Abdominal Conditions 3

NURS4321
 Acute Abdominal Conditions 3

• Substance abuse: p. 2347-2352

• Blood borne pathogens: Hepatitis p. 1212-1219
• HIV: p. 1543; p. 1669-1673; chart 53-5;
• p. 1677-1687; p. 1702-1703; p. 2312
• Cirrhosis: p.1221-1232
• Pain and pain management 248-249, p. 254-266,
p. 268-269, p. 277-279
• Jill Calder RMT/Accupuncturist
• Review Functions of the Liver p. 1192-1194
 DSM V: Substance Use Disorder
• Problematic pattern of substance use leading to
clinically significant impairment or distress.
• Manifested by 2 or more within a 12 month period:

– Taking larger amounts or for longer period of time

– Unsuccessful attempt or desire to cut down
– Life’s focus is on obtaining, using, recovering
– Strong craving
– Failure to fulfill major obligations at work, home or
school
 DSM Substance Use Disorder
– Continued use despite persistent or recurrent social
or interpersonal problems (interpersonal
relationships)
– Giving up important social, occupational,
recreational activities because of substance use
– Recurrent use in situations in which it is physically
hazardous
– Ongoing use despite knowledge of persistent
physical or psychological problems
– PLUS
– Tolerance and withdrawal
 Risk Factors
• Genetics / Parental substance abuse
• Poverty
• Abuse/neglect
• Single-parent home
• Depression, anxiety, ADHD, PTSD
• Unemployment
• Alienation / Social isolation
• Availability of substance
Centre for Addiction and Mental Health 2011
 Alcohol
• CNS depressant
• Signs/symptoms of intoxication:
– drowsiness, incoordination, slurred speech, mood
changes, aggression, belligerence, uninhibited
behavior, poor judgment
• Excess may result in stupor, coma, death
• Long-term/heavy use may result in:
– nutritional deficiencies(thymine, folate), trauma,
resp infections, some cancers
 Remember

**If you suspect intoxication remember that

hypoxia, hypoglycemia, hypovolemia, or
neurologic impairment must be ruled out**
 Assessment Tools
CAGE Questionnaire

• 1. Have you ever felt you should cut down on your

drinking?
• 2. Have people annoyed you by criticising your
drinking?
• 3. Have you ever felt bad or guilty about your
drinking?
• 4. Have you ever had a drink first thing in the
morning to steady your nerves or get rid of a
hangover (eye-opener)?
 Alcohol Abuse Management
• Diagnostics:
– blood alcohol level (blood test)
– Abd u/s (alcohol abusers – liver damage)
– LFTs

• AWS / Delirium Tremens can be life threatening ***

– Fear/anxiety, agitation, insomnia, incontinence, hallucinations, seizures,
tachycardia, diaphoresis, dilated pupils

• How do we manage seizure risk in acute phase?

– Benxzodiapepines (diazepam or valium) Has a longer half life.

• Pharmacologic management
– Vitamin therapy. Which ones? (Thymine and folate)
– Preventative medication used in alcoholism?
• Antabuse
 Non-Pharmacologic Management
• Denial and defensiveness common
• Calm, firm, non-judgmental approach
• Quiet environment
• Sleep it off. Positioning? (side lying – vomit)
Monitor for? (seizures, respiratory depression)
• High protein diet

• Promote Detox, 12 steps programs (AA)

 Benzodiazepines

• Psychoactive drugs

• Also known as anxiolytics,

tranquilizers, sedatives

• Therapeutic uses?
– Anxiety, seizures, sleep,
pre-operatively

• Generic/trade names and

usual dosage?
 Benzodiazepines
• Diazepam (Valium)
– 2.5-10mg, po, IV, IM q8h/tid
• Lorazepam (Ativan)
– 0.5-2mg range q8h; s/l, po. IV
• Alprazolam (Xanax)
– 0.25 to 0.5 mg orally po q8hr
• Clonazepam
– 0.25-1mg po bid/tid
• Oxazepam (Serax)
– 10-30mg po tid or hs
 Benzodiazepines

• What are some cautions

and concerns with
benzodiazepines?
Stimulants
 Long Term Effects

• Mood swings, delusions, psychosis, DEPRESSION

• Hypertension, irregular HR, MI, CVA

• Insomnia, impotence

• Blood borne pathogens

• Overdose/Death
 Treatment Strategies

• What effective treatment strategies are there

for cocaine/crack cocaine addiction?
– None. No medications help. Detox and 12-step
programs

• Are there pharmacologic management

strategies?
Opioids
 Opioids Therapeutic Uses

• What are some therapeutic

uses for opioids?
– Pain relief, cough, diarrhea
relief

• What are some commonly

abused opioids?
– Percocet, hydromorphone,
oxycontin, fentanyl, codeine
(buy it OTC)

• Will discuss more with pain

mgmt
 An Epidemic
• Retail pharmacies across Canada dispensed 19
million prescriptions for opioids in 2016
– Our population is 36 million so…..

• 259 million prescriptions were written for opioids in

the US
– That is one for every person

• Substance abuse kills a ¼ of a million people worldwide

every year

• Accidental overdoses leading cause of accidental

deaths in the US, ahead of car crashes
 Opioid Intoxication/Overdose
• Acute intoxication/OD -> a multisystem toxin
– Maintain airway and observe for CNS depression
and hypo/hypertension
– Rule out other potential causes of the behaviours
– Consider polysubstances
– Use a nonjudgmental, calm manner

• What is the antidote for opioid overdose?

– 0.4-4mg IV, IM, SC, intranasally
– NARCAN
 Injection Drug Use - IDU

• 13 million IDU (pwid) worldwide

• 4.1 million Canadians have injected drugs

• 125,000 current IDU in Canada

• Polysubstance users

Public Health Agency of Canada (2014)

 Health Consequences of IDU
• Soft tissue infections (abscesses, cellulitis)
• Endocarditis
• Blood borne pathogens (HIV, Hepatitis B, C)
• Overdose
• Tuberculosis
• Malnutrition
• Drug-related accidents
• Premature death
Health Canada (2012)
 Soft Tissue Infections

• Occur in up to 65% of
IDU

• Abscesses/Cellulitis/Nec
rotizing ulcers or
fasciitis
Soft Tissue Infections
• Factors that favor
infection:
– Poor hygiene/bacteria on
skin
– Lack of aseptic technique/
unsterile
equipment/contaminants
– Frequent
injection/injecting multiple
substances
– Missing the vein/leakage of
substance out of vein
 Soft Tissue Infections
• S/s of soft tissue infections? (think cellulitis)
– Red, warm, pain

• Management
– Teaching re prevention
– Pharmacologic
• Antibiotics
– Non-pharmacologic
• Fluids, elevate the limb, apply heat
 Infective Endocarditis
• Bacterial infection
– Causes inflammation of lining of heart
– Vegetations - most commonly tricuspid valve

• Mortality rate of S aureus IE is 40-50%

• 2/3 of IVDU patients have no prev hx of heart

disease, no murmur on adm

• *Note can also occur with valvular disease,

valvular prostheses*
 Endocarditis
• A high index of suspicion with IDU
– Track marks (scarring along a vein)
• Diagnostics: CBC, blood cultures, TTE/TEE
• Dyspnea, cough, and chest pain common
– Chills
– Fever
– Fatigue
– Loss of appetite
– Muscle aches and joint pain
– Sweating
– Weight loss
Up to Date (2016
 Management of Endocarditis

• IV antibiotics

• Valve repair/replacement surgery

– Mechanical or tissue valve? Why?
• Mechanical (warfarin – INR – routine blood work) NO
• Tissue valve (life span is short however) YES

• Antibx prophylaxis
– When?
 Blood Borne Pathogens

• What infections are considered blood

borne pathogens?
– Hep b, c, HIV

• Which behaviors are high risk?

– IV drug use, anal sex, smoking on a crack pipe
 Human Immunodeficiency Virus
• Virus that causes AIDS
– Is HIV curable?
• No it is a chronic disease

• Risk factors?
– Unprotexted sez with multiple partners, MSM, IV drug users

• Which body fluids can contain HIV virus?

– Blood, seminal fluid, vaginal secretions, amniotic fluid, and
breast milk
– Should HIV+ mothers breast feed? No, only exception is in
countries where there is no access to formula

• Laboratory/diagnostic tests?
– Importance of viral load
 Human Immunodeficiency Virus
• What type of precautions are required for
HIV+/AIDS patients?
– See chart 53-4 for routine precautions
– See chart 53-5 post-exposure prophylaxis for hcp

• What is the tx for HIV infection?

– Considerations? If people aren't consistent with meds
they will become resistant.
– PEP, PrEP
• Post exposure prophylaxis, pre-exposure prophylaxis
 Hepatitis C

• Among IVDU, +/- 59% are infected HCV

• Will discuss with Cirrhosis

 Addiction Management
• Assessment for complications
– Alcohol: Nutritional deficiencies, DT, CNS sedation
– Soft tissue infections: endocarditis

• Immunizations
– Hep A & B (covered for people who inject drugs)
– Influenza (immunocompromised)
– Pneumonia
– Tetanus

• Treatment options?
– Detox,
• Referral to community agencies
– What community services are available?
• AA, NA, AIDS Saint John, Mental health, Food Bank, salvation army, Romero house
 Harm Reduction

• What is harm reduction?

– Reducing negative consequences associated with risky
behaviours
– Keeping people alive until they are ready to make better
decisions
– Respect that people have the right to make bad decisions

• What are some examples of harm reduction strategies?

– Needle exchange production
 Needle Exchange and Crack Pipe
Distribution Programs

• Reduce the spread of

blood-borne diseases
by facilitating the use of
new equipment

• DOES NOT PROMOTE

OR INCREASE DRUG
USE
Methadone Maintenance Therapy
for Opioid Dependence
• Opiate replacement therapy
• Legal
• Controlled dosing
• Retention in treatment
• Decreases IVDU and drug sharing
• Reduces spread of blood-borne pathogens
• Reduces drug related mortality
• Increases employability

• Treatment $6,000 year/patient

• Untreated $49,000 year/patient
 Methadone and Pregnancy
• The standard of care for opiate dependent
women during pregnancy
• WD dangerous to fetus
• Stable dose reduces stress on fetus
• Reduction in risky behaviors
• Reduction in drug seeking behaviors
• Increase in prenatal care
• Better maternal/fetal outcomes
 Take Away Messages
• Management of substance abuse is
complicated

• Considered chronic, relapsing disease

• Public health and social issue

– Blood borne pathogens
• Be kind. Don’t judge
– A lot of neglect, physical abuse, sexual abuse
 Liver Disorders and Cirrhosis

• Where is the liver

located?

• What are the functions

of the liver?
 Metabolic Functions
• Glucose metabolism
• Ammonia conversion
• Protein metabolism
• Vitamin and iron
storage
• Drug metabolism
• Bile formation
• Bilirubin excretion
 How do we Evaluate
How the Liver is Working?
• Liver Function Tests (see Table 40-1)
• Serum levels of ALT, Alk Phos
• Pigment studies: direct and indirect serum
bilirubin, urine bilirubin
• INR
• Serum ammonia
• Cholesterol (prep?)
• Albumin (assessment of nutritional status)
• Amylase
• **Remember we are using the values on D2L*
 Additional Diagnostic Tests

• Liver biopsy / Fibroscan

• Ultrasound
• CT
• MRI
• Other
 Hepatitis
• Viral Hepatitis
– Hepatitis A
– Hepatitis B
– Hepatitis C
– There are others

• Causes necrosis and

inflammation of liver
cells with characteristic
symptoms
 Hepatitis A (HAV)
• Mode of transmission?
– Fecal, oral
• Manifestations:
– mild flulike symptoms
– low-grade fever, anorexia
– indigestion and epigastric distress
– later jaundice and dark urine
– enlargement of liver and spleen
• Lab tests
– HAV IgM - infection
– HAV IgG - immunity

• Prevention?
• Immunization (A&B)
 Hepatitis B (HBV)
• A major worldwide cause of cirrhosis and liver cancer

• Mode of transmission?
– Blood borne

• Manifestations
– long incubation period, 1-6 months
– insidious and variable, similar to hepatitis A

• Lab tests
• HBsAb – to determine immunity
• HBsAg - acute or chronic infection
 Management
• Prevention
– Vaccine: for persons at high risk, routine of infants
– Passive immunization for those exposed
– Universal precautions and infection control measures
– Screening of blood and blood products

• Bed rest, nutritional support

• Medications for chronic hepatitis type B:

– alpha interferon and antiviral agents
 Hepatitis C Virus (HCV)
• Most common blood borne infection

• According to the WHO (2014) 130-150 MILLION

people worldwide are infected with HCV

• Mode of transmission/Risk factors?

– Needlestick, iv drug use, unprotected sex (men having
sex with men), exposure to blood products in a foreign
country

• Incubation period usually 2wks-6 mths

• Symptoms usually mild, many not aware of infection

 Hepatitis C Virus
Laboratory/Diagnostic Tests

• Screening
– Anti HCV (reactive or non-reactive)
– If reactive, Genotype and viral load done
– If undetectable vl, then no active disease

• Who should be screened for HCV?

 HCV Management
Pharmacologic Non-Pharmacologic
• Alcohol should be avoided
– Metabolized through the liver
• ***New all oral anti-viral • Medications that affect the liver
treatment regimes*** should be used cautiously
– Acetaminophen, anti-
inflammatories
– Others excreted via liver
• Treatment challenges? • Prevention
– Money, 85,000 for 12 weeks – Screening of blood
of treatment – Prevention of needle sticks for
health care workers
– Harm reduction strategies
– Measures to reduce spread of
disease
 True or False

• HCV can be cured

• HCV can be easily transmitted during sex

• Mothers who are HCV+ can infect their fetus during

pregnancy (vertical transmission)

• Mothers who are HCV+ should not breastfeed

• HCV is the most common cause of liver cancer and liver

transplant
 Hepatic (Liver) Cirrhosis
• Chronic condition

• Replacement of normal liver tissue with

scarring/fibrosis

• Types:
– Hepatocellular-> Hepatitis/Alcoholic
– Metabolic -> Hemochromatosis
– Chronic biliary obstn (less common)
 Manifestations of Cirrhosis
• Increase in severity as disease progresses

• 1) Compensated cirrhosis
– Often asymptomatic or vague symptoms

• 2) Decompensated
– Jaundice – yellowing of sclera
– Ascites
– Weight loss
– Spontaneous bleeding/epistaxis
– Purpura

• ** See Chart 40-11 p. 1222

 Jaundice

• Symptom of underlying disease process

– Hyperbilirubinemia
– Bilirubin cannot be excreted through liver
– Builds up in blood, deposited in skin, body tissues
– Manifested where?

• Hepatocellular and obstructive jaundice are

most associated with liver disease
 Ascites
• Accumulation of fluid in space between abd
lining and abd organs

• Can be up to 15 litres!

• Abd straie, distended veins, pain, bloating,

rapid wt gain, SOB, umbilical hernia
 Assessment of Ascites
• Record abd girth and wt daily

• Assess for fluid in abd cavity by percussion or

by fluid wave

• Monitor for potential fluid and electrolyte

imbalances
– Sodium and potassium
 Treatment of Ascites
• Low-sodium diet
• Diuretics
– Lasix (furosemide) 40mg PO or IV, UID BID
• Bed rest
• Paracentesis
• Administration of salt-poor albumin
• Transjugular intrahepatic portosystemic shunt
(TIPS)
 Gastrointestinal Varices
• Fibrosis impairs blood flow through liver
– Blood re-routed
• Prominent, distended blood vessels
– GI tract
– Lower rectum
• May rupture and bleed
• Can be LIFE THREATENING
 Variceal Bleeding
• Diagnostics?
– CBC, LFTs, stool OB
– Endoscopy, ba swallow, CT, angio

• Manifestations
– Hematemesis, melena, mental/physical deterioration
– Nursing assessment?
• Decreased LOC

• Management
– IV fluids
– Blood and blood products
– Vasopressin (contraindictions?), Beta blockers prophylactically
– Balloon tamponade
– Surgical options but high risk
 Hepatic Failure
• Often develops within 8 weeks of first s/s of jaundice

• Accompanied by
– Coagulation defects, renal failure, electrolyte abn,
infection, hypoglycemia, encephalopathy

• Prognosis can be poor

• Management?
– Transplant
 Hepatic Encephalopathy/Coma
• A life-threatening complication of liver disease
• May result from accumulation of ammonia and
other toxic metabolites in the blood
• Stages: see Table 40-3
• Assessment
– Changes in level of consciousness; assess
neurologic status frequently
– Potential seizures
– EEG
– Fetor hepaticus -> breath has sweet, fecal
smell
 Management
• Address/eliminate precipitating cause
• Monitor fluid, electrolyte, and ammonia levels
• Reduction of ammonia levels
– Name of medication, dose?
• Lactulose
• IV glucose to minimize protein catabolism
• Protein restriction
• Discontinue sedatives, analgesics, and tranquilizers
• Monitor for/ tx complications and infections
 Pharmacologic Management of
Cirrhosis
• Tx of underlying cause
• Antacids
• PPIs
• K+ sparing diuretics
• Spironolactone (Aldactone)

• Milk thistle
 Hepatocellular Carcinoma
• Primary liver tumors
– Few cancers originate in the liver, usually associated
with hepatitis B and C
• Liver metastasis
– Liver is a frequent site of metastatic cancer
• Manifestations
– Pain, dull continuous ache in RUQ, epigastrium, or
back
– Weight loss, loss of strength, anorexia, anemia may
occur
– Jaundice if bile ducts occluded, ascites if obstructed
portal veins
 Surgical / Non-Surgical Management
of Liver Cancer
• Liver transplant
• Cirrhosis increases risks of surgery
• Major effect of nonsurgical therapy may be
palliative
– Radiation therapy
– Chemotherapy
– Percutaneous biliary drainage
– Other nonsurgical treatments
 4 Categories of Pain
• Acute Pain
– From days – 6 months

• Does acute pain serve a purpose?

• What are some conditions associated with

acute pain?
 Procedural Pain
• Brief (seconds to hours)
intense pain from
diagnostic, therapeutic
and preventative
procedures

• Eg venipuncture,
lumbar puncture,
wound debridement
 Chronic (Noncancer)
Pain

• Experienced by 20% of adult Canadians

• Can be constant or intermittent

• Persists beyond expected healing time

• Poorly defined onset

• Seldom attributed to specific cause or injury

 Chronic Non-Cancer Pain
See chart 14-2
• Nociceptive
– Constant stimulation of pain receptors in skin, bones,
joints
– Aching, throbbing
– Eg arthritis, fibromyalgia
• Neuropathic
– Nerve damage or malfunction of PNS, CNS
– Burning, tingling, piercing
– Diabetic neuropathy, phantom limb pain
• Mixed
– Migraines an example
 Cancer Related Pain
• Most feared cancer outcome

• May be acute or chronic

• Can result directly from cancer, or from cancer

tx

• See chapter 16 for cancer pain mgmt

 Pain Assessment
• Pain is whatever the person says it is, existing
wherever the patient says it does

• What are some other words patients may use

instead of ‘pain’?

• What are some non-verbal signs of pain?

 Characteristics of Pain
• Location
• Quality (description)
• Quantity (Intensity)
• Timing
• Exacerbating/alleviating factors
• Pain behaviors
 Food for Thought
• Treatment of Pain: A Basic Human Right
• Almost all acute and cancer pain can be relived,
most chronic noncancer pain can be helped
• People have the right to access the best care
possible for pain
• HCP have a responsibility to routinely assess pain,
accept patient’s pain reports, and intervene to
manage pain
• The best approach to pain mgmt involves a
collaborative approach with pts, families and hcp.
 Pharmacologic Management
General Principles

• Premedication assessment
– True allergies
– Medication hx (rx and otc)
– Pain sttus
– Ethnic and racial background (codeine
metabolism)

• NSAIDS, opioids, local anaesthetics, adjuvant

meds
 NSAIDS
• Effective for arthritis, bone pain
• Both COX 1 and COX 2 inhibition
• Aspirin
– Increased risk of s/e
• Ibuprofen (Advil)
• Naproxen

• Selective Cox 2 inhibitors

– ie Celebrex

• All NSAIDS monitor renal function, bleeding

• Don’t administer with other anticoagulants ie Warfarin
 Opioids Table 14-2
• Natural derivatives of opium poppy
– Codeine (T1-T4) 1-2 tabs po q4-6 hrs; also susp, suppositories
– Morphine IR 5-10 mg po q4hr; 10mg IM/PR; 2.5 mg IV/SC
– MS Contin (long-acting) 30mg po q12hr

• Semi-synthetic
– Hydromorphone 2-4mg po q4-6 hr; 2mg IM/SC/(IV) q4-6hr
– Oxycontin, Oxyneo, Hydrocodone, Percocet, heroin

• Synthetic
– Meperidine 50mg po/IM q4-6hr
– Fentanyl 25-100 mcg IV
– Fentanyl patch NOT FOR OPIATE NAÏVE PATIENTS
– Methadone
 Side Effects
• Respiratory depression and sedation
– Monitor, high risk with multiple meds
• Nausea and vomiting
– Adequate hydration, anti-emetics
• Pruritis
– Not considered an allergic reaction
– antihistamines
• Constipation
– Fluids, bowel regime,
 Local Anaesthetics
• Block nerve conduction

• Long acting agents may be used pre-post op

• Topical application
– Ie lidocaine, EMLA cream
– Sprays ie sunburn

• Epidurals
– Ie during labor & delivery
 Other Adjuvant Medications
• Tricyclic antidepressants
– Amitriptyline

- Other antidepressant medications

- Ie Duloxetine (Cymbalta)

• Antiseizure Medications
– Pregabalin (Lyrica) or Gabapentin (Neurontin)
– What kind of pain specifically?
 Pain Management Considerations
• Difference between addiction and tolerance

• Scheduled vs prn

• Pain management in opioid dependence

• New Guidelines
– http://nationalpaincentre.mcmaster.ca/guidelines.html

• Complementary therapies
Jill Calder RMT