Med-Surg
Which blood values are expected to be elevated in a client with worsening liver cirrhosis?
- Ammonia - Bilirubin - PT (Prothrombin time)
Which hematologic symptoms might be noted in a patient with cirrhosis of the liver? SATA
- Anemia, Leukopenia, Thrombocytopenia
A nurse is caring for a client who has cirrhosis. Which of the following medication can the nurse expect to administer to this client? SATA
- Diuretics - Lactulose - Beta-blocking agent
A client with worsening liver failure presents to the med-surg floor. Which assessment findings should the nurse EXPECT? SATA
- Enlarged abdomen from ascites - bruise marks on the skin (lack of clotting factors) - Fatigue and poss. confusion (ammonia levels) - Sclera that appears yellow (jaundice) -Reports of itchy skin
What should you do to the client after they receive a liver biopsy?
- Lay client on RIGHT SIDE to prevent bleeding
A nurse is teaching a client who has HEP. B about home care. Which of the following instructions should the nurse include in the teaching? SATA
- Limit physical activity (frequent rest breaks is needed to conserve energy, recovery process) - Avoid Alcohol - Eat small frequent meals (To improve nutrition due to anorexia)
The nurse is reviewing the lab results for a pt with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be presribed for this pt? a. Low-protein b. High-protein c. Moderate-fat d. High-carb
- Low-protein diet The liver breaks down protein, which results in the formation of ammonia.
What statement made by a client who is traveling to a non-industrialized country indicated the need for further teaching regarding the prevention of viral hepatitis?
"I should eat plenty of fresh fruit."
A client with advanced cirrhosis has begun treatment with lactulose. The client reports experiencing several soft stool per day. What is your best response?
"This is the normal expected response to this medication."
A liver who underwent liver transplantation 2 weeks ago reports a temp. of 101 (38) and flank pain. What would be your best response?
"You may be rejecting the transplanted liver and should go to the hospital immediately." NCLEX Tip: any question with "transplant" think of these 3 things... - hemorrhage/bleeding - rejection (jaundice, fever) - infection
What are the types of cirrhosis?
- Post necrotic: caused by viral hepatits or some medication or toxins - Laennec's: Caused by chronic alcohol use disorder - Billary: caused by chronic billary obstruction or autoimmune disorder
During an assessment of a patient the nurse finds asterixis, twitching of the extremities, and notices that the patient is displaying inappropriate behavior and disorientation. Which condition does the nurse suspect?
Hepatic encephalopathy
Diet?
High calories, low sodium, low protein (if ammonia is elevated)
a client is admitted with Lannec's cirrhosis. What data in the client's past HX should you inquire about in taking a current HX from this client?
History of alcohol abuse
The nurse has administered lactulose to a client with cirrhosis. The following day, the client reports having seen loose stools in the past 12 hours. What alteration in laboratory data would you expect to be present in this client as a result?
Hypokalemia
The physician is performing a paracentesis on a client with cirrhosis. For what potential complication of rapid removal of ascitic fluid should you monitor for this client?
Hypovolemia - removing too quickly can cause LBP, hypovolemia
Other TX for cirrhosis?
Liver transplant Shunt surgery (alleviates ascites) Administer blood products and Vitamin K to help with clotting.
A client with esophageal varices you should avoid?
NO NG NO STRAINING (bowel movement)
Lab Levels that are elevated?
PT/INR, PTT AST: (0-35) ALT: (4-36) ALP: (30-120) Bilirubin: (0.2-0.8) Ammonia: (10-80mcg/dL) creatinine: --> deteriorating kidney function, can result to advanced liver disease
A patient with cirrhosis and esophageal varices is vomiting, and the nurse notes hematemesis. Which action should the nurse take 1st?
Place the patient in the side-lying position - abc's
a client with end-stage cirrhosis admitted with gastrointestinal bleeding becomes combative and confused. What complication of cirrhosis may this client be experiencing?
Portal systemic encephalopathy
A nurse is caring for a client who has a new diagnosis of hepatits C. Which of the following lab findings should the nurse expect?
Positive EIA test
1st action when a client with cirrhosis begins vomiting blood after a meal?
Protecting the airway
A nurse on a medical surgical unit is admitting a client who has hepatits B with ascites. Which of the following actions should the nurse include in the plan of care?
Provide a high calorie diet, high carb diet. (Avoid protein, increases ammonia levels)
The nurse is caring for a patient with severe liver cirrhosis and imbalanced nutrition. Which nursing intervention would prevent malnutrition in this patient?
Provide oral care before meals - use soft tooth brush
For a client with cirrhosis, what nursing interventions would be most appropriate to control fluid accumulation in the abdominal cavity?
Providing a low-sodium diet
A client is admitted with cirrhosis. The liver of this client is enlarged, and the nurse suspects it is congested w/venous blood. Which clinical manesfistation would you expect to find considering the origin of cirrhosis in this client?
Pulmonary congestion
What is paracentesis?
Removal of fluid from the peritoneal cavity (ascites) - Keep HOB elevated - Document fluid - send specimen to lab - monitor vitals (can cause LBP) - daily weight
A client was diagnosed with HEP. A asks you how the infection may have been contracted. What is your best response?
"You may have been exposed through contaminated hepatitis A"
What causes cirrhosis?
* Viral infection; HEP. B,C *Alcohol Consumption: Heavy amount *Too much fat collecting in the liver (nonalcoholic): obese, hyperlipidemia, diabetics *Problems with bile duct (carries bile from liver to small intestine): bile stays inthe liver and damages cells *Autoimmune
A nurse is assessing a client who has ADVANCED cirrhosis. The nurse should identify which of the following findings as indicators of hepatic encephalopathy? (SATA)
*Change in LOC (Indicates encephalopathy, advanced cirrhosis) *Asterixis (tremors of the wrist & fingers, signs of late complication) *Fetor hepaticus (fruity, musty breath odor, advanced cirrhosis)
Expected findings of cirrhosis?
*Fatigue *weight loss *GI symptoms *Abdominal Pain, distention *Pruritus (severe itching of skin) *Confusion or difficulty thinking (ammonia elevated levels) * euphoria, personality changes, depression
Which of the following client is most at risk of developing HEP. B?
24 year old college student who has had several sexual partners
What assessment finding would you expect to note in a client with cirrhosis who is exhibiting Fector hepaticus?
A fruity or musty breath odor - toxins building up
A patient is admitted with hepatic encephalopathy secondary to cirrhosis. Which meal option selection below should be avoided with this patient? A. Beef tips and broccoli rabe B. Pasta noodles and bread C. Cucumber sandwich with a side of grapes D. Fresh salad with chopped water chestnuts
A. Beef tips and broccoli rabe
You're providing an in-service to new nurse graduates about esophageal varices in patients with cirrhosis. You ask the graduates to list activities that should be avoided by a patient with this condition. Which activities listed are correct: Select all that apply A. Excessive coughing B. Sleeping on the back C. Drinking juice D. Alcohol consumption E. Straining during a bowel movement F. Vomiting
A. Excessive coughing D. Alcohol consumption E. Straining during a bowel movement F. Vomiting
Your patient with cirrhosis has severe splenomegaly. As the nurse you will make it priority to monitor the patient for signs and symptoms of? SATA A. Thrombocytopenia B. Vision changes C. Increased PT/INR D. Leukopenia
A. Thrombocytopenia C. Increased PT/INR D. Leukopenia
You are receiving shift report on a patient with cirrhosis. The nurse tells you the patient's bilirubin levels are very high. Based on this, what assessment findings may you expect to find during your head-to-toe assessment? SATA A. Frothy light-colored urine B. Dark brown urine C. Yellowing of the sclera D. Dark brown stool E. Jaundice of the skin F. Bluish mucous membranes
B. Dark brown urine C. Yellowing of the sclera E. Jaundice of the skin
The physician orders Lactulose 30 mL by mouth per day for a patient with cirrhosis. What findings below demonstrates the medication is working effectively? SATA A. Decrease albumin levels B. Decrease in Fetor Hepaticus C. Patient is stuporous. D. Decreased ammonia blood level E. Presence of asterixis
B. Decrease in Fetor Hepaticus D. Decreased ammonia blood level
While providing mouth care to a patient with late-stage cirrhosis, you note a pungent, sweet, musty smell to the breath. This is known as: A. Metallic Hepatico B. Fetor Hepaticus C. Hepaticoacidosis D. Asterixis
B. Fetor Hepaticus
a 28-year client involved in a MVA is brought to the emergency dept. What clinical sign would alert you to the prescence of possible liver trauma?
Abdominal pain referred to the right shoulder
Which medication should you AVOID with cirrhosis? What is the antidote?
Acetaminophen (Tylenol) - Aceytlcysteine (mucomyst)
A client with acute hepatitis B has begum treatment with ribavirin (Virazole). What manifestation would alert you to a serious side effect of this medication?
Anemia
A patient with late-stage cirrhosis develops portal hypertension. Which of the following options below are complications that can develop from this condition? SATA A. Increase albumin levels B. Ascites C. Splenomegaly D. Fluid volume deficient E. Esophageal varices
B. Ascites C. Splenomegaly E. Esophageal varices
The liver receives it blood supply from two sources. One of these sources is called the _________________, which is a vessel network that delivers blood _____________ in nutrients but ________ in oxygen. A. hepatic artery, low, high B. hepatic portal vein, high, low C. hepatic lobule, high, low D. hepatic vein, low, high
B. hepatic portal vein, high, low
Which complication is a patient with cirrhosis at risk for?
Bleeding
A client with end-stage cirrhosis develops severe vomiting and is admitted to a medical-surgical unit. What complication of cirrhosis should the nurse be alert for in this client?
Bleeding esophageal varices.
Which of the following is NOT a role of the liver? A. Removing hormones from the body B. Producing bile C. Absorbing water D. Producing albumin
C. Absorbing water
The nurse is reviewing the record of a client with a dx of cirrhosis and notes that there is documentation of the presence of asterixis. How should the nurse assess for its presence? A. Dorsiflex the foot B. Measure abdominal girth C. Ask pt to extend the arms D. Instruct pt to lean forward
C. Ask pt to extend the arms - Asterixis: is irregular flapping movements of fingers and wrist. Encephalopathy is developing
During your morning assessment of a patient with cirrhosis, you note the patient is disoriented to person and place. In addition while assessing the upper extremities, the patient's hands demonstrate a flapping motion. What lab result would explain these abnormal assessment findings? A. Decreased magnesium level B. Increased calcium level C. Increased ammonia level D. Increased creatinine level
C. Increased ammonia level
Lab Levels that are low in cirrohsis?
Calcium --> (9-11) Albumin --> Lack of hepatic synthesis (Normal: 3.5-5) protein --> lack of hepatic synthesis (6.4-8.3) HGB Hematocrit Platelet count RBC
A client who is jaundiced and is suspected of having contracted HEP. B has been admitted to the hospital. Which of the following nursing interventions would be most appropriate for this client?
Encourage bedrest during this period - rest the liver, decrease metabolic demands
A client diagnosed 8 months ago with hepatitis B is suspected of having chronic hepatitis. What serologic marker would you expect to be present if this client is indeed a carrier of the disease?
HBsAg Antibodies - "g" think gansgter it is not leaving
________ reside in the liver and help remove bacteria, debris, and old red blood cells. A. Hepatocytes B. Langerhan cells C. Enterocytes D. Kupffer cells
D. Kupffer cells -These cells play a role in helping the hepatocytes turn parts of the old red blood cells into bilirubin.
A 45 year old male has cirrhosis. The patient reports concern about the development of enlarged breast tissue. You explain to the patient that this is happening because?
D. The liver cells are failing to remove the hormone estrogen properly from the body, which causes the level to increase in the body, and this leads to gynecomastia.
Medications:
Diuretics: decrease excessive fluid Beta-blocking agent: clients who have varices, to prevent bleeding Lactulose: to promote excretion of ammonia from the body to the stool Nonabsorable antibiotic: can be used in placed of lactulose
Which condition is NOT a known cause of cirrhosis? A. Obesity B. Alcohol consumption C. Blockage of the bile duct D. Hepatitis C E. All are known causes of cirrhosis
E. All are known causes of cirrhosis
which laboratory data would serve to alert you that the client with cirrhosis has advanced disease?
Elevated serum ammonia levels (advanced liver disease) - protein food increases the amount of ammonia
Diagnostic Tests and Procedures
U/S: detects acites , hepatomegaly, splenomegaly, biliary stones/obstruction Abd. X-ray & CT: poss. acites , hepatomegaly, splenomegaly MRI: visualize mass, lesions, benign/malignant Liver Biopsy: progression of cirrhosis Esophagogastrodudenoscopy: esophageal varices, ulcerations in the stomach, duodenol ulcers/bleeding Endscopic retrograde cholangiopancreateography: to view biliary tract, collect specimin for biopsy, stent replacement
The pt with cirrhosis is being taught self care. which statement indicates the pt needs MORE teaching?
a. if i notice a fast heart rate and irregular beats, this is normal for cirrhosis -may indicative of hypokalemia and should be reported to healthcare provider, this is not normal for cirrhosis
A pt with type 2 diabetes and cirrhosis asks if it would be okay to take silymarin (milk thistle) to help minimize liver damage. The nurse responds based on what knowledge?
a. milk thistle may affect liver enzymes and thus alter drug metabolism
The pt with cirrhosis has increased ab girth from ascites. The nurse should know that this fluid gathers in the ad for which reasons? Select all that apply.
a. there is decreased colloid oncotic pressure from the liver's inability to synthesize albumin b. hyperaldosteronism related to damaged hepatocytes increases sodium and fluid retention c. portal hypertension pushes proteins from the blood vessels, causing leaking into the peritoneal cavity
When caring for a pt with liver disease, the nurse recognizes the need to prevent bleeding resulting from altered clotting factors and rupture of varices. Which nursing interventions would be appropriate to achieve this outcome? Select all that apply.
a. use smallest gauge needle possible when giving injections or drawing blood. b. teach pt to avoid straining at stool, vigorous blowing of nose, and coughing c. advise pt to use soft-bristle toothbrush and avoid ingestion of irritating food. e. instruct pt to avoid aspirin and NSAIDs to prevent hemorrhage when varices are present.
portal hypertension causes
ascites and esophageal varices
The pt with advanced cirrhosis asks why his abdomen is so swollen. The nurse's best response is based on the knowledge that? a. a lack of clotting factors promotes the collection of blood in the abdominal cavity b. portal hypertension and hypoalbuminemia cause fluid shift into the peritoneal space. c. decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel d. bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid.
b. portal hypertension and hypoalbuminemia cause fluid shift into the peritoneal space.
The condition of the pt who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the pt has developed liver cancer?
c. hepatic structure ultasound
During the assessment of a pt with obstructive jaundice, the nurse would expect to find?
clay colored stools
The health care provider orders lactulose for a patient with hepatic encephalopathy. The nurse will monitor for effectiveness of this medication for this pt by assessing what? a. relief of constipation b. relief of ab pain c. decreased liver enzymes d. decreased ammonia levels
d. decreased ammonia levels - Lactulose traps ammonia in the intestinal tract. It's laxative effect then expels ammonia from the colon, resulting in decreased ammonia levels, correcting hepatic encephalopathy.
When planning care for a pt with cirrhosis, the nurse will give highest priority to which nursing diagnosis? a. impaired skin integrity related to edema, ascites, and pruritis b. imbalanced nutrition: less than body requirements related to anorexia c. excess fluid volume related to portal hypertension and hyperaldosteronism d. ineffective breathing pattern related to pressure on diaphragm and reduced lung volume
d. ineffective breathing pattern related to pressure on diaphragm and reduced lung volume - ABC's, airway is first
What is cirrhosis?
scarring of the liver (dead tissue) Caused by necrotic injury or chronic reaction to inflammation over prolonged period of time such as alcohol
portal hypertension
the elevation of blood pressure within the portal venous system