Chapter 43- Hepatic Disorders (Liver Cancer)

What are essential nursing interventions for a pt. with a hepatic artery catheter?

1) ENSURE catheter stays in place 2) assess vital signs 3) s/s of infections, etc.

Treatments for liver cancer include which of the following? SATA A) Hepatic artery embolization- supplies blood to tumor to block blood flow B) Chemotherapy C) Radiation therapy D) Surgical resection- if cancer only involves one lobe of the liver, surgical removal is indicated. Can result in survival rate of up to 5 years. Most tumors are nonresectable E) Liver transplantation - option for clients who have small primary tumors F) Ablation procedures- used to destroy cancerous cells G) Blood transfusions

A) Hepatic artery embolization- supplies blood to tumor to block blood flow B) Chemotherapy C) Radiation therapy D) Surgical resection- if cancer only involves one lobe of the liver, surgical removal is indicated. Can result in survival rate of up to 5 years. Most tumors are nonresectable E) Liver transplantation - option for clients who have small primary tumors F) Ablation procedures- used to destroy cancerous cells

A patient with end-stage liver disease has developed hypervolemia. What nursing interventions would be most appropriate when addressing the patient's fluid volume excess? Select all that apply. A. Administering diuretics B. Administering calcium channel blockers C. Implementing fluid restrictions D. Implementing a 1500 kcal/day restriction E. Enhancing patient positioning

A. Administering diuretics B. Administering calcium channel blockers E. Enhancing patient positioning Rationale: Administering diuretics, implementing fluid restrictions, and enhancing patient positioning can optimize the management of fluid volume excess. Calcium channel blockers and calorie restriction do not address this problem.

A patient's physician has ordered a liver panel in response to the patient's development of jaundice. When reviewing the results of this laboratory testing, the nurse should expect to review what blood tests? Select all that apply. A. Alanine aminotransferase (ALT) B. C-reactive protein (CRP) C. Gamma-glutamyl transferase (GGT) D. Aspartate aminotransferase (AST) E. B-type natriuretic peptide (BNP)

A. Alanine aminotransferase (ALT) B. C-reactive protein (CRP) D. Aspartate aminotransferase (AST) Rationale: Liver function testing includes GGT, ALT, and AST. CRP addresses the presence of generalized inflammation and BNP is relevant to heart failure; neither is included in a liver panel.

A 55-year-old female patient with hepatocellular carcinoma (HCC) is undergoing radiofrequency ablation. The nurse should recognize what goal of this treatment? A. Destruction of the patient's liver tumor B. Restoration of portal vein patency C. Destruction of a liver abscess D. Reversal of metastasis

A. Destruction of the patient's liver tumor Rationale: Using radiofrequency ablation, a tumor up to 5 cm in size can be destroyed in one treatment session. This technique does not address circulatory function or abscess formation. It does not allow for the reversal of metastasis.

A nurse is caring for a patient with cancer of the liver whose condition has required the insertion of a percutaneous biliary drainage system. The nurse's most recent assessment reveals the presence of dark green fluid in the collection container. What is the nurse's best response to this assessment finding? A. Document the presence of normal bile output. B. Irrigate the drainage system with normal saline as ordered. C. Aspirate a sample of the drainage for culture. D. Promptly report this assessment finding to the primary care provider.

A. Document the presence of normal bile output. Rationale: Bile is usually a dark green or brownish-yellow color, so this would constitute an expected assessment finding, with no other action necessary.

A triage nurse in the emergency department is assessing a patient who presented with complaints of general malaise. Assessment reveals the presence of jaundice and increased abdominal girth. What assessment question best addresses the possible etiology of this patient's presentation? A. How many alcoholic drinks do you typically consume in a week? B. To the best of your knowledge, are your immunizations up to date? C. Have you ever worked in an occupation where you might have been exposed to toxins? D. Has anyone in your family ever experienced symptoms similar to yours?

A. How many alcoholic drinks do you typically consume in a week? Rationale: Signs or symptoms of hepatic dysfunction indicate a need to assess for alcohol use. Immunization status, occupational risks, and family history are also relevant considerations, but alcohol use is a more common etiologic factor in liver disease.

A nurse on a solid organ transplant unit is planning the care of a patient who will soon be admitted upon immediate recovery following liver transplantation. What aspect of nursing care is the nurse's priority? A. Implementation of infection-control measures B. Close monitoring of skin integrity and color C. Frequent assessment of the patient's psychosocial status D. Administration of antiretroviral medications

A. Implementation of infection-control measures Rationale: Infection control is paramount following liver transplantation. This is a priority over skin integrity and psychosocial status, even though these are valid areas of assessment and intervention. Antiretrovirals are not indicated.

A patient with a liver mass is undergoing a percutaneous liver biopsy. What action should the nurse perform when assisting with this procedure? A. Position the patient on the right side with a pillow under the costal margin after the procedure B. Administer 1 unit of albumin 90 minutes before the procedure as ordered C. Administer at least 1 unit of packed red blood cells as ordered the day before the scheduled procedure D. Confirm that the patient's electrolyte levels have been assessed prior to the procedure

A. Position the patient on the right side with a pillow under the costal margin after the procedure. Rationale: Immediately after a percutaneous liver biopsy, assist the patient to turn onto the right side and place a pillow under the costal margin. Prior administration of albumin or PRBC's is unnecessary. Coagulation tests should be performed, but electrolyte analysis is not necessary.

A patient is being discharged after a liver transplant and the nurse is performing discharge education. When planning the patient's continuing care, the nurse should prioritize which of the following risk diagnoses? A. Risk for infection related to immunosuppressant use B. Risk for injury related to decreased hemostasis C. Risk for unstable blood glucose related to impaired gluconeogensis D. Risk for contamination related to accumulation of ammonia

A. Risk for infection related to immunosuppressant use Rationale: Infection is the leading cause of death after liver transplantation. Pulmonary and fungal infections are common; susceptibility to infection is increased by the immunosuppressive therapy that is needed to prevent rejection. This risk exceeds the threats of injury and unstable blood glucose. The diagnosis of risk for contamination related to environmental toxin exposure.

Signs/Symptoms of liver cancer include: SATA A) Dull pain in right upper quadrant; epigastric or back pain B) Loss of appetite C) Weakness/fatigue D) Weight loss/anorexia E) Loss of strength F) Enlarged liver upon palpation G) Jaundice H) Ascites I) Edema J) Bleeding/bruising- anemia K) Pruritis L) Encephalopathy M) Increased thirst

ALL BUT M A) Dull pain in right upper quadrant; epigastric or back pain B) Loss of appetite C) Weakness/fatigue D) Weight loss/anorexia E) Loss of strength F) Enlarged liver upon palpation G) Jaundice H) Ascites I) Edema J) Bleeding/bruising- anemia K) Pruritis L) Encephalopathy

Risk Factors for liver cancer include which of the following? SATA A) Older age B) Cirrhosis C) Chronic hepatitis B/C infection D) Alcohol-related liver disease E) Hemochromatosis (inability to breakdown iron) F) Male gender G) Tobacco use/smoking H) Mediterranean/Asian (particularly Vietnamese heritage) I) African American/Hispanic clients J) History of STIS

ALL BUT i!! A) Older age B) Cirrhosis C) Chronic hepatitis B/C infection D) Alcohol-related liver disease E) Hemochromatosis (inability to breakdown iron) F) Male gender G) Tobacco use/smoking H) Mediterranean/Asian (particularly Vietnamese heritage) I) African American/Hispanic clients

A nurse is caring for a client 24 hr following a liver lobectomy for hepatocellular carcinoma. Which of the following laboratory reports should the nurse monitor? A) Urine specific gravity B) Blood glucose C) Serum amylase D) D-dimer

B) Blood glucose For first 24-48 hours after procedure due to decreased glucogenesis and stress to the liver from surgery

A patient has been diagnosed with advanced stage breast cancer and will soon begin aggressive treatment. What assessment findings would most strongly suggest that the patient may have developed liver metastases? A. Persistent fever and cognitive changes B. Abdominal pain and hepatomegaly C. Peripheral edema unresponsive to diuresis D. Spontaneous bleeding and jaundice

B. Abdominal pain and hepatomegaly Rationale: The early manifestations of malignancy of the liver include pain, a continuous dull ache in the right upper quadrant, epigastrium, or back. Weight loss, loss of strength, anorexia, and anemia may also occur. The liver may be enlarged and irregular on palpation. Jaundice is present only if the larger bile ducts are occluded by the pressure of malignant nodules in the hilum of the liver. Fever, cognitive changes, peripheral edema, and bleeding are atypical signs.

A nurse is caring for a patient who has been admitted for the treatment of advanced cirrhosis. What assessment should the nurse prioritize in this patient's plan of care? A. Measurement of abdominal girth and body weight B. Assessment for variceal bleeding C. Assessment for signs and symptoms of jaundice D. Monitoring of results of liver function testing

B. Assessment of variceal bleeding Rationale: Esophageal varices are a major cause of mortality in patients with uncompensated cirrhosis. Consequently, this should be a focus of the nurse's assessments and should be prioritized over the other listed assessments, even though each should be performed.

A patient with cirrhosis has experienced a progressive decline in his health; and liver transplantation is being considered by the interdisciplinary team. How will the patient's prioritization for receiving a donor liver be determined? A. By considering that patient's age and prognosis B. By objectively determining the patient's medical need C. By objectively assessing the patient's willingness to adhere to post-transplantation care D. By systematically ruling out alternative treatment options

B. By objectively determining the patient's medical need Rationale: The patient would undergo a classification of the degree of medical need through an objective determination known as the Model of End-Stage Liver Disease (MELD) classification, which stratifies the level of illness of those awaiting a liver transplant. This algorithm considers multiple variables, not solely age, prognosis, potential for adherence and the rejection of alternative options.

A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurse's most recent assessment reveals subtle changes in the patient's cognition and behavior. What is the nurse's most appropriate response? A. Ensure that the patient's sodium intake does not exceed recommended levels B. Report this finding to the primary care provider due to the possibility of hepatic encephalopathy C. Inform the primary care provider that the patient should be assessed for alcoholic hepatitis. D. Implement interventions aimed at ensuring a calm and therapeutic care environment.

B. Report this finding to the primary care provider due to the possibility of hepatic encephalopathy Rationale: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patient's mental status closely and reports changes so that treatment of encephalopathy can be initiated promptly. This change in status is likely unrelated to sodium intake and would not signal the onset of hepatitis. A supportive care environment is beneficial, but does not address the patient's physiologic deterioration.

A patient with a diagnosis of cirrhosis has developed variceal bleeding and will imminently undergo variceal banding. What psychosocial nursing diagnosis should the nurse most likely prioritize during this phase of the patient's treatment? A. Decisional Conflict B. Deficient Knowledge C. Death Anxiety D. Disturbed Thought Processes

C. Death Anxiety Rationale: The sudden hemorrhage that accompanies variceal bleeding is intensely anxiety-provoking. The nurse must address the patient's likely fear of death, which is a realistic possibility. For most patients, anxiety is likely to be a more acute concern than lack of knowledge or decisional conflict. The patient may or may not experience disturbances in thought processes.

A previously healthy adult's sudden and precipitous decline in health has been attributed to fulminant hepatic failure, and the patient has been admitted to the intensive care unit. The nurse should be aware that the treatment of choice for this patient is what? A. IV administration of immune globulins B. Transfusion of packed red blood cells and fresh-frozen plasma (FFP) C. Liver transplantation D. Lobectomy

C. Liver transplantation Rationale: Liver transplantation carries the highest potential for the resolution of fulminant hepatic failure. This is preferred over other interventions, such as pharmacologic treatments, transfusions, and surgery

Diagnostic testing has revealed that a patient's hepatocellular carcinoma (HCC) is limited to one lobe. The nurse should anticipate that this patient's plan of care will focus on what intervention? A. Cryosurgery B. Liver transplantation C. Lobectomy D. Laser hyperthermia

C. Lobectomy Rationale: Surgical resection is the treatment of choice when HCC is confined to one lobe of the liver and the function of the remaining liver is considered adequate for postoperative recovery. Removal of a lobe of the liver (lobectomy) is the most common surgical procedure for excising a liver tumor. While cryosurgery and liver transplantation are other surgical options for management of liver cancer, these procedures are not performed at the same frequency as a lobectomy. Laser hyperthermia is a nonsurgical treatment for liver cancer.

A nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patient's liver? A. Place hand under the right lower abdominal quadrant and press down lightly with the other hand. B. Place the left hand over the abdomen and behind the left side at the 11th rib. C. Place hand under right lower rib cage and press down lightly with the other hand. D. Hold hand 90 degree to right side of the abdomen and push down firmly.

C. Place hand under right lower rib cage and press down lightly with the other hand. Rationale: To palpate the liver, the examiner places one hand under the right lower rib cage and presses downward with light pressure with the other hand. The liver is not on the left side or in the right lower abdominal quadrant.

A patient with liver disease has developed jaundice; the nurse is collaborating with the patient to develop a nutritional plan. The nurse should prioritize which of the following in the patient's plan? A. Increased potassium intake B. Fluid restriction to 2L per day C. Reduction in sodium intake D. High-protein, low-fat diet

C. Reduction in sodium intake Rationale: Patient with ascites require a sharp reduction in sodium intake. Potassium intake should not be correspondingly increased. There is no need for fluid restriction or increased protein intake.

A nurse is amending a patient's plan of care in light of the fact that the patient has recently developed ascites. What should the nurse include in this patient's care plan? A. Mobilization with assistance at least 4 times daily B. Administration of beta-adrenergic blockers as ordered C. Vitamin B12 injections as ordered D. Administration of diuretics as ordered

D. Administration of diuretics as ordered Rationale: Use of diuretics along with sodium restriction is successful in 90% of patients with ascites. Beta-blockers are not used to treat ascites and bed rest is often more beneficial than increased mobility. Vitamin B23 injections are not necessary.

A patient with liver cancer is being discharged home with a biliary drainage system in place. The nurse should teach the patient's family how to safely perform which of the following actions? A. Aspirating bile from the catheter using a syringe B. Removing the catheter when output is 15 mL in 24 hours C. Instilling antibiotics into the catheter D. Assessing the patency of the drainage catheter

D. Assessing the patency of the drainage catheter Rationale: Families should be taught to provide basic catheter care, including assessment of patency. Antibiotics are not instilled into the catheter and aspiration using a syringe is contraindicated. The family would not independently remove the catheter; this would be done by a member of the care team when deemed necessary.

A patient with liver cancer is being discharged home with a hepatic artery catheter in place. The nurse should be aware that this catheter will facilitate which of the following? A. Continuous monitoring for portal hypertension B. Administration of immunosuppressive drugs during the first weeks after transplantation C. Real-time monitoring of vascular changes in the hepatic system D. Delivery of a continuous chemotherapeutic dose

D. Delivery of a continuous chemotherapeutic dose Rationale: In most cases, the hepatic artery catheter has been inserted surgically and has a prefilled infusion pump that delivers a continuous chemotherapeutic dose until completed. The hepatic artery catheter dose not monitor portal hypertension, deliver immunosuppressive drugs, or monitor vascular changes in the hepatic system

A nurse is caring for a patient with liver failure and is performing an assessment in the knowledge of the patient's increased risk of bleeding. The nurse recognizes that this risk is related to the patient's inability to synthesize prothrombin in the liver. What factor most likely contributes to this loss of function? A. Alterations in glucose metabolism B. Retention of bile salts C. Inadequate production of albumin by hepatocytes D. Inability of the liver to use vitamin K.

D. Inability of the liver to use vitamin K. Rationale: Decreased production of several clotting factors may be partially due to deficient absorption of vitamin K from the GI tract. This probably is caused by the inability of liver cells to use vitamin K to make prothrombin. This bleeding risk is unrelated to the roles of glucose, bile salts, or albumin.

o Catheter used for direct infusion of chemo into the tumor of a patient with liver cancer o Allows for a more direct delivery of chemo, resulting in more effective treatment of tumors in the liver o Systemic adverse effects of chemo are avoided through this delivery method o Watch for evidence of infection at the catheter site, hepatic toxicity (jaundice, liver function tests), and immunosuppression (fatigue, decreased WBCs) ENSURE catheter stays in place: assess vital signs, s/s of infections, etc.

Hepatic Artery Catheter

What type of interventions are required for long-term survival in liver cancer?

Surgical interventions- resection or transplantation

Education in regards to which type of treatment for liver cancer? § Inform client about diagnostic tests that are done to determine if cancer has metastasized- x-ray, MRI, laparoscopy, PET scan. § Monitor for bleeding, and replace fluids and blood as necessary

Transplantation

Prognosis for liver cancer:

Very poor- treatments such as chemo and radiation therapy may prolong survival and improve quality of life by reducing pain/discomfort, their major effect is palliative. Surgical interventions are required for long-term survival: surgical resection or liver transplantation.

Nursing interventions in regards to which type of treatment for liver cancer? o Monitor for hypothermia, bile leak, and hemorrhage o Monitor urine for myoglobinuria o Tunneled abdominal drain- used to remove excess ascetic fluid o Empty drain and maintain the system o Don't remove more than 2,000 mL @ one time to prevent hypovolemic shock

Ablation procedures

A patient who has undergone liver transplantation is ready to be discharged home. Which outcome of health education should the nurse prioritize? A. The patient will obtain measurement of drainage from the T-tube. B. The patient will exercise three times a week. C. The patient will take immunosuppressive agents as required. D. The patient will monitor for signs of liver dysfunction.

C. The patient will take immunosuppressive agents as required. Rationale: The patient is given written and verbal instructions about immunosuppressive agent doses and dosing schedules. The patient is also instructed on steps to follow to ensure that an adequate supply of medication is available so that there is no change of running out of the medication or skipping a dose. Failure to take medications as instructed may precipitate rejection. The nurse would not teach the patient to measure drainage from a T-tube as the patient would;t go home with a T-tube. The nurse may teach the patient about the need to exercise or what the signs of liver dysfunction are, but the nurse would not stress these topics over the immunosuppressive drug regimen.

Nursing interventions in regards to which type of treatment for liver cancer? o Monitor for bleeding

Hepatic artery embolization- supplies blood to tumor to block blood flow