Lauren Oliveira Utilize vocabulary associated with the unit correctly 1.

List functions of the liver

Study Guide-hepatic + skin disorders

Liver -> Gould pg 406-18 Skin -> Gould ch 27 Adams ch 48

The liver has many vital functions and whenever there is an infection or damage to the liver, these functions are impaired. The liver regulates blood glucose during hours of sleep, detoxifies blood, and has kuppfer cells that engulf pathogens. It creates amino acids and plasma proteins and coagulation factors. It helps to regulate blood pressure by producing angiotensinogen which is the first step in the cascade that produces angiotensin II (potent vasoconstrictor). The liver also produces cholesterol, glucogen (from glucose), urea (from ammonia), amino acids, plasma proteins, coagulation factors, bile and angiotensinogen. It processes carbohydrates fats and protein and stores vitamins and minerals.

2. explain the reason for ordering labs (AST, ALT, alkaline phosphatase) including where these enzymes are normally found When your patient has hepatic disease these values will be on the chart. AST (SGOT before) is aspartate aminotransferase (found in liver and heart cells, when liver damage or heart damage AST level will increase.) The ALT (formerly SGPT) alanine aminotransferase is found mainly in the liver and is much more specific to test for hepatic disease than the other labs. Alkaline phosphatase is found mainly in the liver, bone (some in kidney, intestine, placenta). IF trying to diagnose hepatic disease, alkaline phosphatase may also be ordered. You should look for AST, ALT and alkaline phosphatase elevation to diagnose hepatic disease, while keeping in mind damage to other organs can cause this elevation. ALT is the most specific to liver disease. 3. explain the function of bile Bile is a mixture of water, electrolyte, bilirubin, bile acids, cholesterol and phospholipids. Its main function is to emulsify fats in the intestines.

4. explain how bilirubin is made beginning with the breakdown of red blood cells
RBC are constantly broken down by the spleen and kuppfer cells, they only live about 120 days so those that are worn out are removed by the spleen and kuppfer cells in the liver, when these old cells are broken down they release hemoglobin which is a combo of heme, an iron pigment and globin which is a protein. The heme or the iron pigment is saved, carbon monoxide is exhaled and biliverdin then becomes bilirubin. Bilirubin is the yellow pigment. An increase in bilirubin will give the pt a jaundice color. Jaundice is a symptom, not a disease. And it causes the yellowish discoloration of the skin and mucosa.

5. differentiate between direct and indirect bilirubin including terms used i.e. conjugated Free bilirubin is also called fat soluble, indirect, or unconjugated. Indirect, free fat soluble bilirubin combines with albumin where its carried to the liver and converted to direct, water soluble, conjugated bilirubin. This direct is part of bile. The difference between the direct measure and the indirect measure of bilirubin occurs in the lab. Water soluble (direct) bilirubin in blood reacts with diazo reagent (dye). Indirect bilirubin (fat soluble) needs alcohol added to diazo reagent in order to react. Conjugated, water soluble direct bilirubin is in the bile and bile enters the intestine. Bilirubin is then converted to urobilinogen by intestinal bacteria. This urobilinogen is excreted into the stool/urine which gives stool brown color and urine yellow color.

6. list reasons why direct bilirubin levels can increase

Related to obstruction in biliary tract, gallbladder inflammation (drug induced), liver or pancreatic cancer, hepatitis, pancreatitis, liver disease 7. list reasons why indirect bilirubin levels can increase Indicates hemolytic anemia (rapid break down of RBC)

8. explain why icterus neonatorum develops and why it may be dangerous

Jaundice that occurs about 24 hours after birth in all babies mostly pre-term (not a disease), its a clinical jaundice if the bilirubin level is above 5mg/dL (normal is 0.2 -1.4 mg/dL). It begins and the head and travels downward. Important that all newborns return to pediatrician for well baby check up 2 to 3 days after birth ** can travel to brain so it is dangerous, bilirubin is deposited in brain cells if too high, this will cause bilirubin encephalopathy, the parent will notice the baby being lethargic, hypotonia (poor muscle tone), poor sucking reflex and a high pitched cry. Untreated, high levels of bilirubin can lead to cerebral palsy, deafness, mental retardation may develop The reason why almost all newborns will have hyperbilirubinemia is because of the rapid destruction of RBCs after birth. Infants have a low albumin level so that bilirubin that is released cant be carried to the liver. They also have low gut bacteria in their intestines so that the bilirubin cant easily be converted to urobilinogen easily to be excreted. They also have low glucuronyl transferase, which is an enzyme that conjugates bilirubin and makes it water soluble. RX: feed infant = encourage passage of bilirubin-rich meconium, increases intestinal bacteria and stimulates peristalsis

9. explain why early onset breast feeding jaundice occurs and how it is treated
Breast fed infants often have early onset jaundice, colostrum which is a clear or pale yellow fluid that is a natural laxative. It is first created in breast tissue. When the baby is first breast fed they may have a low fluid intake (dehydration) because there is a lag time between when the baby begins to nurse and when breast milk fully comes in. So, even though the baby may be breast feeding they may not be getting enough fluid. We tell parents to monitor how many wet diapers the baby has a day. If the baby that is being breast fed has less than 6 wet diapers a day, nursing less than 8 times a day or has lost 10% weight loss since birth they may be dehydrated. The mother will then be encouraged to give the baby a supplement of water.

10. explain how the bililight treatment for icterus neonatorum reduces jaundice
To treat hyperbilirubinemia in infants if it doesnt resolve on its own, we put the baby under a bililight, it is a florescent light that is absorbed by bilirubin and it converts the indirect bilirubin to direct bilirubin or water soluble bilirubin so that can be excreted in bile and the babies jaundice goes away. It takes 24 or more hours under the light to lower bilirubin to a safe amount sometimes.

11. explain causes of cirrhosis (i.e. alcoholic, cardiac etc)

Viral hepatitis that is not resolved Idiopathic, chronic hepatitis, CHF which causes cardiac cirrhosis, can be hereditary, alcoholism counts for most cases (65%)

12. explain the causes of hepatitis

Inflammation of the liver, it can be caused by medications that we give, by chemicals, viruses and by alcohol intake. If someone develops hepatitis then they have developed a viral infection that invades and destroys liver cells, it cause stasis of bile, cell death, kupffer cells proliferate and random regeneration of liver cells, normally people recover from hepatitis with no chronic affects. Viral hepatitis is often asymptomatic, 4 in 10 Americans have Hep A dont remember being ill, 1 in 10 Americans with hep B doesnt remember being ill. Non viral hepatitis is associated with chronic alcoholism or exposure to cleaning agents, acetaminophen in large doses and poison mushrooms. Fulminating hepatitis is acute life threatening condition where there is extensive death of liver tissue, high fever, hemorrhage, confusion, stupor, coma, the death rate is 90%!

13. explain why someone with hepatic disease will have clay colored stools, icterus and bright yellow urine Jaundice, dark colored urine and clay stools because the liver cant form bile normally. They will have anorexia, malaise, anorexia, myalgia, fever, abdominal pain and hepatomegaly. ??

14. explain cirrhosis including signs/symptoms, causes and functional liver changes Cirrhosis is a chronic irreversible degenerative disease of the liver. In a person who has cirrhosis, once they develop ascites they have a life span of about 5 years. What happens is that healthy liver cells are replaced by scar tissue. Blood flow cant easily enter the liver from the portal system and the function of the liver is greatly reduced. The liver cant function. Portal HTN is a complication of cirrhosis. It is because the blood that drains the portal system that drains the esophagus, stomach area, that blood travels to portal vein and enters the liver so the blood can be detoxified. But with portal HTN, it means that there is a stricture in that portal vein because the liver itself has a lot of scar tissue and it closes off the little tributaries of that portal vein increasing pressure trying to get blood from the GI system through portal vein into the liver, the blood cant flow easily to liver so it backs up. That is why the person develops esophageal varicies.

15. explain why hepatic encephalopathy occurs

Occurs because when protein is metabolized it creates ammonia, normally the liver converts this ammonia to urea which is then secreted by the kidneys. With a damaged liver you cant detoxify this ammonia so it builds up in the blood stream. Pts will have mental confusion tremors, stupor and it will progress to a coma.

16. explain the action of lactulose Lactulose is a synthetic sugar that is broken down by bacteria in the intestines, so then the contents of the colon become acidic. This helps to prevent ammonia absorption into the blood stream. Lactulose also pulls water into the colon so it an osmotic laxative. That laxative effect pulls ammonia from the blood into the colon and gets it out of the intestines. It is given by mouth 3 to 4 times a day. It can also just be used as a general laxative and not for cirrhosis.

17. Explain the function of the following skin layers: epidermis, dermis

The epidermis is the outermost layer of the skin (visible); It relies on the dermal layer for nutrition and does not contain blood vessels. Cells are replaced every 30 days. The langerhans cells, or the immune cells in the epidermis are there to protect against invasion by pathogens. When UV light damages these Langerhans cells increases your risk for developing skin cancer. 4 or 5 layers (inner to outer - > is stratum basale or germativum, stratum spinosum, stratum granulosum, stratum lucidum, stratum corneum). The stratum corneum contains keratin which forms the barrier that repels bacteria. The innermost basale supplies the epidermis with new cells after the old die, over time the new cells migrate from the basale to the outermost layers, takes about 3 wks. Melanocytes that secrete melanin are in the deep layers of epidermis. The # and type of melanocytes determine pigment color and the more melanin the darker the skin color. 5% of skin thickness.

The dermis is the thickest layer that contains connective tissue, sebaceous glands, sweat glands, hair follicles. it is thin and contains sensory receptors for pain, temperature, touch and vibration. 95% of skin thickness, under dermis is the subcutaneous tissue (mainly adipose tissue).

18. Explain the four factors that determine skin color

It is determined by the amount of certain pigments. Carotene will give skin a yellowish hew. If extremely large intake of carrots, sweet potatoes and leafy vegetables it will give you a temporary yellow hue. Melanin is the brownish pigment that is genetically determined. If you are exposed to UV light, your melanin cells will become more active and you will develop a tan. This brownish pigment is meant to protect pigment skin from UV rays. Oxyhemoglobin gives us a reddish hue, while deoxyhemoglobin gives us a bluish hue.

19. Discuss the mode of transmission, cause, S/S and treatment for the following skin infections: impetigo, tinea infections (pedia, corporis, capitis)

Impetigo: A superficial skin infection caused by staph, strep. It is very contagious. There are two types: bullous and vesicular. Bullous impetigo occurs in the nursery and is very contagious. Vesicular impetigo occurs mainly in school age children, is also highly contagious, the child will have little pustules that will rupture and have a honey colored crust. Treatment is:

Tinea is a superficial fungal infection of the skin. Tinea pedis = athletes foot tinea corporis = ringworm (not a worm, its a fungus that causes a circular rash).

Tinea capitis is the fungal infection of the scalp. S/S of tinea infections are redness, itching, secondary infection is a possibility because of scratching.

20. Discuss the mode of transmission, cause, S/S and Rx for the following: rubella, rubeola, 5th disease

Rubella: very contagious viral infection transmitted through the respiratory tract. Once exposed to rubella it has a 2-3 week incubation. Prodromal symptoms happen 1-4 days before the rash is seen; these symptoms include low fever, malaise, enlarged lymph nodes, sore throat, and headache. The rash is diffuse and maculopapular and begins on the trunk only lasting 2-3 days. The danger of rubella is if a pregnant woman develops rubella during pregnancy, it can cause the rubella syndrome; the fetus will have a small brain (microcephaly), patent ductus arteriosis and cataracts. It is easy to tell if someone has had rubella by performing the rubella titer test to check for past infection. This is recommended before a woman becomes pregnant. It is rare for children to have rubella because of the MMR immunization of children, this live attenuated virus is given at 15 months of age and 4-5 years of age. If a child has not has MMR immunization can develop rubella and give to pregnant women. Women who work in day care and nurseries are most at risk.

Rubeola (measles) causes a 10 day rash. It is a URI (respiratory) method of transmission; it is highly contagious and has a 7-12 day incubation. The prodromal symptoms that occur before the rash include a high fever, barking cough, runny nose and enlarged lymph glands. We can see koplick (little white spots surrounded by a red ring) over cheek mucosa. The rash itself is maculopapular starting on the face. The danger is that it can cause encephalitis and pneumonia. This is prevented with the MMR vaccine.

Fifth disease:5th recognized to cause a rash in children, spread by respiratory droplets, highly contagious. It is epidemic in late winter and early spring. There is NO prevention and has a 1-4 week incubation period after exposure. The prodromal symptoms include low fever, sore throat, coryza (runny nose), and body ache. In 20% of the people with 5th disease there are no symptoms. What you will notice is that the child will have a facial rash that looks like the child was slapped on the cheeks, on the body they will have a fine red lacey rash on the arms, legs, trunk and butt that lasts 2-4 days. Exposure to heat and high temperatures increases the rash and pruritus. Some children have short-lived anemia from 5th disease. Some children a week after the beginning of 5th disease will have some joint pain. Once the rash develops the child is no longer contagious!!!! It may cause fetal death if a pregnant women is exposed to it, it can also cause fetal CHF and fetal bone marrow defects.

21. Discuss the following insect/parasite infestations: method of infestation, method of detection, S/S, Rx: scabies, lice

Scabies is a parasite, female mite; to treat it we apply a topical cream called lindane which can cause neurotoxicity in children under two years old. If someone in the house has scabies we treat everyone in the household. We usually give Benadryl to control itching and antibiotics if a secondary skin infection develops. They are little mites that burrow under the epidermis, they lay eggs, the eggs hatch and they travel to other areas of the skin. Usually you can see little tunnels where the mite has traveled. There is intense itching and it is worse at night. It is contagious by direct contact with the skin or infested clothing/shared linens. Barely visible without magnification, most commonly occur between fingers, on extremeties, in the pubic area. Smaller than lice

Lice: parasite that attaches to the hair shaft close to the scalp, it has nothing to do with cleanliness. It is seen in daycares and preschools. The parasite reproduces every 2 weeks and produces hundreds of nits (eggs). It feeds on blood and can live 72 hours on clothing, bedding and combs. It is highly contagious and causes SEVERE itching especially at night. This is a reaction to louse saliva and feces. School nurses use a wood lamp (UV light) that allows nuts to be seen. People with curly hair like AA are not as prone to getting lice because the round hair shaft makes it hard for lice and nits to attach. RX = kwell shampoo and then a fine tooth comb to remove the nits, clothing should be boiled for 10 minutes, iron clothing seams to kill the nits, you may also need to cut the childs hair but it is not necessarily necessary. Spread by infected clothing and close contact. The bute of a louse and the release of saliva into the wound leads to intense intching, followed by vigorous scratching followed by a possible secondary infection.

22. Discuss the following meds (action, teaching, SE): Nix, anthralin, dovonex

Psoriasis Treatment Topical

Anthralin

Synthetic product similar to the Goa powder from the bark of a tree in South America. It has been used topically to treat psoriasis for 100 years. It is however, less thorough and slower to work than topical steroids. The benefit is that there are no long-term side effects. It inhibits DNA synthesis and arrests abnormal cell growth. Second line therapy

Dovonex

Retinoid like compound. Synthetic form of vitamin D3, it slows the rate of skin cell growth, flattens lesions and removes scales. It does not decrease inflammation. It is not related to the vitamin D in vitamin pills

calcipotriene Same benefits as topical corticosterioids, lower incidence of adverse effects. May cause hypercalcemia if applied to large areas of the body or used in very high doses, its not usually used for extended basis. Burning, stining, folliculitis, intching, no serious adverse effects.

topical immunodulators

Apply thin layer one to two times/day. NIX --preferred drug for lice. Chemical from flowers, 1% liquid. Effective in 90-99% of patients, repeat application may be needed. Marketed as a cream, lotion, shampoo to kill head lice and crab lice and mites, and to eradicate their ova.

Permethrin Antiparasitic

Medication should remain in the half and on the scalp for 10 minutes before removal. Patients should be aware that penetrations of the skin with mites causes itching that will last for 2 to 3 weeks after the parasites have been killed. Successful elimination of parasitic infections should include removal of the nits, with a nit comb, washing bedding (boiling), and removal of objects that have been in contact with the head or hair. Do not use on under 2 yrs old, do not use on areas that have abrasions/rash/inflammation. Use with caution if patient as asthma or is lactating.

No more lindane! Neurotox in children

Dont apply to eyes, open skin lesions, and dont use excessive because systemic SE. inspect hair for 1 wk daily after treatment.

SE = few systemic, local reactions may occur and include pruritus, rash, tingling, burning, stinging, erythema, edema

23. Discuss the following skin disorders (cause, appearance, Rx): atopic dermatitis (eczema), psoriasis, cellulitis

Eczema:

Infantile eczema is allergic or atopic dermatitis. It is a chronic, recurrent inflammatory response to the over stimulation of T cells. It is seen mostly in infants and toddlers between 1-12 months of age and resolves during adolescence. It is caused by food allergies such as allergies to eggs, peanuts, milk and wheat. It can also be caused by infection, chemicals and temperature extremes. It is the inflammatory response = edema, pruritus (itching), dry skin, crusting and scaling. Breast feeding prevents the development.

Cause: genetic predisposition, family history of asthma and allergies Appearance: lesions usually begin on the face and scalp and then progress to other body parts. Red cheeks.

Rx: symptomatic medications, ointments and lotions to control itching and skin flaking. Antihistamines to control inflammation and reduce itching and analgesics or topic anesthetics for pain relief. It can be controlled not cured. Must identify and control for allergic triggers that cause flare ups. Topical corticosteroids are the most effective but have the most harsh long term SE (irritation, hypo pigment, thinning, topical is mood, loss of bone mass, adrenal insuff) they are limited in how long they can be used.

Psoriasis:

It is the rapid turnover(skin cells reach surface in 4 to 7 days) that creates an increase in metabolic needs, increased blood supply to the area which gives the pscoriac areas a red look (erythema and poorly developed or immature cells). It tends to be genetic. S/S = well demarcated red plaques covered in silvery white scales especially on the knees, scalp, skin folds ad elbows but it can occur anywhere. Someone may have mild with one or two lesions that can be taken care of by topical meds or it can be widespread. RX = topical or systemic steroids depending on how advanced it is. A common treatment is ultraviolet light that slows the production of skin cells. Psoralen (PUVA) makes the skin cells more sensitive to UV light so the rapid turnover of cells decreases. It takes 2030 treatments before results can be seen. When getting light treatment, protective goggles must be used because UV exposure can cause cataracts and skin cancer. Vitamin D3 is also used.

Cause: genetic and autoimmune components, not entirely understood. Immune because overactive cytokines increase the production of skin cells. Also environmental components- stress, smoking, alcohol, climate changes and infections can trigger flare ups, also certain drugs like ACEI.

Appearance: silver scales, when shed the underlying skin is inflamed and irriated, shape tends to be round, usually discovered on scalp, elbows, knees and exterior surfaces of extremities. *anthralin and dovonex

Methotrexate that binds to and inhibits an enzyme involved in the rapid growth of cells, SE are nausea and mouth ulcers (give folic acid to prevent mouth ulcers), if these SE develop the dose is lowered, other SE are fatigue, headache, fever, easy bruising, bleeding, bloody diarrhea and reversible liver damage. If bloody diarrhea the drug is discontinued.

Tar: slows rapid proliferation of skin cells, reduces inflammation, itching and scaling

Salicylic acid: removes scales, may be combined with topical steroids, anthralin or tar

There is also OTC or RX

Pulsed dye lasers: destroy the tiny blood vessels, mildly painful and in 15-30 minute sessions that take about 3 to 4 sessions.

Cellulitis

Bacterial infection of the dermis or subcutaneous layer (Staph or streptococcus). Risk factors include insect bites, scratching and surface wounds. The skin is red, edematous, tender, warm, possible exudate (serous or purulent) and comes with a possible fever.

Rx: treat by antibiotics, topical or IV. To help relieve pain and swelling, warm soaks are done.

24. List the warning signs of skin cancer (A,B,C,D, E)

A = asymmetry (one side of the area looks different than the other)

B = irregular border (not round)

C = color (change in color, black or blue or red color)

D = increasing diameter (is this lesion getting bigger > 0.5 about the size of pencil eraser)

E = evolution (lesion changing in any way)

25. Discuss the following types of skin cancer (risk factors, appearance, likelihood of metastasis) : basal cell, squamous, malignant melanoma

Geriatric patients are at a higher risk for skin infection and cancers because of the decrease in langerhan cells.

Rx factors for skin cancer: people living at high altitudes, sun bathing and light skin color

There are different types

Basal cell

Superficial cancer of immature epithelial cells, it is the most common type. Slow growing and doesnt usually metastasize. The cause of this cancer is UV radiation. It is commonly seen in the elderly because of the cumulative effect of being exposed to the suns but it is also being seen in young adults who use tanning beds.

S/S: dome-shaped papules or nodules well circumscribed (round, contained in small area), it can be raised or flat and the area may be white, the lesion is painless.

Squamous Cell

It is a cancer of the epidermis which can spread horizontally or vertically into the dermis. It can have a slow or aggressive spread. It may metastasize. Risk factors include prolonged exposure to UV radiation.

S/S: may develop on areas of skin previously damaged. You have scaly red plaques or raised nodules with central necrosis. It looks as if scabs are forming.

Malignant Melanoma

It is an aggressive tumor of melanin-producing cells at the base of the epidermis. IT is induced by exposure to radiation and a decrease in langerhan cells (occurs as we age). Langerhan cells are the immune cells of the skin. It may develop at the site of a mole. It is commonly seen during middle age. It may occur on exposed surfaces, palms, soles, oral or vaginal mucosa. Risk factors include intense blistering burns (2nd degree) during the first or second decades of life, fair skin, freckles and light colored hair.

S/S: multicolored nodules growing vertically or as a circular spread of pigmentation larger than a centimeter. It has an irregular shape; it grows in size and may bleed.

Some skin vocabulary

Urticaria: hypersensitivity response characterized by hives, often accompanied by pruritus (itching). Pruritus: general condition associated with dry, scaly skin or a parasite infestation, may also be systemic sign. Erythema: redness, accompanies inflammation. Rosacea occurs in age 30-50, papules wih no pus that swell, thicken and become painful, reddened, flushed appearance. Exacerbated by alcohol, spicy foods, skin care products and warm things. Rhinophyma: tissues of the nose thickening, giving the nose a red, bullous, irregular swelling from rosacea with time. Excoriation: intense scratching of dermatitis that leads to scratches that break the skin surface and fill with blood forming crusty scales.