absorption and water absorption is compromised. IBS triad of signs and symptoms include; cramping, abdominal pain, and altered bowel habits (constipation/diarrhea). 

Signs of IBS include abdominal distention, food intolerance, and occasionally weight loss. 

Factors that contribute to IBS are linked to muscle contractions in the intestine, abnormalities in the nervous system including poor coordination between the brain and intestine, inflammation of the large intestine, and severe infections caused by bacteria or viruses. The symptoms of IBS can be triggered by food, stress and hormones. 

Those who are at an increased risk of developing IBS include; females, individuals under age 50, those with a family history of IBS, and those who have preexisting mental health problems such as anxiety and depression.

To diagnosis and treat IBS, a comprehensive health history and physical exam are done. Diagnostic criteria include; X-ray, CT scan, colonoscopy, sigmoidoscopy, lactose intolerance test, upper endoscopy, and stool test. Treatment options are geared toward lifestyle and diet modifications consisting of high fiber foods, the intake of plenty of fluids, rest and adequate sleep, and exercise. Other options for treatment include medication management such as fiber supplements (Metamucil), laxatives (Miralax), anti-diarrheal medication (Imodium), anticholinergic medications, (Bentyl), tricyclic antidepressants and pain medications (Neurontin).

Reference:

Chang, L. (n.d.). Irritable Bowel Syndrome (IBS). Retrieved November 23, 2019, from https://www.niddk.nih.gov/health-information/digestive-diseases/irritable-bowel-syndrome.

Edited by Shirley Comer DNP, RN, JD, CNE, ACNS-BC, APN

Acute Bronchitis 

Written by Judith Ose RN, BSN, MSNc and Nwachukwu Nkechi RN, BSN, MSNc, Edited by Shirley Comer 

In general, Acute Bronchitis is a viral infection whose predominant symptom is a cough which can last up to three weeks (Hart, 2014, p. 34). Moreover, this viral infection can present like a mild cold. In addition, an individual with acute bronchitis can also present with wheezing, especially if there is an underlying disease process of asthma (Hart, 2014, p. 34).

            Antibiotics are usually not needed in the treatment of acute bronchitis unless cases of high fever, high pulse rate, and respiration are involved.

Risk factors of acute bronchitis

• Close contact with someone who has a cold or acute bronchitis
• Failure to get age-appropriate immunizations
• Exposure to tobacco smoke, fumes, dust, and air pollution

Diagnostic criteria and treatments. 

History is one of the main steps in diagnosing acute bronchitis. The following symptoms may help in the diagnosis of acute bronchitis; CBC with differential, procalcitonin to rule out a bacterial infection, blood culture if bacterial is highly suspected, chest x-ray in elderly patients or if physical findings are suggestive of pneumonia.

The most debilitating complication of this disease process is the actual cough and therefore the treatment focuses primarily on suppressing the cough The treatments for acute bronchitis include Dextromethorphan 20 mg PO, q4hrs or 60 mg extended-release liquid BID for the cough, inhaled bronchodilator albuterol 2.5 mg TID/QID by nebulizer, for wheezing, and Benzonatate  200mg and Guaifenesin 600mg PO q6hrs, for the mucus production (Hart, 2014, p.36). 

References 

Hart, A. (2014). Evidence-based diagnosis and management of  acute bronchitis. The Nurse Practitioner 39(9), 35-36 doi: 10.1097/01.NPR. 0000452978.99676.2b

Kinkade, S., & Long, N. (2016). Acute bronchitis. American Family Physician, 94(7), 560-565. Retrieved from https://www.aafp.org/afp/2016/1001/p560.pdf

Fayyaz, J. (2018). Bronchitis essential practice, background, pathophysiology. Retrieved from: https://emedicine.medscape.com/article/297108-overview   

Knutson, D., Braun, C. (2015). American family physician. Diagnosis and management of acute bronchitis retrieved from:  https://www.aafp.org/afp/2002/05/15/p2039.html           

Gout

By Kimberly Lopez RN, BSN, MSNc 

and Mia Watkins RN, BSN, MSNc

Edited by Shirley Comer

Gout is a type of arthritis that predominately affect older males, but can affect women too.  It is more common in African Americans (5%) than whites (4%) (ncbi.nlm.nih.gov).  It is caused by a build-up of uric acid in the blood; which comes from ingesting purine-rich foods and drinks such as red meat, seafood, fish, poultry, bacon, organ meats, alcohol, and chocolates (arthritis.org).  Someone affected by gout should limit their intake, if not abstain, from these foods and drinks to keep flare ups at bay. 

Risk factors for developing gout are: 1. excessive daily use of purine diet; 2. excessive alcohol usage; 3. male gender; 4. obesity; 5. hereditary; and 5. being African American.

Diagnosis is made based on symptoms, which may include, inflamed joint, (particularly the big toe), pain, and tenderness to attached limb; elevated uric acid in the blood, and synovial fluid analysis.  However, the symptoms of gout are not always obvious.  For example, a person may present with pain in the joints, but no inflammation.  The key is to look at the bigger picture, i.e. diet, lifestyle, history, and risk factors, before making a diagnosis. Aspiration and examination of synovial fluid and blood test for uric acid are done to confirm the diagnosis of gout. 

Treatment for gout includes limited purine diet, NSAIDs, and the prescription drug, colchicine.  Patients should also maintaining adequate fluid intake, reduce alcohol intake, and lose weight if obese.

References

Safe Foods for Gout. (2019). Retrieved April 25, 2019, from https://www.arthritis.org/living-with-arthritis/tools-resources/expert-q-a/gout-questions/food-for-gout.php

Singh, J. A. (2013, February). Racial and gender disparities among patients with gout. Retrieved April 15, 2019, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC3545402/

Dunphy, L., Winland-Brown, & J., Porter, B.O. (2015). Endocrine and metabolic problems. Primary Care: The Art and Science of Advanced Practice Nursing. Zycowicz, M., South, T., Martin-Plank, L., & Dunphy, L. (Eds.). (4^th ed., pp. 840-919). Publisher: F.A. Davis Company.

Perry, G, Castellani, R., Moreira, P., Lee, H., Zhu, X., and Smith, M. (2008). Pathology’s new role: Defining disease process and protective response. International Journal of Clinic & Experimental Pathology. 1(1):1- 4.

Pharmacotherapies for smoking cessation in the elderly

by Kathleen Zanlocki RN

Every year in the U.S. over 392,000 people die from tobacco caused diseases, making it the leading cause of preventable death. Another 50,000 people die from exposure to secondhand smoke ("Stop smoking," 2011). The most common causes for smoking related mortality in patients over age 60 are lung cancer, cardiovascular disease, and chronic obstructive pulmonary disease (Mauk, 2010). Today’s elderly population grew into adulthood when smoking was socially acceptable by most adults and even some teenagers (Elhassan & Chow, 2007). Smoking was allowed in physician offices and even hospitals, and until 1969 elderly patients in nursing homes were still being given free cigarettes on the annual “respect for the aged” holiday (Elhassan & Chow, 2007). However, awareness of the addictive properties of tobacco spead, and smoking cessation became a recognized public health effort as more research data and evidence accumulated. (Elhassan & Chow, 2007).
The use of pharmacotherapy can be a key part of various methods used in assisting patients with their tobacco dependence (Mauk, 2010). According to the FDA, there are 2 first-line therapies used to treat withdrawal symptoms from smoking cessation; Wellbutrin XL and nicotine replacement therapy (Fiore, Jaen & Baker, 2009). Nicotine replacement therapy is the most widely used form of pharmacotherapy for managing nicotine dependence and withdrawal. These therapies include the transdermal patch, nasal spray, gum, lozenges, and nicotine inhalers. All have been shown to be effective in comparison with placebo (Fiore, Jaen & Baker, 2009). Wellbutrin XL is an antidepressant unrelated to selective serotonin reuptake inhibitors or tricyclic antidepressants. This drug’s mechanism of action related to smoking cessation is unknown. Side effects may include insomnia and loss of appetite (Fiore, Jaen & Baker, 2009). Second-line pharmacotherapies that are not approved for use for smoking cessation by the FDA are: clonidine and nortriptyline. The side effects of clonidine may include hypotension, rebound hypertension, dizziness, constipation, and agitation. The side effects of nortriptyline may include a risk of arrythmias (Fiore, Jaen & Baker, 2009).

All of these therapies may or may not be effective, but the first step in treating tobacco dependence is the patient's willingness to quit(Mauk, 2010).

References

Elhassan, A., & Chow, R. (2007). Smoking cessation in the elderly. Clinical Geriatrics, 15(2), 38-45. Retrieved from http://www.sbggpr.org.br/artigos/Como on 10/28/2011.
American Lung Association, (2011). Stop smoking. Retrieved from http://www.lungusa.org/stop-smoking
Fiore, M. C., Jaen, C. R., & Baker, T. B. US Department of Health and Human Services, Office of the Surgeon General. (2009). Treating tobacco use and dependence: 2008 update. Retrieved from http://www.surgeongeneral.gov/tobacco/tobaqrg2.htm
Mauk, K. L. (2010). Gerontological Nursing (2nd Ed.). Valpraraiso, Indiana: Jones and Bartlett Publishers.

NOTE: This blog post reflects the work of a Registered Nurse with minor editing by Shirley Comer RN and was completed as a class assignment. The content of this blog is for informational purposes only. Before beginning or changing a treatment or lifestyle regime you should consult your primary health care provider.

Saw Palmetto as Treatment for BPH

by Angelique Todd, RN

Benign prostatic hyperplasia, more commonly known as BPH is a non-cancerous enlargement of the prostate gland. This can be due to long- term stimulation of male sex hormone androgen. Microscopic appearance of BPH occurs typically by age 30 and is present in 50 percent of men by the age of 50 and 80 percent of men by age 80 (Burnett, 2006). It is said that, with longevity, every male will experience some level of this condition (Mauk, 2010). Symptoms may vary, but usually include urinary frequency, urgency, or inability to urinate.

Saw palmetto comes from a palm- like plant found in the southeast part of the U.S. It has been used to relieve symptoms related to BPH. Supporters claim that it has an anti-androgenic effect that with long-term use can reduce prostate cell proliferation, therefore minimizing symptoms. Some side effects include: nausea and vomiting, diarrhea, and bad breath. It is also believed to have anti-inflammatory and anti-platelet effects, and may be useful in chronic pelvic pain, bladder disorders, decreased sex drive, hair loss and hormone imbalance (Margaret A. Fitzgerald, December 2007). Finasteride is also a commonly used drug in the treatment of BPH. Effects are similar to those of saw palmetto and results of both are evident in PSA levels. In contrast the side effects are considerably different. Impotence, abnormal ejaculation and loss of sex drive are just a few. Older adult males may consider this to be more of a disadvantage when deciding whether to use a more traditional method of treatment.

As with most herbal supplements, safety, effectiveness or purity is not governed by the FDA making its use risky. When weighing the pros and cons of both a more holistic approach is needed it is the responsibility of the nurse to be knowledgeable about the modalities the client may be using and contraindications involved with other medications (Mauk, 2010). Basic knowledge in this area will give the nurse the tools necessary to help the patient make the most informed decision possible.

References

Burnett, A. W. (2006). "Benign Prostatic Hyperplasia in Primary Care: What you need to know.". Journal of Urology Issue75 , 19-24

Margaret A. Fitzgerald, D. A.-C. (December 2007). Herbal facts, herbal fallacies. Amercan Nurse Today , 27-32.

Mauk, K. L. (2010). Review of the Aging of Physiological Systems. In K. L. Mauk, Gerontological Nursing : Competencies for Care (pp. 150-151). Sudbury: Jones and Bartlett Publishers.

NOTE: This blog post reflects the work of a Registered Nurse with minor editing by Shirley Comer RN and was completed as a class assignment. The content of this blog is for informational purposes only. Before beginning or changing a treatment or lifestyle regime you should consult your primary health care provider.

Screening for Prostate Cancer

by Mikayo Streeter, RN

Should men get screened for Prostate Cancer?

Prostate cancer is the second leading cause of cancer death in U.S. males, with an estimate of over 186,320 new cases and 28,669 deaths in 2008” (Mauk 2010, p. 418) This cancer is known for its unusual behavior because the patients can go asymptomatic for awhile before the cancer has spread throughout the body. “The incidence of disease varies according to race, with Americans black having the highest risk in the world” (Granville 2006, p.53) According to the American Cancer Society, men especially African Americans should get screened at the age of 40. They often go to say that men who have a family history should consider discussing the option with their doctor. “Men with one close relative affected have more than a two-folded increased risk, and men with two close relatives affected have more than an eight-fold increased risk” (Granville 2006, p. 53). Studies have shown that it increases with age for the older population of men. “Over half of men 70 and older show some histologic evidence, though only a percentage die from this disease” (Mauk 2010, p. 418).

According to Mauk, she mentions that it is highly suggested that older men get screened because they are normally asymptomatic. Most men complain if symptoms are present that there is pain in the lower back, difficulty urinating, painful ejaculation, or blood in the urine/semen. There is two ways a screening can be done to detect prostate cancer: digital rectal exam (DRE) and PSA blood test. During the digital rectal exam the doctor inserts a glove fingered thru the rectum to feel for anything unusually hard or enlarged prostate that may exhibit lumps. The PSA test is used to detect a higher level of prostate cells thru the blood stream. “A PSA of less than 4ng/ml is considered normal for ages 60-69 years, whereas 7ng/ml may be normal in the 70-79 age group, because PSA rises with age” (Mauk 2010, p.418).

When the cancer is detected, it depends on the stages and growth of the cancer and the severity of the disease. The doctor discusses several options with the family and patient: surgery (radical prostatectomy), radiation/chemotherapy, or watchful waiting. “Surgery is considered the best option when the cancer is caught early; however, because a radical prostatectomy is major surgery and carries some inherent risks, all options should be considered with the older patient” (Mauk 2010, p. 143). The nurse responsibility after surgery is to explain the potential side effects to the patient: inform the patient they may experience urinary incontinence, loss of interest in sex, hot flashes, and impotence. “Sometimes, radiation is suggested where x-rays are passes through an external machine or through radioactive isotopes inside the body” (Moore 2007, p.1) Watchful waiting is recommended for the elderly men because of the complications after surgery. It is also recommended if they have other medical comorbidities. Older men should take a holistic approach by including a “low fat diet and the addition of vitamin E, selenium, and soy protein” (Mauk 2010, p. 418). The nurse should encourage the patient to consult with doctor before taking a holistic approach.

Prostate cancer is known as a chronic disease. That if it occurs in older men watchful waiting is the best decision for these patients. These patients need frequent monitoring but no treatment is needed. “Most prostate cancers are slow-growing and unlikely to be a cause of significant morbidity and mortality in older men” (Mauk 2010, p. 372). The pro of doing the screening is to early detect prostate cancer before it metastasize to other organs of the body. For older men, it will help to decrease the altered mental status changes if these men frequently develop urinary tract infections, urinary incontinence, or inability to urinate. The con is that majority of the older men that is diagnosed with prostate cancer usually die from the other medical comorbidities. “The greatest controversy regarding screening for prostate cancer is the inability to accurately predict which cancers will be aggressive and require treatment, and which are unlikely to metastasize” (Mauk 2010, p. 372).

References

Ginger, L. (2007). The Importance of cancer screening. Retrieved October 29, 2011, from http://cancerawarenesscenter.com
Granville, L. J. (2006). Prostate disease in later life. Chronic conditions in later life, , 51-56. Mauk, K. L. (2010). Gerontological nursing competencies for care (2nd ed.). Sudbury, MA: Jones and Bartlett Publishers. Moore, K. (2007). Prostate cancer. Retrieved October 29, 2011, from http://cancerawarenesscenter.com

NOTE: This blog post reflects the work of a Registered Nurse with minor editing by Shirley Comer RN and was completed as a class assignment. The content of this blog is for informational purposes only. Before beginning or changing a treatment or lifestyle regime you should consult your primary health care provider.