23 Liver and Biliary System

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					23     Liver and Biliary System


Core Skill 23.1         Perform an accurate assessment of a patient with liver
                        failure and biliary system dysfunction


Core Skill 23.2         Care of a patient with liver failure


Core Skill 23.3         Care of a patient with biliary system dysfunction
23         Liver and Biliary System



Core Skill 23.1:            Perform an accurate assessment of a patient with liver failure and
                            biliary system dysfunction.

Underpinning Knowledge:

1.         Normal anatomy and physiology of the liver and biliary system
2.         Classification of liver failure
3.         Causes of liver failure
4.         Signs and symptoms of liver failure
5.         Grading of encephalopathy
6.         Signs and symptoms of biliary dysfunction



In relation to:

Level                        Abnormalities
     0-3     Chronic liver failure
     0-3     Acute liver failure
     0-3     Hepatitis A,B,C,D,E
     0-3     Yellow fever
     0-3     Drugs/chemicals/poisons – paracetamol, alcohol, anaesthetics, anti-depressants, anti-microbial, anti-
             epileptic, recreational drugs.
     0-3     Ischaemia
     0-3     Cancers
     0-3     Pancreatitis
     0-3     Cholecystitis
     0-3     Cholangitis




Level                     Observations
     0-3      Respiratory rate, rhythm, depth
     0-3      Oxygen saturations
     2-3      Non-invasive ventilator observations
      3       Mechanical ventilator observations
     0-3      Arterial blood gases
     0-3      Non-invasive blood pressure monitoring
     2-3      Invasive blood pressure monitoring
     2-3      Central venous pressure monitoring
     0-3      Temperature
     0-3      12 lead ECG recording
     2-3      Continuous ECG monitoring
     0-3      Hourly fluid balance monitoring
     0-3      Blood Glucose Level
     0-3      Glasgow coma scale/AVPU
      3       Sedation scoring/Holding
     0-3      Pain scoring
     0-3      ICP monitoring (invasive/non-invasive)


Level                     Patient history
     0-3      Review medical notes
              - blood results
              - current medication
              - psychiatric history
              - foreign travel
              - drug/alcohol use
23        Liver and Biliary System


Core Skill 23.1:           Perform an accurate assessment of a patient with liver failure and
                           biliary system dysfunction


                                                                               Dates of Assessment

Taxonomy Level to be Achieved
                                                                               Self-   Initial   1st       2nd    Final
Student
                                                                               Ass.    Ass.      Int.      Int.   Ass.
Assessor
1.   Demonstrates the ability to perform an accurate assessment of a patient
     with liver failure and biliary dysfunction (Cross reference with
     assessment criteria 1.1.1, 2.1.1, 3.1.1, 4.1.1, 4.2.1, 6.1.1)

2. Demonstrate the ability to select and safely use appropriate equipment
   for assessment. ( Cross reference with assessment criteria 1.1.6, 2.1.3,
   2.5.3, 6.1.6)

3. Utilise various sources of information to gather a comprehensive patient
    history. (Cross reference with assessment criteria 7.2.1)


4. Identify, prioritise and act on assessment findings


5. Demonstrates the ability to produce accurate, clear, legible and timely
    communication and documentation. (Cross reference with assessment
    criteria 7.2.5)



Notes on Achievement/Non Achievement and Further Action Planned




                                                                               Signature of Assessor
Overall Level Achieved
                                                                               Signature of Practitioner
23         Liver and Biliary System

Core skill 23.2:      Care of a patient with liver failure

Underpinning knowledge:

1.         Normal anatomy and physiology of the liver
2.         Classification of liver failure
3.         Causes of liver failure
4.         Signs and symptoms of liver failure
5.         Grading of encephalopathy
6.         Effects of liver failure on other systems
7.         Investigations and equipment used to diagnose and treat liver failure
8.         Local policies and procedures in the diagnosis and management of liver failure
9.         Consideration of and criteria for liver transplantation



Level                      Abnormalities                 Level                   Abnormalities
     0-3       Airway obstruction                            0-3      Acute renal failure
     0-3       Hyperventilation                              0-3      Hepatorenal failure syndrome
     0-3       Intrapulmonary shunts                         0-3      Hypoglycaemia
     0-3       Hypoxia                                       0-3      Vitamin deficiencies
     0-3       Pulmonary oedema                              0-3      Sepsis
     0-3       ARDS                                          0-3      Immunosuppression
     0-3       Splinting                                     0-3      Acid-base imbalance
     0-3       Bronchopneumonia                              0-3      Agitation and confusion
     0-3       Atelectasis                                   0-3      Cerebral oedema
     0-3       Aspiration pneumonia                          0-3      Encephalopathy
     0-3       Hypotension                                   0-3      Ascites
      3        High cardiac output                           0-3      Oesophageal varices
      3        Low Systemic Vascular Resistance              0-3      Portal vein hypertension
               Index                                         0-3      Jaundice
     0-3       Hypovolaemia                                  0-3      Palmar erythema
     0-3       Arrhythmias                                   0-3      Hepatic foetor
     0-3       Electrolyte disturbances                      0-3      Pancreatitis
     0-3       Hypothermia                                   0-3      Impaired skin integrity
               Coagulopathies




Level                     Equipment
     0-3        Airway adjuncts
     0-3        Oxygen therapy delivery systems
     0-3        Pulse Oximetry
     0-3        Cardiac monitoring devices
     0-3        Infusion pumps
     0-3        Renal replacement therapies
     0-3        Urometers
     0-3        Glucometer
      3         Enteral and parentral feeding devices
     0-3        ICP monitors
     0-3        Warming blankets
     0-3        Pressure relieving devices

     0-3        Sengstaken-Blakemore tube/Sengstaken (4-lumen Minnesota tube)
                Equipment for Sengstaken tube insertion
                    •   Laryngoscope
                    •   Tongue depressor
                    •   Magill’s forceps
                    •   Anaesthetic spray
                    •   Lubricating jelly
                    •   Tape
                    •   Weight for traction
                    •   50ml syringe
Level                 Observations
   0-3   Respiratory rate, rhythm, depth
   0-3   Oxygen saturations
   2-3   Non-invasive ventilator observations
    3    Mechanical ventilator observations
   0-3   Arterial blood gases
   0-3   Non-invasive blood pressure monitoring
   2-3   Invasive blood pressure monitoring
   2-3   Central venous pressure monitoring
   0-3   Temperature
   0-3   12 lead ECG recording
   2-3   Continuous ECG monitoring
   0-3   Hourly fluid balance monitoring
   0-3   Daily weight
   0-3   Blood Glucose Level
   0-3   Glasgow coma scale/AVPU
    3    Sedation scoring/Holding
   0-3   Pain scoring
   0-3   ICP monitoring (invasive/non-invasive)


Level         Investigations, procedures and treatments
   0-3   CT scan
   0-3   Ultrasound
   0-3   Endoscopy

   0-3   Arterial blood gas analysis
   0-3   Urea and electrolytes
   0-3   Full blood count
   0-3   Clotting screen (PT most sensitive index)
   0-3   Cross match
   0-3   Liver function tests
   0-3   Amylase
   0-3   Toxicology/Virology
   0-3   Banding, injection or tamponade of varices
    3    Insertion of ICP bolt
   0-3   Correction of abnormalities and support of failing systems
   0-3   Biopsy
   0-3   Antibiotics
   0-3   Analgesia
   0-3   Lactulose
   0-3   Antioxidants – parvolex,Vit.E, Vit.C, selenium
23       Liver and biliary system

Core skill 23.2: Care of a patient with liver failure

                                                                                    Dates of Assessment

 Taxonomy Level to be Achieved
                                                                                    Self-   Initial   1st       2nd    Final
 Student
                                                                                    Ass.    Ass.      Int.      Int.   Ass.
 Assessor
 1. Demonstrate the ability to accurately monitor a patient
     with liver failure.
 2. Identify and prioritise patient needs and act appropriately on changing
     clinical parameters. (Cross reference with assessment criteria 1.2.6,
     2.1.3, 2.1.4, 3.1.3, 4.1.3, 4.1.4)

 3. Prepare the patient for specified investigations, and procedures and utilise
     the results to deliver appropriate treatments.

 4. Demonstrate the ability to liaise with and assist the multi-disciplinary team
     in effective care and management of a patient with liver failure. (cross
     reference with assessment criteria 5.1.6, 7.1.1)

 5. Demonstrates the ability to provide essential physical care. (cross
     reference with assessment criteria 5.2.3, 9.3.1, 9.3.3, 10.1.2, 10.1.3,)

 6. Demonstrates the ability to produce accurate, clear, legible and timely
    communication and documentation
    (cross reference with Core skill 7.2)

 Notes on Achievement/Non Achievement and Further Action Planned




                                                                                    Signature of Assessor
 Overall Level Achieved
                                                                                    Signature of Practitioner
23         Liver and Biliary System

Core Skill 23.3:                Care of a patient with Biliary System Dysfunction

Underpinning Knowledge:

1.         Normal anatomy and physiology of the biliary system
2.         Causes of biliary system dysfunction
3.         Signs and symptoms of biliary system dysfunction
4.         Effects of biliary problems on other systems
5.         Investigations used to diagnose and treat biliary system dysfunction
6.         Local policies and procedures in the diagnosis and management of patients with biliary
           problems

In Relation to:

Level                                                       Abnormalities
     0-3        Acute epigastric & mid abdominal/back pain
     0-3        Nausea & Vomiting
     0-3        Abdominal distension
     0-3        Pyrexia, occasionally hypothermia
     0-3        Hypotension
     0-3        Tachycardia
     0-3        Small bowel ileus
     0-3        Grey- Turner sign
     0-3        Cullen’s sign
     0-3        Raised amylase
     0-3        Hypocalcaemia
     0-3        Hypomagnesia
     0-3        Arrythmias
     0-3        Hyperglycaemia
     0-3        Hyperbilirubinaemia
     0-3        Hypoalbuminaemia
     0-3        Raised transaminase and alkaline phosphatase
     0-3        Jaundice
     0-3        Sepsis
     0-3        Respiratory & cardiovascular complications
     0-3        Renal dysfunction
     0-3        Disseminated Intravascular Coagulation (DIC)
     0-3        Gallstones
     0-3        Cholangitis
     0-3        Cholecystitis




Level                                      Investigations, Treatment & Procedures
     0-3        Blood tests –     Full blood count
     0-3                          Clotting screen
     0-3                          Amylase
     0-3                          U & E’s
     0-3                          Glucose
     0-3                          LFT’s (alkaline phosphatase, gamma-glutyl transferase, alanine transaminase, albumin,
                                  bilirubin)
     0-3        Urinalysis
     0-3        Ultrasound scan
     0-3        Chest x-ray
     0-3        Abdominal x-rays
     0-3        CT scan
     0-3        ERCP – endoscopic-retrograde-cholangiopancreatography
     0-3        MRCP –magnetic resonance cholangiopancreatography
     0-3        Biopsy
     0-3        Percutaneous transhepatic cholangiography
     0-3        MRI scan
     0-3        Laparoscopy
   0-3   Cholecystectomy
   0-3   Insertion of stents
   0-3   TPN
   0-3   Antioxidants
   0-3   Antibiotics
   0-3   Abdominal pressure measurements
   0-3   Analgesia
   0-3   Antihistamines


Level                Observations
   0-3   Respiratory rate, rhythm, depth
   0-3   Pulse Oximetry
   2-3   Non-invasive ventilator observations
    3    Mechanical ventilator observations
   0-3   Arterial blood gases
   0-3   Non-invasive blood pressure monitoring
   2-3   Invasive blood pressure monitoring
   2-3   Central venous pressure monitoring
   0-3   Temperature
   0-3   12 lead ECG recording
   2-3   Continuous ECG monitoring
   0-3   Hourly fluid balance monitoring
   0-3   Daily weight
   0-3   Blood Glucose Level
   0-3   Glasgow coma scale/AVPU
    3    Sedation scoring/Holding
   0-3   Pain scoring
23       Liver and Biliary System

Core Skill 14.3 Care of a Patient with Biliary System Dysfunction

                                                                                    Dates of Assessment

 Taxonomy Level to be Achieved
                                                                                    Self-   Initial   1st       2nd    Final
 Student
                                                                                    Ass.    Ass.      Int.      Int.   Ass.
 Assessor
 1. Demonstrate the ability to accurately monitor a patient with biliary
    problems

 2. Identify and prioritise patient needs and act appropriately on changing
     clinical parameters. (Cross reference with assessment criteria 1.2.6, 2.1.3,
     2.1.4, 3.1.3, 4.1.3, 4.1.4)

 3. Prepare the patient for specified investigations, and procedures and utilise
    the results to deliver appropriate treatments

 4. Demonstrate the ability to liaise with and assist the multi-disciplinary team
    in effective care and management of a patient with biliary system
    dysfunction (cross reference with assessment criteria 5.1.6, 7.1.1)

 5. Demonstrates the ability to provide essential physical care. (cross
    reference with assessment criteria 5.2.3, 9.3.1, 9.3.3, 10.1.2, 10.1.3,)

 6. Demonstrates the ability to produce accurate, clear, legible and timely
    communication and documentation (cross reference with Core Skill 7.2)



 Notes on Achievement/Non Achievement and Further Action Planned




                                                                                    Signature of Assessor
 Overall Level Achieved
                                                                                    Signature of Practitioner

				
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posted:11/9/2011
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