AH 2 Ch. 53 Care of Patients with Liver Problems

Assessment: Noticing

Ask about exposure to someone with hepatitis. Ask about chemical exposure. Inquire about alcohol, drug, herbal use. Inquire about travel, sexual activities, needle-stick exposure, drug (IV) use, military service. Assess for family history of liver disease.

More Assessment: Noticing

Assess for exposure to alcohol and drugs, herbs, chemicals. Determine if there has ever been a needlestick injury, tattoo placement, imprisonment, or employment as a healthcare worker, firefighter, or police officer. Assess sexual history and orientation. Inquire about family history. Collect previous medical history.

Assessment: Noticing Physical Assessment

Because cirrhosis has a slow onset, many of the early signs and symptoms are vague and nonspecific. Assess for: • Fatigue • Significant change in weight • GI symptoms, such as anorexia and vomiting • Pain in the abdominal area and liver tenderness (both of which may be ignored by the patient)

Interventions

-Surgical resection and liver transplantation are only treatments -TACE Transcatheter arterial chemoembolization -SIRT Selective Internal Radiation Therapy RFA and cryotherapy Palliative approaches

Case Study A 59-year-old patient with a history of alcohol abuse spanning 15 years has been diagnosed with cirrhosis. The patient will be undergoing abdominal paracentesis today. Which assessment finding alerts the nurse that the paracentesis has been successful? A.Decrease in post-procedure weight B.No residual obtained during procedure C.Substantial decrease in blood pressure D.Immediate sensation of a need to urinate

A.Decrease in post-procedure weight

Which does the nurse recognize as the primary reason for a higher incidence of liver cancer in the United States? A.Incidence of hepatitis C B.Incidence of HIV infection C.Incidence of illicit drug use D.Incidence of hepatitis A

A.Incidence of hepatitis C

2.The nurse is caring for a patient with cirrhosis who has hepatic encephalopathy. Which assessment finding should the nurse report to the primary health care provider? A. Fatigue B. Difficulty sleeping C. Seizure D. Disorientation

Answer: C Rationale: Choices A, B, and D are associated with early hepatic encephalopathy. However, seizures occur later and indicate that the complication is progressing. Therefore, Choice C is the most concerning and should be reported to the primary health care provider.

The nurse is caring for a client diagnosed with hepatitis A. Which transmission-based precautions are required when providing care for this client? Select all that apply. A. Place client in a private room. B. Wear a mask when handling patient bedpan. C. Wear gloves when touching the client. D. Wear a gown when providing personal care to this patient. E. Wear eye goggles when providing care.

Answer: D Rationale: Hepatitis A is transmitted via the fecal-oral route. Therefore, the nurse needs to use gloves and a gown when providing care to the client and having contact with the client's stool Choice D). Gloves are not needed to touch the client unless the nurse is cleaning after the client has a stool (Choice C). A mask and googles are not needed because hepatitis of any type is not transmitted as an airborne or droplet disease (Choice B and E). Therefore, a private room is not necessary (Choice A).

The nurse is caring for a client who is diagnosed with cirrhosis. Which serum laboratory value(s) will the nurse expect to be abnormal? Select all that apply. A. Prothrombin time B. Serum bilirubin C. Albumin D. Aspartate aminotransferase (AST) E. Lactate dehydrogenase (LDH) F. Acid phosphatase

Answers: A, B, C, D, E Rationales: Acid phosphatase is not usually affected by liver disease (Choice F). However, serum liver enzymes including AST and LDH are elevated (Choices D and E). Serum bilirubin increase due to the inability of the liver to excrete bile (Choice B). Prothrombin time is prolonged because the diseased liver decreases prothrombin production (Choice A). Serum albumin decreases due to the inability of the diseased liver to produce it (Choice C).

1.A client is receiving adefovir for management of hepatitis B. What health teaching will the nurse provide for the client about this drug? Select all that apply. A. "Avoid places with crowds and individuals who have infection." B. "Report increased bruising to your doctor because the drug can cause bleeding." C. "Get your lab work done regularly because the drug can affect your kidneys." D. "Be careful and avoid falls because the drug can cause fractures." E. "Follow up with the dietitian to ensure that you adhere to your special diet."

Answers: A, C Rationales: Adefovir is an immune modulating drug and therefore can weaken a client's immune system. Therefore, teaching the client to avoid sources of infection is a correct response (Choice A). Almost all immune modulating drugs are excreted via the kidneys and kidney function may be impaired. Regular follow-up with lab work for monitor renal function is essential (Choice C). The other choices are not associated with this medication.

The nurse is caring for a client in end-stage liver failure. Which interventions should implemented when observing for hepatic encephalopathy? Select all that apply. A. Assess the client's neurologic status as prescribed. B. Monitor the client's hemoglobin and hematocrit levels. C. Monitor the client's serum ammonia level. D. Monitor the client's electrolyte values daily. E. Prepare to insert an esophageal balloon tamponade tube. F. Make sure the client's fingernails are short.

Answers: A, C Rationales: The client experiencing encephalopathy has chronic confusion and other mental status changes caused by increased ammonia levels. Therefore, monitoring the serum ammonia levels and the client's neurologic status during treatment can help determine the effectiveness of the treatment plan (Choices A and C). Monitoring electrolytes is appropriate for patients who have ascites (Choice D). Preparing to insert an esophageal tamponade tube and monitoring the client's hemoglobin and hematocrit are interventions for clients experiencing bleeding varices (Choices B and E). Choice F is appropriate to prevent tissue damage when clients have pruritus as a result of jaundice.

Case Study pt 3 When a complete assessment of this patient is performed, what other signs and symptoms does the nurse expect? (Select all that apply.) A.Muscle twitching B.Dry skin with rash C.Personality changes D.Peripheral dependent edema E.Ecchymosis, spider angiomas

B.Dry skin with rash D.Peripheral dependent edema E.Ecchymosis, spider angiomas

Case Study pt 2 The patient's assessment reveals yellowish coloration of skin and sclerae. Which laboratory values does the nurse anticipate? A.Increased urine bilirubin, decreased direct bilirubin B.Increased direct bilirubin, increased indirect bilirubin C.Decreased direct bilirubin, increased indirect bilirubin D.Increased direct bilirubin, decreased indirect bilirubin

B.Increased direct bilirubin, increased indirect bilirubin

What is the priority nursing intervention in the management of a patient with decompensated cirrhosis? A.Limiting protein intake B.Managing nausea and vomiting C.Monitoring fluid intake and output D.Elevating the head of bed >30 degrees

B.Managing nausea and vomiting

Case Study pt 4 The patient tells the nurse that once he is discharged to home, he has no intention to stop drinking alcohol. What is the appropriate nursing response? A."Why do you continue to drink?" B."It's your choice to drink or not to drink." C."Does it frighten you to consider quitting?" D."If you continue to drink, you are going to die."

C."Does it frighten you to consider quitting?"

Cellular Regulation Concept : What is Cirrhosis?

Characterized by widespread fibrotic (scarred) bands of connective tissue This changed the liver's normal makeup and its associated cellular regulation. Inflammation destroys hepatocytes. Liver become nodular; blood and lymph flow are impaired.

Cellular Regulation Concept Exemplar: Cirrhosis (cont.)

Compensated versus decompensated Ø+ no symptoms & + with dysfunction Complications --Portal hypertension *persistent increase in pressure within the portal vein *Blood flow backs into the spleen, causing splenomegaly (spleen enlargement). * can result in ascites --Ascites and esophageal varices * the collection of free fluid within the peritoneal cavity caused by increased hydrostatic pressure from portal hypertension *Esophageal varices occur when fragile, thin-walled esophageal veins become distended and tortuous from increased pressure. Tx: *Give patient Packed RBC then platelets+plasma Upper endoscopy and use probes to cauterize --Coagulation defects * In patients with cirrhosis, the production of bile in the liver is decreased. This prevents the absorption of fat-soluble vitamins (e.g., vitamin K). Without vitamin K, clotting factors II, VII, IX, and X are not produced in sufficient quantities, and the patient is susceptible to bleeding and easy bruising --Jaundice --PSE with hepatic coma •Portal systemic encephalopathy * cognitive syndrome that results from liver failure and cirrhosis --Spontaneous bacterial peritonitis *may be the result of low concentrations of proteins; proteins normally provide some protection against bacteria.

Health Promotion and Maintenance

Vaccines for HAV and HBV HAV-specific recommendations ØProper handwashing (especially after handling shellfish) ØAvoid contaminated food or water.

Which assessment finding requires immediate nursing intervention in a patient with severe ascites? A.Confusion B.Temperature 38.2º C C.Tachycardia, rate 110 beats/min D.Shallow respirations, rate 32 breaths/min

D.Shallow respirations, rate 32 breaths/min

Liver Transplantation

For patients with end-stage liver disease or acute liver failure Transplantation considerations Transplantation complications Interventions include addressing the major psychosocial impact of transplantation.

Incidence and Prevalence

HAV and HBV are declining due to vaccination. HCV most common—no vaccine

Hepatitis

Viral hepatitis Toxic and drug-induced hepatitis Classification ØHA and HE ØHBV ØHCV ØHDV or Delta hepatitis

Cirrhosis Etiology and Genetic Risk

Hepatitis C—leading cause of liver disease, liver cancer, and liver-related death Hepatitis B and D—most common cause worldwide NAFLD (nonalcoholic fatty liver disease) is associated with aging, obesity, diabetes mellitus type 2, and metabolic syndrome Alcohol use—excessive and prolonged

Care Coordination and Transition Management

Home care management varies depending on type of hepatitis. Education regarding infection control is important.

Assessment Labs

Laboratory assessment ØLiver enzymes ØBlood tests specific to hepatitis type Other diagnostic assessment ØLiver biopsy

Evaluation: Reflecting

Maintain nutritional status adequate for body requirements. Report increasing energy levels as the liver rests. Remain infection-free.

Planning and Implementation

Managing fluid volume Preventing or managing hemorrhage (see next slide) Preventing or managing hepatic encephalopathy

Late-Stage Cirrhosis

Monitor for asterixis —a coarse tremor characterized by rapid, nonrhythmic extensions and flexions in the wrists and fingers (hand flapping).

Liver Trauma

Most common organ injured during abdominal trauma Observe for early signs of hypovolemic shock. May require enhanced critical care monitoring, surgery, blood replacement, volume infusion

Fatty Liver (Steatosis)

NAFLD versus NASH ALT/AST, MRI, US, nuclear medicine are used to diagnose Interventions include weight loss, glucose control, lipid-lowering agents.

Assessment

Physical assessment/signs and symptoms ØAbdominal pain ØChanges in skin or sclera (icterus) ØArthralgia (joint pain) or myalgia (muscle pain) ØDiarrhea/constipation ØChanges in color of urine or stool ØFever ØLethargy ØMalaise ØNausea/vomiting ØPruritus (itching)

Cancer of the Liver

Primary versus metastatic tumors One of the most fatal types of cancer Cirrhosis increases risk

Planning and Implementation: Responding

Promoting nutrition Addressing fatigue Reducing the potential for infection

Analysis: Interpreting

Weight loss due to complications associated with inflammation of the liver Fatigue due to decreased metabolic energy production Potential for infection related to state of immunocompromise

Assessment: Noticing PhysicalAssessment—esophageal varices

hepatomegaly (liver enlargement) occurs in many cases of early cirrhosis. Splenomegaly is common in nonalcoholic causes of cirrhosis.

Laboratory assessment:

ØAST, ALT, LDH ØAlkaline phosphatase ØGGT •enzyme found in many of your body's tissues and organs, including your liver. ØSerum protein, albumin Imaging assessment Imaging ØAbdominal x-rays ØCT, MRI Other diagnostic assessment ØLiver US EGD(esophagogastroduodenoscopy) ERCP (endoscopic retrograde cholangiopancreatography)

Overall concerns

ØFluid overload due to third spacing of abdominal and peripheral fluid ØPotential for hemorrhage due to portal hypertension ØPotential for hepatic encephalopathy due to shunting of portal venous blood and/or increased serum ammonia levels

Types of Liver Cirrhosis depending on the cause of the disease

• Postnecrotic cirrhosis (caused by viral hepatitis [especially hepatitis C] and certain drugs or other toxins) • Laennec's or alcoholic cirrhosis (caused by chronic alcoholism) • Biliary cirrhosis (also called cholestatic; caused by chronic biliary obstruction or autoimmune disease)