Chapter 58 Liver Disorders
The registered nurse is teaching a group of student nurses about assessment findings of each stage of portal systemic encephalopathy. Which statement made by a student nurse indicates a need for further teaching? "The patient in stage I will have slurred speech." "The patient in stage II will have muscle twitching." "The patient in stage III will have hyperreflexia." "The patient in stage IV will have seizures."
"The patient in stage II will have muscle twitching." Stage II of portal systemic encephalopathy is characterized by mental changes, mental confusion, and asterixis. Muscle twitching is not observed in stage II; therefore, this statement of the student nurse indicates a need for further teaching. Stage IV, comatose, is the stage in which patients experience seizures. Stage III is stuporous, characterized by hyperreflexia and muscle twitching. Stage I, prodromal, is characterized by slurred or slowed speech.
A patient who has liver disease with ascites refuses the evening dinner tray and reports moderate abdominal pain. The nurse notifies the provider after assessing a low-grade temperature elevation and rigidity of the abdomen. The provider prepares to perform a paracentesis and orders an antibiotic to be given. When does the nurse expect to administer the antibiotic? After a sample of fluid is sent to the lab for culture After a short-term ascites drain has been placed Before the paracentesis to prevent sepsis from the procedure After the culture and sensitivity results are returned from the lab
After a sample of fluid is sent to the lab for culture This patient has symptoms characteristic of spontaneous bacterial peritonitis. The nurse should give the ordered antibiotic after a sample of ascitic fluid has been sent for culture. Since the patient is symptomatic, the antibiotic should be given before the culture results are known.
In discussing long-term care needs with a patient with alcoholic cirrhosis, the patient tells the nurse that long-term abstinence from alcohol seems impossible and asks if small amounts of alcohol may be tolerated. Which nursing action is correct? Ask the patient to identify a person who can be supportive during alcohol withdrawal. Enlist the help of a family member to remove alcohol from the patient's home. Suggest that the patient discuss safe amounts of alcohol with the provider. Tell the patient that any alcohol intake may cause a fatal progression of the disease.
Ask the patient to identify a person who can be supportive during alcohol withdrawal. If alcohol is the cause of cirrhosis, abstinence from alcohol is essential. The patient who feels hopeless should be steered towards a support group or person who can be helpful and supportive. Asking a family member to remove alcohol from the home and reminding the patient that consumption of alcohol may be fatal do not address the problem of hopelessness.
The nurse is caring for a patient with cirrhosis. What factors may lead to hepatic encephalopathy in the patient? Select all that apply. Low-protein diet Decreased fluid volume Increased serum potassium Constipation Gastrointestinal bleeding
Decreased fluid volume Constipation Gastrointestinal bleeding Decreased fluid volume, constipation, and gastrointestinal bleeding may cause hepatic encephalopathy in patients with cirrhosis. Other causes include a high-protein diet and decreased serum potassium levels.
Which is an important institutional measure that a hospital may take to prevent the transmission of hepatitis B (HBV) to health care workers? Develop a hospital-wide needles system for delivery of medications. Provide immunoglobulin injections within 14 days of exposure to the virus. Provide information about HBV transmission to at-risk employees. Reinforce Standard Precautions procedures among all hospital employees.
Develop a hospital-wide needles system for delivery of medications. Needlesticks are the leading cause of HBV exposure among health care workers, so eliminating needles would make a huge impact on preventing transmission of the disease. Providing immunoglobulin injections, providing HBV information, and reinforcing Standard Precautions may all be done as well, but are not as important as the implementation of needleless systems.
When teaching a patient with viral hepatitis, which instructions does the nurse include in the plan of care? Select all that apply. Do not consume any alcohol Consume a high-protein diet Do not drive a car for 1-2 weeks Monitor blood pressure and pulse daily Avoid medications containing acetaminophen Avoid carbonated beverages
Do not consume any alcohol Avoid taking medications containing acetaminophen The patient with hepatitis should avoid all alcohol as well as hepatotoxic medications such as acetaminophen unless instructed otherwise by the provider. The diet should be high in carbohydrates with moderate fat and moderate protein content. The patient may drive if he or she feels well. As hepatitis does not directly affect the cardiovascular system, there is no need to monitor vital signs. While carbonated beverages may contribute to a sense of fullness, it is not required that they be absolutely excluded.
Which diet instruction does the nurse give to a patient with active hepatitis? Consume soft, easy-to-chew foods Follow a low-protein, low-fat diet Eat a normal diet with fluid restrictions Eat small meals at frequent intervals
Eat small meals at frequent intervals Small, frequent meals are often preferable to three standard meals for the patient with hepatitis because these patients often experience nausea and vomiting and dietary intolerance. Soft, easy-to-chew foods are used with patients who have problems with dentition/chewing. The diet of the patient with hepatitis should be high in carbohydrates and calories with moderate amounts of fat and protein after nausea and anorexia subside; patients with liver disease should limit fat in the diet due to intolerance. Fluid restriction is only recommended in patients with severe ascites and anasarca.
What laboratory finding signifies an immune response to liver disease? Decreased serum total protein Decreased serum albumin Elevated serum globulin Elevated serum ammonia
Elevated serum globulin An increase in the serum globulin level indicates an immune response to liver disease. A decrease in serum total protein signifies chronic liver disease, and a decrease in serum albumin signifies severe liver disease. The serum ammonia level is elevated in advanced liver disease or portal-systemic encephalopathy because the liver is unable to detoxify protein byproducts.
When caring for a patient with portal hypertension, the nurse assesses for which potential complications? Select all that apply. Esophageal varices Hematuria Fever Ascites Hemorrhoids
Esophageal varices Ascites Hemorrhoids Portal hypertension results from increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. The blood meets resistance to flow and seeks collateral (alternative) venous channels around the high-pressure area. Veins become dilated in the esophagus (esophageal varices), rectum (hemorrhoids), and abdomen (ascites due to excessive abdominal [peritoneal] fluid). Hematuria may indicate insufficient production of clotting factors in the liver and decreased absorption of vitamin K. Fever indicates an inflammatory process.
A patient is admitted with bleeding esophageal varices. The nurse anticipates which factors may be included in the patient's plan of care? Select all that apply. Liver biopsy Frequent vital signs Antiplatelet medication Red blood cell transfusion Sengstaken-Blakemore tube Beta-adrenergic blocking agent
Frequent vital signs Red blood cell transfusion Sengstaken-Blakemore tube Beta-adrenergic blocking agent Frequent vital signs are necessary during bleeding episodes to assess for shock and evaluate therapies. Red blood cells are given to replace fluid volume and oxygen-carrying capacity lost during hemorrhage. Esophageal balloon tamponade with a Minnesota or Sengstaken-Blakemore tube is used to control bleeding through direct pressure. Beta-adrenergic blockers are used to reduce portal pressure and therefore bleeding. Platelets, rather than antiplatelet medications which can cause bleeding, are usually administered. A liver biopsy is done to diagnose the cause of the cirrhotic process, but it is not a treatment for bleeding esophageal varices.
Which factors may lead to the development of hepatic encephalopathy in a patient with cirrhosis? Select all that apply. Diarrhea Gastrointestinal bleeding Hypokalemia Hypertension High-protein diet Hypermagnesemia
Gastrointestinal bleeding Hypokalemia High-protein diet The development of hepatic encephalopathy is believed to be the result of the shunting of portal venous blood into the central circulation so that the liver is bypassed. A buildup of ammonia and gamma aminobutyric acid (GABA) is the result. Factors that may precipitate hepatic encephalopathy include a high-protein diet, infections, hypovolemia, hypokalemia, and constipation. GI bleeding that causes a large protein load in the intestine, and medications such as hypnotics, opioids, sedatives, analgesics, and diuretics also contribute to encephalopathy. Diarrhea, hypertension, and hypermagnesemia are not known to be contributing factors for hepatic encephalopathy.
The nurse is reviewing the medical history of a patient with severe liver disease. Which physiological changes does the nurse expect to be present? Select all that apply. Increased urinary flow Increased creatinine levels Increased osmolarity of urine Increased blood urea nitrogen Increased urine sodium excretion
Increased creatinine levels Increased osmolarity of urine Increased BUN If a patient has severe liver disease, the result will be hepatorenal syndrome (HRS). This syndrome is characterized by increased urine osmolarity, increased blood urea nitrogen, and creatinine levels. In patients with HRS, urine flow decreases and urine sodium excretion decreases.
A patient with viral hepatitis has clay-colored stools and dark urine. These findings are typically characteristic of which complication of hepatitis? Cirrhosis of the liver Hepatic carcinoma Intrahepatic obstruction Obstructive jaundice
Intrahepatic obstruction Patients with hepatitis may develop intrahepatic obstruction, which will cause clay-colored stools and dark urine when the bile ducts are blocked. These findings may occur with hepatic obstruction in cirrhosis or carcinoma, but do not necessarily indicate that these have occurred. Obstructive jaundice is another sign of intrahepatic obstruction.
A patient with refractory ascites has a tunneled ascites drain (PleurX catheter). The community health nurse teaches the patient and family which most important aspect of care while this device is in place? Remaining on bedrest Keeping hands and the area clean Observing for diminished urine output Learning to take blood pressure each day
Keeping hands and area clean Patients with an indwelling device are prone to infection. Patients with ascites may also develop spontaneous bacterial peritonitis. Therefore, hands should always be cleansed before touching the area or using the device. Bedrest is necessary after a procedure such as paracentesis, but is not necessary while the drainage device is in place. Diminished urine output and a lower blood pressure are typically present with hepatic failure and ascites because fluid is third-spaced. Blood pressure may also drop with bleeding varices; however, daily monitoring is not needed with the ascites drainage device.
A patient who is being treated for hepatic encephalopathy reports intestinal bloating and cramping. On assessment, the nurse finds that the patient is experiencing alcohol withdrawal. The nurse reviews the patient's medication profile and identifies that which medication will likely be discontinued? Lactulose Rifaximin Metronidazole Alprazolam
Lactulose Lactulose is a laxative, prescribed to promote excretion of ammonia in the stool by preventing absorption of ammonia in the colon. Lactulose causes abdominal cramping and bloating as side effects; therefore, lactulose would be discontinued and replaced with another medication. Rifaximin is the most effective, safe, and long-term drug in the treatment of hepatic encephalopathy. Metronidazole is used as an antiseptic for intestinal infections and is not associated with abdominal cramping or bloating. A benzodiazepine, such as alprazolam, is used when the patient is experiencing alcohol withdrawal.
Which instruction is essential for the nurse to include when teaching a patient who is undergoing treatment for hepatitis with ribavirin? Never miss a dose Avoid going out in the sun Take the medication on an empty stomach Take the medication at the same time each day
Never miss a dose Patients being treated with Ribavirin for hepatitis C are instructed to never miss a dose of the drug. The nurse should assist the patient in methods to use for reminders such as setting an alarm or alert. Exposure to sun is not contraindicated with ribavirin; this restriction pertains to sulfonamides or antipsychotic medications. This medication is often taken with food.
A patient who was previously treated for hepatitis B virus (HBV) is tested for the presence of the hepatitis B surface antigen (HBsAg) in the blood. The test is positive. What does this result indicate? Permanent immunity to HBV Recurrence of infection Long-term liver damage Patient is infectious
Patient is infectious As long as the HBsAg is present, the patient is infectious and may be in a carrier state. It does not indicate permanent immunity, recurrence of infection, or long-term liver damage.
What type of cirrhosis is caused by hepatitis C? Postnecrotic Laennec's Biliary Cholestatic
Postnecrotic The hepatitis C virus causes postnecrotic cirrhosis. Laennec's cirrhosis is caused by chronic alcoholism. Biliary cirrhosis is also called cholestatic cirrhosis; it is caused by chronic biliary obstruction or autoimmune disease.
The nurse is administering spironolactone to a patient with portal hypertension and portal systemic encephalopathy. Which additional medication order does the nurse question? Potassium chloride Lactulose Neomycin Propanolol
Potassium chloride Spironolactone is a potassium-sparing diuretic; additional potassium may result in potassium intoxication. Lactulose and neomycin are used to control hepatic encephalopathy, which is part of the expected treatment plan. Propranolol is used to prevent gastrointestinal hemorrhage secondary to portal hypertension and gastroesophageal varices, which is an expected treatment for portal hypertension.
When caring for a patient with Laennec's cirrhosis, which of these does the nurse expect to find on assessment? Select all that apply. Prolonged partial thromboplastin time (PTT) Icterus of skin Swollen abdomen Elevated magnesium Currant jelly stool Elevated amylase level
Prolonged partial thromboplastin time (PTT) Icterus of skin Swollen abdomen The liver produces clotting factors; when it is damaged, prolonged coagulation times and bleeding may result. Icterus, or jaundice, results from cirrhosis. The patient with cirrhosis may develop ascites, or fluid in the abdominal cavity. Currant jelly stool is consistent with intussusception, a type of bowel obstruction. Cirrhosis is consistent with elevations of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase; amylase is typically elevated in pancreatitis.
A patient with severe cirrhosis of the liver has a urine output of 400 mL for the past 2 days despite adequate intravenous fluid administration. What is the priority nursing action for this patient? Contact the provider to discuss obtaining a urine culture Encourage the patient to increase oral fluid intake Perform a bladder scan to assess for urinary retention Request an order for blood urea nitrogen (BUN) and serum creatinine levels
Request an order for blood urea nitrogen (BUN) and serum creatinine levels Patients with cirrhosis may develop hepatorenal syndrome (HRS), which is characterized by oliguria less than 500 mL/day and elevated BUN and creatinine levels. The nurse should request these additional tests to help determine this. Decreased urine output is not a sign of urinary tract infection (UTI), so a culture is not indicated. The patient has been receiving adequate fluids, so additional intake is not indicated. If BUN and creatinine levels are normal, assessing for retention may then be warranted
A health care worker believes that he or she may have been exposed to hepatitis A. Which intervention is the highest priority to prevent the health care worked from developing the disease? Request a vaccination for hepatitis A Using a needless system in daily work Getting the three-part hepatitis B vaccine Requesting an injection of immunoglobulin
Requesting an injection of immunoglobulin The administration of immunoglobulin, antibodies to hepatitis A, may prevent development of the disease. The vaccine for hepatitis A will take several weeks to stimulate the development of antibodies; passive immunity in the form of immunoglobulin is needed. Implementing a needleless system and getting the three-part vaccine may prevent the development of hepatitis B, not hepatitis A.
When assessing a patient with hepatitis B, the nurse anticipates which assessment findings? Select all that apply. Recent influenza infection Brown stool Tea-colored urine Right upper quadrant tenderness Itching
Tea-colored urine Right upper quadrant tenderness Itching The urine may be brown, tea-, or cola-colored in patients with hepatitis. Inflammation of the liver may cause right upper quadrant pain. Deposits of bilirubin on the skin, secondary to high bilirubin levels, and jaundice irritate the skin and cause itching. Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored.
A patient with hepatic encephalopathy may require which dietary or pharmacologic therapy to help decrease serum ammonia levels? Diet high in carbohydrates and protein with moderate fats Diet low in protein and moderate in fats and carbohydrates Trial of lactulose to increase the excretion of ammonia Nonabsorbable antibiotics given for long-term therapy
Trial of lactulose to increase the excretion of ammonia Lactulose can be used with hepatic encephalopathy to increase the excretion of ammonia through the stools. To help minimize serum ammonia, patients may be started on a moderate protein, fat, and carbohydrate diet. High protein increases ammonia and low protein does not provide enough protein for healing. Nonabsorbable antibiotics may be used, but are given short-term only.