Cirrhosis

(PANCREATITIS) While performing an assessment of a client with acute pancreatitis, a nurse notes the following skin appearance. What should be the nurse's interpretation of this finding? 1. Seepage of blood-stained exudates from the pancreas has occurred. 2. The pancreatitis has caused the stomach to bleed and the blood is now in the interstitial tissue. 3. An intestinal obstruction that has increased vascular pressure has developed due to the pancreatic inflammation. 4. Portal hypertension has developed

ANS; 1 Grey Turner's sign is a bluish flank discoloration. It is caused by the seepage of blood-stained exudates from the pancreas and indicates a severe disease process. Pancreatitis will not cause stomach bleeding or intestinal obstruction. Portal hypertension is related to cirrhosis. ➧ Test-taking Tip: Eliminate options 2, 3, and 4 because these are describing related organs and not the pancreas. Only option 1 addresses the pancreas

A patient with a history of cirrhosis is admitted to the ICU with a diagnosis of bleeding esophageal varices; an attempt to stop the bleeding has been only partially successful. What would the critical care nurse expect the care team to order for this patient? A) Packed red blood cells (PRBCs) B) Vitamin K C) Oral anticoagulants D) Heparin infusion

Ans: A Patients with liver dysfunction may have life-threatening hemorrhage from peptic ulcers or esophageal varices. In these cases, replacement with fresh frozen plasma, PRBCs, and platelets is usually required. Vitamin K may be ordered once the bleeding is stopped, but that is not what is needed to stop the bleeding of the varices. Anticoagulants would exacerbate the patients bleeding.

Which assessment question is priority for the nurse to ask the client diagnosed with end-stage liver failure secondary to alcoholic cirrhosis? 1. "How many years have you been drinking alcohol?" 2. "Have you completed an advance directive?" 3. "When did you have your last alcoholic drink?" 4. "What foods did you eat at your last meal?"

ANS: 3 3. The nurse must know when the client had the last alcoholic drink to be able to determine when and if the client will experience delirium tremens, the physical withdrawal from alcohol.

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 patients 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

ANS: B Esophageal varices are a major cause of mortality in patients with uncompensated cirrhosis. Consequently, this should be a focus of the nurses assessments and should be prioritized over the other listed assessments, even though each should be performed.

A family notices that their father, who has been diagnosed with cirrhosis, has become increasingly irritable and restless. A health-care practitioner orders a protein-restricted diet. A nurse should explain to the client and family that this dietary change will: 1. help to restore their father's liver function. 2. help reduce the amount of ammonia in their father's blood. 3. give their father's liver a chance to rest, since proteins in the diet make the liver work harder. 4. prevent fluid from leaking into their father's abdomen.

ANS 2 ANSWER: 2 When body protein is deaminated, the resulting ammonia is converted to urea by the liver and excreted by the kidney. Liver damage results due to the increase in serum ammonia, which also causes neurological symptoms. Decreasing protein intake will decrease the amount of ammonia formed in the body. Decreasing the protein will not restore the liver function or rest the liver. Decreasing body protein will not decrease ascites.

The client has end-stage liver failure secondary to alcoholic cirrhosis. Which complication indicates the client is at risk for developing hepatic encephalopathy? 1. Gastrointestinal bleeding. 2. Hypoalbuminemia. 3. Splenomegaly. 4. Hyperaldosteronism.

ANS: 1 1. Blood in the intestinal tract is digested as a protein, which increases serum ammonia levels and increases the risk of developing hepatic encephalopathy.

After completing discharge education, a nurse recognizes the need for further teaching when a client, diagnosed with cirrhosis, says: 1. "I know propranolol (Inderal®) has been ordered to decrease my blood pressure." 2. "I plan to stop drinking alcohol." 3. "I am going to work only part-time." 4. "I know furosemide (Lasix®) will help to keep me from developing abdominal swelling."

ANS: 1 Prophylactic treatment with a nonselective beta blocker such as propranolol has been shown to reduce the risk of bleeding from esophageal varices and reduce bleeding-related deaths. Though it does decrease blood pressure, it is not ordered for this purpose. Alcohol intake is a major cause of cirrhosis and must be eliminated from the client's diet. Rest may enable the liver to restore itself and should be encouraged. Furosemide is used in combination with potassium-sparing diuretics to decrease ascites.

A client diagnosed with cirrhosis is scheduled for a transjugular intrahepatic portosystemic shunt (TIPS) placement. A nurse realizes the client does not understand the procedure when the client says: 1. "I hope my abdominal incision heals better after this procedure then it did when I had my appendix out." 2. "This procedure should decrease the risk that I might have another episode of bleeding from my esophagus." 3. "I know the shunt they are placing could become occluded in the future." 4. "This procedure should keep me from getting so much fluid buildup in my abdomen."

ANS: 1 The TIPS is placed through the jugular vein and threaded down to the hepatic vein. There is no need for an abdominal incision. The procedure will decrease pressure in the portal vein and thus decrease the risk of bleeding from esophageal varices. There is a risk that the stent that is placed will become occluded. The shunt will decrease ascites formation.

A nurse is beginning client care and has been assigned to the following four clients. Which client should the nurse plan to assess first? 1. A 50-year-old client who has chronic pancreatitis and is reporting a pain level of 6 out of 10 on a numeric scale 2. A 47-year-old client with esophageal varices who has influenza and has been coughing for the last 30 minutes 3. A 60-year-old client who had an open cholecystectomy 15 hours ago and has been stable through the night 4. A 54-year-old client with cirrhosis and jaundice who is reporting itching

ANS: 2 Bleeding esophageal varices are the most life-threatening complication of cirrhosis. Coughing can precipitate a bleeding episode. The client with a pain rating of 6 out of 10 on a numeric scale and the client reporting itching also need attention, but the pain and itching are not life-threatening concerns. The client who is postcholecystectomy is reported as being stable and could be assessed last. ➧ Test-taking Tip: Use the prioritization criteria: life-threatening concerns must be addressed first; client safety concerns second; and concerns essential to the plan of care third. Use the ABCs (airway, breathing, circulation) to determine priority. Determine if any of the clients are in a life-threatening situation, and select that option.

The serum ammonia level of a client with cirrhosis is elevated. As a priority, a nurse should plan to: 1. monitor the client's temperature every 4 hours. 2. observe for increasing confusion. 3. measure the urine specific gravity. 4. restrict the client's oral fluid intake.

ANS: 2 Elevated serum ammonia levels may cause neurological changes, such as confusion. The client's temperature or urine specific gravity will not be affected. Oral fluid intake should be encouraged if tolerated by the client.

A patient has developed hepatic encephalopathy secondary to cirrhosis and is receiving care on the medical unit. The patients current medication regimen includes lactulose (Cephulac) four times daily. What desired outcome should the nurse relate to this pharmacologic intervention? A) Two to 3 soft bowel movements daily B) Significant increase in appetite and food intake C) Absence of nausea and vomiting D) Absence of blood or mucus in stool

ANS: A Lactulose (Cephulac) is administered to reduce serum ammonia levels. Two or three soft stools per day are desirable; this indicates that lactulose is performing as intended. Lactulose does not address the patients appetite, symptoms of nausea and vomiting, or the development of blood and mucus in the stool.

A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites? a. Monitor intake and output. b. Provide a low-sodium diet. c. Increase oral fluid intake. d. Weigh the client daily.

ANS: B A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake and output does not control fluid accumulation, nor does weighing the client. These interventions merely assess or monitor the situation. Increasing fluid intake would not be helpful.

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 patients treatment? A) Decisional Conflict B) Deficient Knowledge C) Death Anxiety D) Disturbed Thought Processes

ANS: C The sudden hemorrhage that accompanies variceal bleeding is intensely anxiety-provoking. The nurse must address the patients 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 nurse is performing an admission assessment of a patient with a diagnosis of cirrhosis. What technique should the nurse use to palpate the patients 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 degrees to right side of the abdomen and push down firmly.

ANS: C 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 client is hospitalized for conservative treatment of cirrhosis. As part of the collaborative plan of care, a nurse would anticipate: 1. monitoring the client's blood sugar. 2. maintaining NPO (nothing by mouth) status. 3. administering antibiotics. 4. encouraging frequent ambulation.

ANSWER: 1 Clients with cirrhosis may develop insulin resistance. Impaired glucose tolerance is common, and about 20% to 40% of clients with cirrhosis also have diabetes. For some clients with cirrhosis, however, hypoglycemia may occur during fasting because of decreased hepatic glycogen reserves and decreased gluconeogenesis. Clients with cirrhosis should receive a high-protein diet unless hepatic encephalopathy is present. Antibiotics are not part of the treatment plan of cirrhosis because it is not caused by microorganisms. The client with cirrhosis requires rest, thus activity should not be encouraged.

A nurse is caring for a patient with cirrhosis secondary to heavy alcohol use. The nurses most recent assessment reveals subtle changes in the patients cognition and behavior. What is the nurses most appropriate response? A) Ensure that the patients 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.

Ans: B Feedback: Monitoring is an essential nursing function to identify early deterioration in mental status. The nurse monitors the patients 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 patients physiologic deterioration