Care of Patients With Liver Problems

Tenofovir (Viread):

p. 1207

Other Liver Concerns:

- Fatty liver (steatosis) high risks those with obesity, DM, high lipids, alcohol abuse. P 1208 - Hepatic abscess - Liver trauma - look for RUQ pain, guarding of abdomen, Kehr's sign (deep breathing>abd pain>right shoulder p1208), hypovolemia. Suspect liver hemorrhage first before shock Other Liver Disorders: - Non-Viral Hepatitis - Toxic Hepatitis - Drug-Induced Hepatitis - Fulminant Hepatic Failure

Cirrhosis Assessment Notes:

*- When a client has bruising across the lower abdomen post trauma, the nurse first assess for abdominal guarding or rigidity.* *- When assessing arterixis, instruct the client to extend an arm, flex the wrist upward and extend the fingers.* Hepatic encephalopathy or portal systemic encephalopathy (PSE) (Ignatavicius et al. 2016. p1193) Constructional Apraxia Progressive Hepatic Encephalopathy Deterioration of Handwriting & Inability to draw a simple Star figure Hepatocellular & Obstructive Jaundice Signs & Symptoms: - Hepatocellular, may appear mildly or severely ill, lack of appetite, nausea, weight loss, malaise, fatigue, weakness - Headache, chills, and fever if infectious in origin, Obstructive S/S: dark orange-brown urine and light clay-colored stools, dyspepsia and intolerance of fats, impaired digestion, pruritus Portal Hypertension: Obstructed blood flow through the liver results in increased pressure throughout the portal venous system Results in: ascites, esophageal varices; Enlarged spleen can cause thrombocytopenia

Hepatitis C-D-E

*Hepatitis C (HCV):* Transmitted by blood and sexual contact, including needle sticks and sharing of needles, parenterally, occurs year round, any age group Risk Factors: - Incubation period is variable, 5-10 weeks - Symptoms are usually mild Chronic carrier state frequently occurs Testing: anti-HCV (antibody to HCV, measured to detec chronic states of hep C Management: Prevention: strict handwashing, needle precautions, screening of blood donors - Measures to reduce spread of infection as with hepatitis B - Alcohol encourages the progression of the disease, so alcohol and medications that affect the liver should be avoided Antiviral agents: interferon and ribavirin (Rebetol) Complications: cause of 1/3 of cases of liver cancer and the most common reason for liver transplant , chronic liver disease *Hepatitis D (HDV- Delta Hepatitis):* - Only persons with hepatitis B are at risk for hepatitis D - Transmission is through blood and sexual contact - Symptoms and treatment are similar to hepatitis B but more likely to develop fulminant liver failure and chronic active hepatitis and cirrhosis Testing: Serological hepatitis D antigen (HDAg) in the early and later stages Complications: chronic liver disease, fulminant hepatitis Prevention: since HDV coexist with HBV, precautions are the same *Hepatitis E (HEV):* - Transmitted by fecal-oral route; water borne virus, contaminated food - Incubation period 15-65 days (2-9 weeks) - Resembles hepatitis A and is self-limited with an abrupt onset - No chronic form - Prevalent in areas with inadequate sewage disposal, communal bathing areas like rivers - Usually mild infection except for pregnant women in the 3rd trimester (high mortality rate) - Risk factors same as HAV, travelers to countries with high incidences (India, Burma,Afghanistan, Algeria, Mexico) Testing: IgM and IgG antibodies to hepatitis E (anti-HEV) Complications: high mortality rate in pregnant women, fetal demise Prevention: strict hand washing, treatment of water and sanitation measures

Diet for Patients with Liver Problems:

- Consume a moderate or a low-protein diet - Decrease alcohol, and lower sodium

Esophageal Varices:

- Esophageal varices caused by cirrhosis. All patients with cirrhosis must be screened for eso varices (EV) before they bleed which is an emergency. Propranolol (Inderal) or any nonselective beta blocker maybe prescribed. An endoscopic variceal ligation mey be performed. Bleeding of Esophageal Varices Pg. 1200: - Occur when fragile esophageal veins become distended from increased pressure, life threatening, medical emergency. Caused by lifting, vigorous exercise, maybe spontaneous, chest trauma, dry food, increase in abdominal or chest pressure. - Occurs in about 1/3 of patients with cirrhosis and varices First bleeding episode has a mortality of 30%-50% Manifestations include: - Hematemesis (vomiting blood) - Melena (black, tarry stools) - General deterioration - Shock - Patients with cirrhosis should undergo screening endoscopy every 2 years. Treatment of Bleeding Varices: - Treatment of shock - Oxygen - IV fluids; electrolytes; and volume expanders - Blood and blood products - Vasopressin, somatostatin, octreotide to decrease bleeding - Nitroglycerin may be used in combination with vasopressin to reduce coronary vasoconstriction - Propranolol and nadolol to decrease portal pressure; used in combination with other treatment - Balloon TamponadeSengstaken-Blakemore Tube - Endoscopic Sclerotherapy - Esophageal Banding - Portal Scleropathy Bleeding Esophageal Varices: - Nursing Management - Monitor patient condition frequently, including emotional responses and cognitive status. - Monitor for associated complications such as hepatic encephalopathy resulting from blood breakdown in the GI tract, and delirium related to alcohol withdrawal. - Monitor ammonia level in clients with cirrhosis to detect complications of the bleeding episode. - Monitor treatments including tube care and GI suction. - Oral care - Quiet calm environment and reassuring manner - Implement measures to reduce anxiety and agitation - Teaching and support of patient and Sengstaken-Blakemore tube: - In place for the emergency treatment of hemorrhage from esophageal varices. The tube has three openings for (1) gastric aspiration, (2) inflating the esophageal balloon, and (3) inflating the gastric balloon. The esophageal balloon is inflated to a pressure of 20 to 40 mm Hg (monitored by attachment to a gauge or a sphygmomanometer) that compresses the esophageal veins. The gastric balloon, inflated with 250 cc of air, applies pressure to the fundal veins when slight traction is applied.

Nursing Diagnosis Cirrhosis of the Liver: Pg. 1197

- Excess Fluid Volume related to third spacing of abdominal and peripheral fluid (Bile production in the liver helps in the absorption of vitamin K needed for coagulation, thus if reduced, causes bleeding) - Potential for hemorrhage due to portal hypertension* - Potential for *hepatic encephalopathy* due to shunting of portal venous blood/and or increased serum ammonia level - Activity intolerance - Imbalanced nutrition

Cirrhosis of the Liver:

- Extensive, irreverisble scarring, inflammation and necrosis Types: - Postnecrotic - Laennec's - Chronic Alcoholism - Biliary Causes: - Chronic Alcoholism - Chronic Viral Hepatitis - Metabolic Genetic Diseases - Autoimmune Hepatitis - Non-Alcoholic Steatohepatitis (NASH) - Gallbladder Disease - Steatohepatitis (Fatty Liver) - Drugs/Chemical Toxins

Hepatitis A (HAV):

- Formerly known as viral hepatitis - Fecal-oral transmission, person to person, parenteral, contaminated fruits, vegetables, or uncooked shellfish, water or milk, poorly washed utensils Spread primarily by poor hygiene; hand-to-mouth contact, close contact, or through food and fluids - Incubation: 15-50 days (2-7 weeks); infectious period 2-3 weeks before and 1 week after development of jaundice. - Illness may last 4-8 weeks - Permanent immunity to HAV is present when lab results show Risk factors: common with young children, institutionalized individuals, health care personnel - Mortality is 0.5% for younger than age 40 and 1% -2% for those over age 40 Manifestations: mild flu-like symptoms, low-grade fever, anorexia, later jaundice and dark urine, indigestion and epigastric distress, enlargement of liver and spleen - Anti-HAV antibody in serum after symptoms appear Prevention: Family members living with an infected client (HepA) should receive post-exposure prophylaxis (immune globulin (Ig) within 14 days post exposure). Receive HAC vaccine before travelling to Mexico or the Caribbean. - An individual who works in a day care center must be taught that it is important to be vaccinated with Vaqta or Havrix. Proper handwashing, specially after handling shellfish.

Ascites:

- Free fluid in peritoneal cavity Etiology: Pg. 1193, 1196 - Portal hypertension resulting in increased capillary- pressure and obstruction of venous blood flow - Vasodilatation of splanchnic circulation (blood flow to the major abdominal organs) - Changes in the ability to metabolize aldosterone, increasing fluid retention *- Decreased synthesis of albumin, decreasing serum osmotic pressure* - Movement of albumin into the peritoneal cavity Assessment: - Record abdominal girth and weight daily. Measure abdominal girth with patient lying in supine position. - Patient may have striae, distended veins, and umbilical hernia - Assess for fluid in abdominal cavity by percussion for shifting dullness or by fluid wave - Monitor for potential fluid and electrolyte imbalances Assessing for Abdominal Fluid Wave: Treatment of Ascites - Low-sodium diet for control of fluid accumulation in the abd cavity, diuretics, bed rest, paracentesis, administration of salt-poor albumin, transjugular intrahepatic portosystemic shunt (TIPS), paracentesis

Home Care Instructions for the Client with Hepatitis:

- Hand washing - strict and frequent. - Do not share bathrooms or personal items -strict personal hygiene (Individual washcloths, towels, toothbrushes, razors, clippers) - Do not prepare food for others. Use own drinking and eating utensils. - Avoid alcohol and over-the-counter medications, particularly acetaminophen (Tylenol) and sedatives, because these medications are hepatotoxic and other medications unless prescribed - Increase activity gradually to prevent fatigue; increase intake of carbohydrates for energy, PRO for healing. - Increase activity gradually to prevent fatigue. - Consume small, frequent meals - Do NOT donate blood. - May maintain normal contact with persons as long as proper personal hygiene is maintained. - Close personal contact such as kissing should be discouraged until hepatitis B surface antigen test results are negative. - Avoid sexual activity until hepatitis B surface antigen results are negative. - Carry a Medic-Alert card noting the date of hepatitis onset. - Inform other health professionals, such as medical or dental personnel, of the onset of hepatitis. - Follow-up appointments with the health care provider.

Anatomy & Physiology Review of the Liver:

- Largest gland of the body, upper right abdomen - Very vascular organ; receives blood from GI tract via the portal vein and from the hepatic artery - receives a third of cardiac output - Performs > 400 functions Can severely affect: digestion, nutrition, metabolism

Cirrhosis Acute & Chronic S&S: Pg. 1195

- Massive ascites - orthopnea , measure abdominal girth - Umbilicus protrusion, enlarged spleen - Caput medusae (dilated abdominal veins); - Hepatomegaly (liver enlargement; RUQ of abdomen) *- DAILY WEIGHTS is the most reliable indicator of fluid retention* - Assess nasogastric drainage, nausea, vomitus, and stool for presence of blood, abdominal pains - Fetor hepaticus (breath odor) - Amenorrhea. For men gynecomastia, testicular atrophy, impotence - Gynecomastia, testicular atrophy, impotence - Bruising, petechiae, itching, dry skin, spider angioma - Neurologic changes, hepatic encephalopathy or PSE * *- Asterixis (liver flap) stage II* - Constructional apraxia* - Portal hypertension effects

Hepatitis B (HBV)

- N on-seasonal, all ages affected, major cause of cirrhosis and liver cancer Risk factors: IV drug users, long term hemodialysis clients, health care personnel, firefighters/first responders, unprotected sex, gay's/lesbians Transmission: blood and body fluids, infected blood products, saliva, semen, contaminated needles, sexual contact, parenteral, blood and body fluids contact at birth, perinatal period Incubation period: 4-24 weeks (1-6 months) Testing: presence in the blood of hep B antigen-antibody systems = hepatitis B surface antigen (HBsAg) - normally level declines and disappears after acute episode, if still present after 6 months = carrier state or chronic hep. - Presence of ANTIBODIES to hepatitis B surface antigen (anti-HBs) indicates recovery and immunity to hepatitis B Complications: fulminant hepatitis, chronic liver disease, cirrhosis, primary hepatocellular carcinoma Management of Hepatitis B: - Prevention vaccine (series of 3) - Good hand washing, safe water, and proper sewage disposal - Vaccine e.g. Havrix; Vaqta (also for HAV prevention) - Immunoglobulin for contacts to provide passive immunity - Bed rest during acute stage - Nutritional support - Medications for chronic hepatitis type B include: alpha interferon and antiviral agents: Tenofovir (Viread), entecavir (Baraclude), lamivudine (Epivir); adefovir dipivoxil (Hepsera); tenovovir (Viread) p 1207 - Report cases to the health department Prevention: 1.Strict hand washing 2.Screening blood donors 3.Testing of all pregnant women 4.Needle precautions 5.Avoiding intimate sexual contact if test for hepatitis B surface antigen (HBsAg) is positive. 6.Hepatitis B vaccine: Engerix-B (adult), Recombivax HB (pediatric); there is also an adult vaccine that protects against hepatitis A and B known as Twinrix. 7.Hepatitis B immune globulin is for individuals exposed to HBV through sexual contact or through the percutaneous or transmucosal routes who have never had hepatitis B and have never received hepatitis B vaccine.

Jaundice:

- Result of liver dysfunction such s cirrhosis and hepatitis. - Yellowish discoloration of skin Causes: - Hepatocellular disease, liver cannot effectively excrete bilirubin = increased circulating bilirubin levels. - Intrahepatic obstruction due to scarring, fibrosis, edema of liver bile channels and bile ducts = interferes excretion = Pruritis (itching) S&S: Hepatocellular: may appear mildly or severely ill, lack of appetite, nausea, weight loss, malaise, fatigue, weakness - Headache, chills, and fever if infectious in origin, - Obstructive: dark orange-brown urine and light clay-colored stools, dyspepsia and intolerance of fats, impaired digestion, pruritus

Review of the Liver:

- Section of a Liver Lobule - Liver Structure - Blood from hepatic portal vein and hepatic artery mix in sinusoids - The sinusoids empty into central veins, which send the blood to the hepatic vein and inferior vena cava

Diagnostic Studies for Cirrhosis:

- Ultrasonography (First ordered to confirm liver disease, and elevated liver function tests will order U/S) - EGD (Esophagogastroduodenoscopy) - ERCP (Endoscopic retrograde chloangiopancreatography) - CT - MRI - Liver Biopsy (Post liver biopsy, as a priority, the nurse must assess the clients S&S of bleeding and hypovolemia) - Radiographic tests done to detect hepatomegaly, biliary tract obstruction, involvement of surrounding organs

Liver Transplantation:

- Used in the treatment of end-stage liver disease, primary malignant neoplasm of the liver - Donor livers obtained primarily from trauma victims who have not had liver damage - Donor liver transported to the surgery center in a cooled saline solution that preserves the organ for up to 8 hours - Nursing Care of the Patient - Undergoing a Liver - Transplantation - Preoperative nursing interventions -Postoperative nursing interventions - Patient teaching Complications: p1210 table 58-5 - Acute or chronic graft rejection (watch for fever post-op) - Infection (cyclosporin, immunosuppressant drug has been effective ) - Hemorrhage - Hepatic artery thrombosis - Fluid and electrolyte imbalances - Pulmonary atelectasis - Acute renal failure - Psychological maladjustment Post-Op Complications: Table 58-5; Pg. 1210) Not considered as candidates for liver transplants - Metastatic tumors - Severe respiratory distress - Advanced cardiac disease

A 55-year-old patient with a history of alcohol abuse spanning 10 years has been diagnosed with cirrhosis. The patient will be undergoing abdominal paracentesis on the medical unit today. Which assessment finding would alert 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

Answer: A Weight should decrease as fluid is drained from the abdominal cavity. A substantial decrease in blood pressure can indicate shock. Residual should be obtained during the procedure. The patient should not feel a sensation or need to urinate, because a primary safety measure is to have the patient void right before the procedure to avoid injury to the bladder during the procedure.

Interventions for Cirrhosis of the Liver:

Activity Intolerance: - Rest and supportive measures - Positioning for respiratory efficiency - Oxygen - Planned mild exercise and rest periods - Address nutritional status to improve strength - Measures to prevent hazards of immobility Imbalanced Nutrition: - I&O - Encourage patient to eat - Small frequent meals may be better tolerated - Consider patient preferences - High-calorie diet, take supplements like ensure - Sodium restriction due to ascites, do not use table salt - Protein is modified to patient needs *- Protein is restricted if patient is at risk for encephalopathy* - Supplemental vitamins and minerals, especially B complex, provide water-soluble forms of fat-soluble vitamins if patient has steatorrhea - Lactulose therapy -promotes removal of ammonia in stools Impaired Skin Integrity: - Frequent Position Changes - Gentle Skin Care- Lotion to soothe skin/pruritis - Measures to reduce scratching by the patient Monitor for Complications of Cirrhosis: - PSE - Ascties, Jaundice - Neurologic changes hepatic encephalopathy - Esophageal varices note bleeding/coagulation - Hepatorenal syndrome - portal hypertension (P 1201 interventions) - Monitor ammonia level in clients with cirrhosis to detect complications of the bleeding (coagulation)episode. - Observe for thrombocytopenia when there is splenomegaly. - Paracentesis, when performed, nurse must ask the patient to void, weigh the patient before the procedure, obtain/assess heart rate, - Respiration and blood pressure. As a safety measure, paracentesis is performed using ultrasound - Tunneled ascites drain - p1201-1202. - Some patients discharged with this to drain ascites fluid. Teach how to assess drain and how to remove fluid, do not remove more than 2000 ml of fluid to prevent hypovolemic shock. Risk for Injury: - Measures to prevent falls - Measure to prevent trauma/ Risk for bleeding - Careful evaulation of any injury related to potential risk for bleeding (Prevent cuts and injury; ue electric razor or straight edge razor)

What is a 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. Increased Asian population

Answer: A Rationale: In the United States and worldwide, the incidence of liver cancer is increasing because there is an increase in cases of hepatitis C (HCV). Liver cancer tumors are most often seen in regions of Asia and the Mediterranean area. Worldwide the disease kills about 1 million people each year and affects Vietnamese men more than any other group. Black and Hispanic populations have twice the rate of the disease as Euro-Americans, and older adults are affected more than other age-groups (Rossi et al., 2010).

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

Answer: B Rationale: Decompensated cirrhosis has multiple complications. However, bleeding esophageal varices can present a life-threatening emergency. Preventing nausea and vomiting is an important intervention in the management of esophageal varices. Monitoring protein, fluid balance, and patient positioning are also important interventions in the care of the patient with end-stage liver disease.

The patient's assessment reveals yellowish coloration of skin and sclerae. Which laboratory values would 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

Answer: B When a patient's skin is jaundiced, laboratory values of indirect and direct bilirubin are increased. Urine bilirubin is also increased. Urobilinogen in stool is normal to decreased, but in urine it is normal to increased.

When a complete assessment of this patient is performed, what other manifestations would 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

Answer: B, D, E Personality changes and muscle twitching are findings that may be seen when the patient with cirrhosis develops portal-systemic encephalopathy. Additional manifestations that may be found on assessment include palmar erythema, clubbing of fingernails, and fixed flexion of fingers.

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."

Answer: C Asking the patient about quitting allows him to express his feelings about drinking. Response A demands an answer and is nontherapeutic. Response B does not give recognition to the problem of drinking. Response D gives advice as opposed to listening to the patient's concerns.

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

Answer: D Rationale: Ascites can increase abdominal distention, which interferes with lung expansion and compromises ventilation and oxygenation. Risk for infection, fluid displacement, and confusion are also assessment variables requiring monitoring in a patient with ascites.

Planning Goals for Cirrhosis of the Liver:

Goals may include: - Increased participation in activities - Improvement of nutritional status - Improvement of skin integrity - Decreased potential for injury - Improvement of mental status - Absence of complications - Teachings about drug therapy (Drug therapy may include diuretics to decrease fluid acummulation, electrolytes, antibiotics (trimethoprin-sulfamethoxazole (Bactrim), quinolones (norfloxacin) for peritonitis, analgesics, antipyretics, antiemetics, If discharged, the patient with cirrhosis and family must understand that the client-not take any medicines, including over the counter, unless approved by physician) Lactulose Syrup: For ammonia reduction could cause 2-3 bo23l movements everyday Lasix: Diuretic should be taken during the day so the client can rest during the night - Report any lightheadedness or increased muscle weakness to the physician - Alleviate biliary tract obstruction (physician A stent may be placed in the biliary tract to relieve obstruction. The nurse must provide teachings about endoscopic retrograde cholangiopancreatography ERCP)

Hepatitis Prevalence:

Hep C- US Hep B- Worldwide

Complications of Cirrhosis:

Hepatic Encephalopathy and Coma (PSE): - Also known as portal systemic encephalopathy: A life-threatening complication of liver disease. Complex, cognitive syndrome. May result from the accumulation of ammonia and other toxic metabolites in the blood that goes to the brain due to inability of the liver to convert toxins to a less toxic form. Maybe reversible if diagnosed early, may develop slowly, undetected until later stages. Causes: High PRO diet, infection, hypovolemia, hypokalemia, constipation, GI bleed, drugs Manifestations: Sleep, mood, mental status changes/disturbance, speech problems. Later stage: Altered level of consciousness, impaired thinking process, neuromuscular problems, fetor hepaticus (liver breath, sweet, musty odor), stage I-IV s/s Assessment: - Serum ammonia levels and gamma-aminobutyric acid = GABA, EEG, changes in LOC, assess neurological status frequently, potential seizures, fetor hepaticus, monitor fluid, electrolyte levels - The asterixis is a term doctor used to describe a neuromuscular disorder that involves involuntary rhythmic interruptions appearance of a muscular contraction voluntary. Appropriately called tremor one or liver flap was first described in 1949 in patients with liver failure severe and encephalopathy . - The exact causes are unknown but presumably is produced regarding a deficiency in the metabolism of ammonium . 3 Pathologies: The sign is observed in encephalopathies and secondary to sepsis , the hepatic coma , cirrhosis decompensated disorders, electrolyte , hypoxia and others. Occasionally seen in patients with toxicity carbon dioxide and in Wilson 's disease . LABS; other diagnostics: Hepatorenal Syndrome (HRS); hepato-pulmonary syndrome - May cause death Manifestations: - <500 ml urine/24 hours, elevated BUN and creatinine levels with low urine sodium excretion, increased urine osmolarity. - Often occurs after GI bleed, PSE For those with hepato-pulmonary syndrome, assess for crackles in the lungs, administer pulmonary support *notes, p 1199 Acute spontaneous bacterial peritonitis (SBP) - usually in advanced liver disease

Hepatitis:

Viral Hepatitis: A, B, C, D, E - Transmission Mode Onset: Spread - Incubation, infectious period, duration, risk factors, manifestations - Lab tests - Nonsurgical management - Follow-up care - Plan of care for home

Cirrhosis Assessment:

History: - Age - Gender - Family - Employment History - Exposure to ETOH - Drugs - Chemical toxins - Needle stick injury - Sexual history and orientation - Episodes of jaundice or hepatitis (which leads to cirrhosis) - Biliary tract disorders - Surgery - Blood transfusions - Obesity - Viral infections - Lipid profile - Autoimmune disorders - Heart failure - Respiratory disorders - Liver injury - Mental status Assess, observe, inspect for signs and symptoms related to the disease including indicators for bleeding, fluid volume changes, lab data, vital signs.

Interventions for Hepatic Encephalopathy and Coma:

Medical Management: - Eliminate precipitating cause - Lactulose to reduce serum ammonia levels - IV glucose to minimize protein catabolism - Protein restriction (reduces ammonia in the blood) - Reduction of ammonia from GI tract by gastric suction, enemas, oral antibiotics - Discontinue sedatives analgesics and tranquilizers - Monitor for and promptly treat complications and infections

Cancer of the Liver:

Non-surgical management: p 1208 - Underlying cirrhosis, which is prevalent in patients with liver cancer, increases risks of surgery - Major effect of nonsurgical therapy may be palliative - Radiation therapy - selective internal radiation therapy (SIRP) Chemotherapy - chemoembolization (doxorubicin, 5FU, cisplatin, Sorafenib - Percutaneous ethanol injection - Other nonsurgical treatments hepatic artery embolization, (RFA) radio frequency ablation (heat cancer cells and kill them) Hospice end of life care Surgical Management: - Treatment of choice for HCC if confined to one lobe and liver function is adequate - Liver has regenerative capacity Types of surgery: - Lobectomy - Cryosurgery - liquid nitrogen freezes and destroys liver tumor - Liver transplant Cancer of the Liver: - Primary Liver tumors- tumor maker- elevated AFP (Alpha-fetoprotein - Few cancers originate in the liver - Usually associated with hepatitis B and C - Hepatocellular carcinoma (HCC) - Liver metastases - Liver is a frequent site of metastatic cancer Manifestations: - Pain, a dull continuous ache in RUQ, epigastrium, or back - Weight loss, loss of strength, anorexia, anemia may occur - Jaundice if bile ducts occluded, ascites if obstructed portal veins

Liver Function Studies: Table 58-3 Pg. 1197-1199

Serum Enzymes: - AST (Increased) - ALT (Increased) - LDH (Increased) - Alk Phosphotase GGT (Increased) Serum Protein: - Total PRO - Albumin - Globulin Bilirubin Pigment Studies: - Serum & Urine Bilirubin Prothrombin Time & INR: - Coagulation & Bleeding Times Serum Ammonia: - Increased (For hepatic encephalopathy it is initially decreased then increased) - Cholesterol - For clients with ascites and edema, also assess for serum albumin (low), serum globulin (high), sodium. - Look for thrombocytopenia when with splenomegaly. - Hepatic cell destruction will show elevated AST, ALT, LDH and INR, bilirubin - Hypovolemia high BUN, High HCT, low protein may indicate hypovolemia.

Adefovir Dipivoxil (Hepsera):

p. 1207

Entecavir (Baraclude):

p. 1207

Lamivudine (Epivir):

p. 1207