[Music] hello this presentation will be over the endocrine disorders related to the liver and its dysfunctions and this will include discussions about hepatitis which is inflammation or infection of the liver cirrhosis which is scarred or damaged tissue in the liver and then fatty liver which is just fat that accumulates in the liver which will eventually lead to cirrhosis here are the objectives of this presentation at the conclusion the student should be able to identify the metabolic functions of the liver and the alterations that occur with hepatic disorders explain liver function tests and the clinical manifestations of liver dysfunction in relation to pathophysiologic alterations of the liver relate jaundice portal hypertension ascites varices nutritional deficiencies and hepatic encephalopathy and coma to pathophysiologic alterations of the liver describe the medical Surgical and nursing management of patients with esophageal varices use the nursing process as a framework to care for the patient with cirrhosis of the liver this image is to show you some of the classic manifestations of a person with liver disease I think you can notice the yellowing of the skin which comes from the jaundice from the livers not handling the bilirubin in the bloodstream as it is supposed to Additionally you can see the abdomen here is quite full because of the ascites the fluid shift that is happening in the coming out of the bloodstream and into the peritoneum and then I also want you to notice just the upper chest and the arms and how this patient looks so thin not quite emaciated but pretty thin and malnourished and that is also classic of liver disease all right a little review of the anatomy and physiology associated with the liver the liver is the largest gland of the body it is a major organ it has a lot of functions its location is in the right upper quadrant of the abdomen and it's partially housed underneath the rib cage it has a lot of functions in the body it does major things for our overall health it can be considered a chemical Factory that both manufacturer stores alters and excrete substances it is important in the regulation of glucose and protein metabolism it manufactures and secretes bile which helps us to digest and absorb fats in the GI system it cleanses the bloodstream of waste products and excretes them um it partners with the gallbladder to store bile for use in digestion so they kind of work in concert with each other so as I've told you all before when you have an issue with one of the organs between the gallbladder liver and pancreas often the other two will also suffer illness inflammation infection because they are so tightly um associated with each other and and the same approximation within the body um so some of the other functions besides glucose metabolism it also helps to convert ammonia which is a byproduct of just normal body functions cell functions and it takes ammonia and turns it into urea which is then excreted by the kidneys that's what's measured in your bun your blood is your blood urea nitrogen level um protein metabolism is another thing that the liver does it synthesizes plasma proteins it also does fat metabolism and also helps with storage of fat soluble vitamins it helps to excrete bilirubin which comes from the breakdown of hemoglobin cells red blood cells break down and bilirubin is the byproduct of that and the liver is supposed to filter and excrete that when it does not that's how you end up with the yellowing of the skin in jaundice it also helps to metabolize drugs it helps to deactivate a drug so that it doesn't continue to build up in the blood and be used by the body in excess so it will render it inactive and then it will filter it out and then it exits the body through the GI system um briefly hepatitis is really inflammation or infection of the liver from any Source this can be viral and there's a number of different viral hepatitises you know have a have B of C it can be drug-induced from perhaps excess medications that are hepatotoxic like a acetaminophen overdose and it can be from toxins just in general toxins that enter the body they end up being filtered through the liver and this can cause inflammation in the liver and this is also inclusive of alcohol which is a toxin and it causes inflammation in the liver especially in excess um your hepatitis can show with or without jaundice generally they have flu-like symptoms but it can vary depending upon what's the causative Factor that's creating this hepatitis this inflammation we have two forms of fatty liver disease we have alcoholic which goes without saying that just means excess alcohol consumption cause is damage to the liver fat builds up in the liver leads to fibrosis which then leads to cirrhosis of the liver which is just body scarring tissue in the liver which then makes that tissue unable to do the functions that it was designed to do non-alcoholic fatty liver disease and non-alcoholic stratohepatitis are two diseases within a spectrum of fatty liver disease that are strongly associated with obesity also associated with dietary carbohydrate intake especially high fructose corn syrup we have seen a huge increase in non-alcoholic fatty liver disease since there is a increase in foods and drinks with high fructose corn syrup especially carbonated beverages so regular sodas that contain high fructose corn syrup are a leading contributor to non-alcoholic fatty liver disease this is why patients that don't drink alcohol and would be offended if you said oh you have cirrhosis you have must be an alcoholic these people are developing non-alcoholic fatty liver disease which still can lead to the same outcome so cirrhosis is this chronic disease it's characterized by replacement of normal liver tissue with fibrose tissue scarring tissue um and this just impacts the liver's ability to do all those functions that we already discussed recall that we've talked before that you know everything that an organ does will be impacted when that organ is malfunctioning so the more complex functions that that organ has the more issues you're going to see when it can't do its job so here's a list of some of the major clinical manifestations that you're going to see with a patient that has liver dysfunction whether that be hepatitis and maybe this is a short-term problem or this is alcoholic or non-alcoholic fatty liver disease or cirrhosis generally speaking the further along the spectrum they are the more pronounced and serious that these manifestations are going to be so we've talked briefly about jaundice that yellowing of the skin that's just an external showing of what's happening on the inside so we see then that the patient's eyes the sclera of the eyes look yellow usually that's our first indication as you can see it in the eye and then over time it becomes more visible as it builds up in the bloodstream and in the tissues that this patient you know has an overall yellow tinge sometimes they get quite bright yellow and a lot of it depends on what their Baseline normal skin tone is then portal hypertension is what happens when the blood flow through the um liver is impaired from stenosis and scarring okay so we have Scar Tissue build up it creates blockage so that the blood flow can't circulate as it's supposed to through the liver and so we start having backup of the fluids um the blood okay and then some of that turns into ascites which is where you see that fluid uh and it's just basically water that's come out of the bloodstream that's free-floating in the peritoneal cavity because it just kind of got filtered out and and now it's out of the bloodstream so you see this big pocket of fluid in the abdomen and you think well this patient's over hydrated but it's not the case because the fluid is in the wrong place so ascites is actually a sign usually a dehydration in the bloodstream because the patient won't have the fluid in the bloodstream it's all leaked out into the peritoneum causing this ascites and then um ascites can also because of its location in the abdomen depending upon the position of the patient and and the way gravity functions could impact how well they can breathe because that big pocket of fluid can press on the diaphragm and cause the patient to have a difficult time with with breathing esophageal varices are also um part of the portal hypertension issue so it causes the backup of fluids esophageal viruses are we're going to have a picture later in the in the discussion about about this that's going to show you what they look like but they're enlarged veins in the esophagus and they kind of swell up and they're um very fragile it's like the veins enlarge and come to the surface so you can imagine that if you tried to swallow something and it nicked one of those because your esophagus is going to be narrowed because these varices are taking up a space that that should not be filled with them um then you could see um a large bleeding issue going on a severe Hemorrhage could happen from this and patients can die from bleeding esophageal varices um hepatic encephalopathy and coma comes from the buildup of the toxins a lot of that has to do with the ammonia buildup in in the um blood because the liver is not filtering out this ammonia which is a natural byproduct of cellular functions and so the buildup of it starts to look it looks like um confusion and lethargy at first but the more and the more it builds up then the more lethargic the patient becomes the more toxic they are they can end up in a coma and it can actually kill a person to have this buildup of it's a toxin and so it's basically a poison that's building up in the body edema can happen bleeding can happen because one of the things the liver does is help with um clotting factors vitamin deficiencies because it's not able to process those fat soluble vitamins like it's supposed to puritis which is an itchyness um like an itchiness of the skin and then asterixis which um we're gonna I have a link for a video for you guys to watch but it's like this hand flapping involuntary hand flapping that happens because of the buildup of the toxins that are going on in the body just a second I'm going to review my notes and make sure I did not leave out anything I wanted to say I do want to also it's not on the on the slide but this this congestion of the the portal hypertension the portal venous system also can cause congestion of the spleen um and then that can make the spleen a hypertrophy um and that can cause uh issues with um infections and bleeding as well patient will have issues so we talked earlier about them having um glucose metabolism is part of what the liver does so this patient will have impaired metabolism of glucose um and they won't the the liver also signals for the release of glucagon as well so insulin glucagon all of these things are impacted by what's going on in the liver and the signals that the body normally would send to help regulate these things all right so as per our Norm we want to think about our priorities when we're assessing this patient we want to think about checking their mental status and their neural functions because of maybe the elevated ammonia that may cause changes in their level of Consciousness and their cognition this patient could be quite confused and and unreasonable difficult to have a conversation with and difficult to maybe convince that they need to stay in the bed or convince that they need to not mess with their IV line and pull it out or that they need to take their medications this can be quite challenging to deal with this patient additionally the ammonia is also and the other toxins that build up in the body are just irritating to the system so this can cause some different nerve function issues that's why neuro is part of this mental status and they kind of all go together the neurological stuff so they may have Tremors in their hands they may have Asterix which is that flapping of their hands and they may have sworn speech even we want to look at skin because the skin can tell us a lot about the liver disease we can see this jaundice we've already talked about excoriation because this patient has a lot of itching and maybe because they're confused and they don't understand that they ought not to scratch so much they can even scratch themselves raw and maybe have some impaired skin integrity because of this this itching that they just can't stop scratching um katikiai and ecchymosis can happen because part of what the liver does is work on clotting vectors and so when it's not functioning properly we can see bruising and ecchymosis and then the patient can sometimes have what's called Palmer erythema which is like a redness that's on the palms of their hands we want to do a good GI and abdominal assessment we may be actually able to palpate the liver and it may be pretty hard depends on the state of that their progression in their disease process I've heard of nurses palpating patients livers that just felt the hardness of break and you knew that that patient's liver was not really able to do its filtration and functions of excretion and all because the tissue had become so fibrous to that it was just solid uh like a brick um we want to check their abdomen for the fluid wave to see if there's a lot of fluid going on there which will help us determine like positioning for them we also want to see if there's any tenderness sometimes the liver is not hard as a brick it's just real inflamed and it's tender we want to watch for that as well we want to take a good health history we don't want to assume alcohol is the cause for their liver dysfunction it used to be so before this non-alcoholic fatty liver became such a prevalent condition um probably the largest percentage of people that had liver issues would be assumed that they had it from excess alcohol consumption but there's a lot of other ways a patient can develop a liver inflammation or develop it along the Spectrum all the way to cirrhosis can be from IV and illicit drug use can be medications either over the counter or prescription can be from Dirty needles in a tattoo parlor getting a tattoo can cause a patient to end up with hepatitis so we want to do a lot of of digging into their health history find out what might be their cause so that we can see about eliminating problems or isolating that issue we also want to um ask about their family health history it could be that uh liver issues run in the family yeah so now we'll discuss um some aspects of the medical management of a patient with liver issues we have some lab results that can help us some serum lab tests that can be done that will tell us some information about what's going on with the liver and how well it's doing it's designed functions those labs will include serum Amino transferase alkaline phosphatase lactic dehydrogenase serum albumin bilirubin ammonia clotting factors and lipids a liver biopsy can be done wherein they will do a needle aspiration and take a small sample of liver tissue for testing sometimes this is indicated when they suspect that a patient has um liver cancer so they'll get a small middle aspiration biopsy and run tests on it when you're caring for a patient that's had one of these you need to consider that they have a sick liver and they are more likely to bleed so we want to monitor that site really well there'll be certain ways that the provider will want them to be positioned and they may have to stay in that position for a while until we're sure that we've got some clotting going on and that it's not going to bleed from that puncture site um other diagnostic tests that can be done include ultrasounds or CTS or MRIs to identify structures that are normal or abnormal and the liver um further medical management would include the treatment of these issues um we think about whatever the presenting symptoms are and we try to address those um generally um it's based on whatever's causing the problem one of the things that we'd use for treating esophageal varices is a medication called octreotide it is the first line treatment for um taking care of varices and then sometimes they will include vasopressins which help decrease the portal pressure and sometimes beta blockers to help with that as well there is a procedure where they can put um a tube down the patient's throat that is um it's like a balloon but you can't have a full balloon down your throat because then you can't breathe so it's a balloon that's Hollow in the center so it's like a tube um but they can blow up that balloon and it'll put pressure on the Pharisees and help with that that pressure stopping the bleed sometimes they'll also do scleral therapy which is where they inject into the vein a medication that causes it to clot um and then there's a thing called transjugular intrahepatic portal system shunts that can be done so they just shunt the blood around so that it um takes pressure off off of those varices ascites tends to either need nutritional therapy will often help ascites get better because there's a lack of protein in the blood especially albumin and so sometimes the patient will get um nutrients in their IV um or and or albumin will be given IV which will help them to pull the fluids out of the abdomen and back into the bloodstream but Additionally the patient might have a paracentesis where they do that tap and pull out the extra fluids just don't forget that if this patient has ascites it looks like fluid overload but the fluid is in the wrong place it's called third spacing when the fluid is not in the place it belongs and it's not in the bloodstream and that's where that fluid is supposed to be so it looks like they're over hydrated it looks like they have an excess of fluid but in reality they they have a decrease of fluid in the bloodstream and that can be very dangerous because uh severe issues with um perfusion and maybe even go so far as to have vascular collapse or shock happen because they don't have enough volume in the circulation encephalopathy is a thing that happens because of the buildup of the ammonia there are drugs that are given that help to evacuate ammonia out of the bloodstream lactulose is one and it is usually needs to be taken it's titrated to its therapeutic level by how many bowel movements the patient has a day and it causes loose stools and so that can be quite challenging because sometimes the patient doesn't like that effect of it they don't want to be in the bathroom having a loose almost diarrhea kind of stool two three four times a day but they need the medication that's how it works so the medication needs to be titrated to how many bowel movements a day keep their ammonia level in the proper range additionally we're probably going to be looking at Vitamin deficiencies and maybe replacing vitamins and or improving their diet I am familiar with United Regional that's the hospital that I worked at and that I this is my hometown that's the hospital I know about they have and I'm sure that it's similar in other facilities but I can't speak for them for sure to have um a mix that they put together in IV fluids that comes up from the pharmacy ordered by the provider and it has a yellow coloration to it because it's filled with the vitamins to replace what's missing from this patient's um body and they call it a banana bag and it's full it's the yellow coloration that comes from like the vitamins that are added to it um um I think I'm going to talk more about the person thesis when we get to one of the later slides so I think yeah it looks like that's everything for this slide this is maybe a little bit redundant um but some of the labs that we want to think about are the liver function ones that I mentioned on the previous section we also probably want to look at cbc's especially if we think this is a hepatitis we want to know what um the white blood cells are looking like and and the differential because the differential will tell us some some indication of whether this might be a bacterial problem or a viral problem because of the way the white blood cells will shift in which ones are elevated and which ones are decreased depending upon whether it's a viral Invasion or a bacterial Invasion we want to check what blood cells we want to check platelet count because platelet count is going to be very important that this patient has their ability to clot because we're going to be watching for injuries from bleeding to this patient hemoglobin and hematocrit BMP is important because with these fluid shifts you can end up with electrolyte imbalances and then obviously when we want to check the blood for the ammonia level as many as mentioned before some of the medications that we're going to be using with this patient will be the lactulose which helps to sequester ammonia from the circulation and the patient eliminates it through their stools beta blockers which will help manage the hypertension in the portal system diuretics that will help with eliminating the excess fluid that's in the wrong place in this third spacing vasopressins which will help with the pressure issues and then vitamins because they have to be replaced in order for the body to function properly and to do any kind of healing so in your text there's a chart in chapter 49 that has different nursing diagnoses that are related for liver dysfunction and various aspects of this patient's care as always we want to think about the safety of the patient they are under our care because they can't take care of themselves there are issues that we can help with but we have to make sure that our first and foremost thought is for their safety think about their mental status think about preventing them from hurting themselves in inadvertently because they have this altered mental status remember that they have an increased risk of bleeding so any kind of fall could cause excess bruising could cause hemorrhaging could cause hematomas and if there's a head injury then that bleed could be in the brain um I want to think about portal hypertension which can lead to ascites and then also bleeding esophageal varices that is a severe emergency if that happens patients can quickly bleed out from that we want to think about the safety of their skin and trying to decrease that itching if at all possible and then they if all we do is give them lactulose for the ammonia levels then um that's a fine treatment but we have to consider the fact that now they're going to have loose stools which um we'll have to help them manage and that can impact the Skin Integrity in their um because of the the life to us and the loose stools so we're going to have to watch for impaired skin integrity and damage and breakdown of skin on their bottoms some of the care we're going to give to this patient is going to be daily weights we want to know what's going on with this fluid and weights are the best way to determine if a patient's gaining and or losing fluids especially in short term um so they're also going to be on eyes and O's we're going to find out what's going in what's coming out we want to see if we can get a balance going on there we may be measuring their abdominal girth which will tell us how much that ascites may be increasing we want to check that respiratory status I have mentioned that already um we want to monitor their Labs including their serum ammonia their electrolytes and those other indicators of the liver function all right so now some of we've mentioned several of the complications now we'll talk a little bit more specifically about trying to manage them if a patient is bleeding from varices this is an emergency this is a fast call situation this is where they need that octreotide or vasopressin right away and depending on how much blood they lose we may end up having to give them a fluid bolus or a transfusion if a patient is confused because of this excess ammonia and toxins built up then we want to try to reorient them get them maybe a sitter or the ab assist camera to help reorient them and remind them that they need to stay in the bed or not to pull on their IV we may be administering lactulose and then dealing with the loose stools helping the patient with that clean up and this patient may end up having to be restrained um it just sometimes becomes necessary if they're having respiratory distress we want to remember that it's a lot easier to set them up if they can breathe a lot easier sitting up that does a couple of things it helps the lungs to be able to expand better and it moves the fluid because of gravity it'll move the fluid down away from the um diaphragm and lessen the pressure on the thoracic cavity um we also probably be trying to give them some albumin to move the fluid back into the vascular space and then diuretics to flush the excess fluid out of the vascular space this patient could have fluid volume deficit because of these fluid shifts so we may end up in the meantime giving them boluses of fluids to keep them from having hypovolemic shock a liver function just dysfunction patient is a challenge to balance all these things we want to monitor them for um keep their blood pressure as a marker of their fluid status um if we start showing signs of decreased blood pressure tachycardia with a weak and thready pulse and a decreased temperature those can be signs of that they're heading towards hypovolemic shock um the electrolyte imbalances are something that we're going to monitor both in patients signs and symptoms that we can see and measure in the labs and then we're going to be replacing as needed as we are ordered all right so we mentioned before about how jaundice often shows up in the whites of the Eyes First this is a good image that shows that we can also see the yellow tinge kind of in the patient's skin as well additionally when there's this excess buildup of the bilirubin in the system that leads to jaundice you'll also see other signs and symptoms the patient could be having nausea and vomiting they could be running a fever they will likely have dark colored yarn because if you think about it what's going on is the bilirubin is stuck in the bloodstream and the liver's not filtering it out and so instead the kidneys are trying to get rid of it so it's in the bloodstream and it's darkening the urine and then because it's not going through the GI system the stools look pale so the color shifts out of the stools and so instead of them being their normal brown color now that color is showing up in the urine um the loss of appetite also goes with the nausea vomiting additionally abdominal pain can occur especially in that right upper quadrant where the liver is located patient might be weak they might be experiencing weight loss which goes with the loss of appetite and pain and nausea and vomiting and then the acid is in the abdomen I can't show you I cannot show you this video clip um through this recording but these slides are available on D2L and I would encourage you to go watch this short little video clip it really shows um some good information about what asterixis looks like all right just a brief word about paracentesis which is done for ascites so um they'll position the patient on about a 30 to 45 degree angle which helps the water the fluid to go down to gravity and the organs kind of float up on top of it and therefore they're out of the way when they insert the needle which helps to withdraw this fluid and it's Guided by an ultrasound so that the whoever's performing this tap will avoid puncturing organs or blood vessels this slide kind of gives a summary a synopsis of what ascites is and what its symptoms look like what its causes are What complications can come from it and what treatments are available for it so I advise you to read over this carefully and make sure that you understand all these aspects that go with this uh symptom of liver dysfunction this image on the left is looking down the esophagus of a patient that has esophageal varices so you can see how instead of a smooth tube that your esophagus is supposed to look like it's all bumpy and it's got these veins that are distended and um very um fragile very fragile for um just just eating something that's that's maybe sharp and you swallow it like say potatoes right you don't think potatoes just being you know they're crunchy and if but if you you swallowed that down and a little edge of that chip mix the sides of that vessel now you can have other extensive bleeding going on and so this slide kind of describes the process of the cirrhosis that's going on in the liver and how the portal hypertension develops and then how this leads to the varices in the esophagus all right so our patient teaching is going to kind of vary somewhat on what's going on with our individual patient um if this is just an acute issue perhaps a viral hepatitis and it's going to clear up then they need to know what to expect and how the recovery process is going to go versus if this is a chronic issue where this is going to be something that the patient will now have life changing from here on out needs then that's going to be a different conversation they need to know all these possible complications that we've talked about they need to know what to look for um at home they need to know when to contact their doctor they need to watch their daily weight and contact their provider if they gain more than three pounds overnight or five pounds in a week so remember how much fluid it is one pound of weight gained in the fluid is equal to 480 mL of water two pounds is approximately a whole liter so that means three pounds of weight gain if they happen to gain that much overnight we're talking about a liter and a half of extra fluid that they shouldn't have held on to okay five pounds is about two and a half extra liters of fluid so these patients need to be taught and their family members who are helping take care of them need to know to watch for these big fluid shifts okay they may not necessarily notice a three pound shift in their abdomen they might but stepping on the scale every day will let them know because you should not have that much of a change in that short of a Time we'll have to teach them about their medications when to take them what side effects to expect complications how to monitor for them and when to do follow-ups with their provider they they need to know about some dietary changes and they might need a sample menu or some resources that they can go to online sometimes um one way we can do that is give a patient the menu from the hospital stay and then they need to then they can use that as a guide to gauge what they ought and not not to eat and we want to talk to them about alcohol consumption even if this is a non-alcoholic fatty liver disease um alcohol is a toxin to the liver it's a toxin to the entire body and so even if it's not an alcohol related liver dysfunction alcohol will damage the liver further or whatever its cause was initially so we need to talk about alcohol and not consuming alcohol once they have this liver problem um we want to help the patient understand about their fall risk when they have these fluid shifts you have to think about both the sides of it now I've got extra weight that's impacting my mobility and it's it's in a place that I'm not used to extra weight being in my belly that can impact my balance right but then you also think about the fact that this fluid came out of the bloodstream and so now the patient may be dehydrated which can cause orthostatic hypotension okay so now we have fall risk increased from two different aspects of the same issue so we definitely want to teach the patient to be careful and then we know because liver dysfunction can cause them to have an increased risk of bleeding they need to be careful that if they have a fall that could cause internal or external bleeding and head injuries can become deadly because of the bleeds um if a patient has chronic problems they may not be able to monitor their own cognitive ability okay they may not realize when they're too confused to make good decisions and judgments so family members have to help monitor if at all possible the patient should have somebody who can monitor their mental status and recognize when they're not um in their normal state nutrition balance is really important when a patient gets to this degree of liver dysfunction protein needs to be very carefully monitored it is needed but large quantities of protein can actually create more ammonia in the body and increase the risk for that metabolic encephalopathy so there needs to be a good balance and this patient may need a dietitian to help them get a good plan for their dietary needs so as always we want to consider the holistic and psychosocial needs of our patient we want to consider those aspects not just the physical things that are going on but these holistic and psychosocial aspects as well so this patient you know if they have to make changes significant changes in their diet that's an issue I've said it before eating and our food habits are very social things and they're also things that are emotionally tied so dietary changes maybe need to be done in increments um rather than just All or Nothing Whole Hog cold turkey kind of stuff um they need to have support for these um lifestyle changes so because especially if it's chronic then this is not something that that's going to leave them they're going to have to live with us and it may progressively get worse in time regardless of how well they treat because just as aging happens organs do um they don't function as well there's a decrease over time as we get older so even if the patients changes all the things that they need to to get this in check over time they're still probably going to get progressively worse because the damage is already there and as we get older it just gets less functional we need to help the patients find foods that they like to eat that are Stills that are safe for them to eat so there's sometimes a hard a hard time to try to match that up um we need to give support for them or provide them with a group to help them if alcohol is an issue for them that they have to stop in order to Halt the continued cirrhosis of the liver um they you know if they need diuretics to help treat this fluid problem then they may need um Our advice on how to deal with the the need to be always running to the bathroom to urinate um if they have to take lactulose they need some advice on how to deal with these frequent loose stools and how to do good skin care so that they can prevent the skin breakdown and issues from this frequent loose stools and it's a chronic illness in a lot of cases so that's going to cause patients to need some extra support and there may even be a little bit of anticipatory grieving because this is so life-altering and chronic in nature and that can cause a lot of grief for a patient and and their families as well all right so this is the last of the slides um I hope this helps you understand the processes that are going on when we have liver disorders and diseases as always if you still don't understand the content re-watch this refer to your textbook go to your online your favorite online source of nursing videos and see if all of this can start to make sense to you if it does not please come see me and we will see how I can help you get this all um kind of gelled in your mind so you can see how this all fits together and I do hope that everyone has a great day and I will see you later