Chapter 43: Assessment and Management of Patients with Hepatic Disorders

Hepatic encephalopathy (a central nervous system dysfunction resulting from liver disease. It is frequently associated with an elevated ammonia concentration that produces changes in mental status, altered level of consciousness, and coma.)

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition?

anorexia, nausea, and vomiting.

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:

cirrhosis

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:

cirrhosis (may also have mild fever, edema, abdominal pain, and an enlarged liver.)

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:

Purpura and petechiae (bleeding)

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

Cirrhosis

chronic degenerative disease of the liver acute or chronic

liver cancer s/s

▪ Dull persistent pain, RUQ, back, or epigastrium ▪ Weight loss, anemia, anorexia, weakness ▪ Jaundice, bile ducts occluded, ascites, or obstructed portal veins

Spironolactone

Which of the following medications would the nurse expect the physician to order for a client with cirrhosis who develops portal hypertension?

peptic ulcer pain

a dull, gnawing epigastric pain that's relieved by eating.

icteric phase

a stage of liver disease marked by jaundice

viral hep

a systemic viral infection that causes necrosis and inflammation of liver cells with characteristic symptoms and cellular and biochemical changes

hep d

blood & sex transmission - IV/ injection drugs, blood transfusion can be a mode of transmission - likely to cause fulminant liver failure or chronic active hep & cirrhosis

hep b and c

infection via bloodborne origins

hep c tx

interferon and ribavirin (antiviral meds - AVOID ALCOHOL & drugs that affect liver - no needle sharing

hepatocellular jaundice ss

▪ Lack of appetite, nausea or vomiting, weight loss ▪ Malaise, fatigue, weakness ▪ Headache, chills, fever, infection

Hepatic encephalopathy tx

❖Eliminate precipitating cause ❖Lactulose to reduce serum ammonia levels ❖IV glucose to minimize protein catabolism ❖Protein restriction ❖Reduction of ammonia from GI tract by gastric suction, enemas, oral antibiotics ❖Discontinue sedatives, analgesics, and tranquilizers ❖Monitor or treat complications and infections

functions of liver

❖Glucose metabolism ❖Ammonia conversion ❖Protein metabolism ❖Fat metabolism ❖Vitamin and iron storage ❖Bile formation ❖Bilirubin excretion ❖Drug metabolism

hepatic dysfunction s/s

❖Jaundice ❖Portal hypertension ❖Ascites and varices ❖Hepatic encephalopathy or coma ❖Nutritional deficiencies

ascites tx

❖Low-sodium diet ❖Diuretics ❖Bed rest ❖Paracentesis ❖Administration of salt-poor albumin ❖Transjugular intrahepatic portosystemic shunt (TIPS) ❖Other methods: peritoneovenous

Octreotide (causes selective splanchnic vasoconstriction by inhibiting glucagon release and is used mainly in the management of active hemorrhage)

A client is actively bleeding from esophageal varices. Which medication would the nurse most expect to be administered to this client?

Acetaminophen (Tylenol)

An important message for any nurse to communicate is that drug-induced hepatitis is a major cause of acute liver failure. The medication that is the leading cause is:

liver biopsy (reveals hepatic fibrosis is the most conclusive diagnostic procedure.)

A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?

b

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is:

ERCP (endoscopic retrograde cholangiopancreatography)

The nurse is caring for a client suspected of having stones that have collected in the common bile duct. What test should the nurse prepare the client for that will locate these stones?

hepatic cirrhosis s/s

liver enlargement, portal obstruction, ascites, infection and peritonitis, varices, GI varices, edema, vitamin deficiency, anemia, mental deterioration

hep b s/s

insidious and variable; similar to HAV, loss of appetite, dyspepsia, abdominal pain, generalized aching, malaise, and weakness, jaundice (may/ may not be evident)

vitamin k (to correct a prothrombin deficiency)

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery?

abstain from drinking

A client with cirrhosis is at risk for developing esophageal varices. Which of the following instructions should a nurse provide the client to minimize such risk?

albumin

A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal?

vitamin A (deficiency results in night blindness and eye and skin changes)

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client?

Alcoholic liver disease

A degenerative liver condition that occurs in three stages: (1) fatty liver, (2) alcoholic hepatitis, and (3) cirrhosis.

hemolytic jaundice

Excessive destruction of red blood cells or absorption of a hematoma

Liver metastasis

Few cancers originate in the liver Frequent site of metastatic cancer

cirrhosis nursing interventions

HOB 30 deg. feet elevated, assess respiratory function & jaundice, give O2 maintain skin integrity- avoid soap (use lotion, wash w/ cold - prevent itching) high protein/carb diet, low fat & Na fluid restriction (I/Os) promote rest Meds: Lactalose - helps excrete ammonia, Diuretics, beta blocker for esophageal varacies, paracentesis

hepatic encephalopathy and coma

Life-threatening complications: accumulation of ammonia and other toxic metabolites in the blood happens due to alterations in: 1. hepatic insufficiency 2. portosystemic shunting

posticteric phase

Liver enlargement, malaise, & fatigue; other symptoms subside; liver function tests begin to return to normal

ascites

abnormal accumulation of fluid in the abdomen

asterixis

aka Liver Flap, a flapping tremor of the hands. When the client extends the arms & hands in front of the body, the hands rapidly flex & extend.

obstructive jaundice

bile ducts are obstructed (by gall stones) so bile cannot drain out of the liver and overflows into the blood results in: - clay colored stool - urine that is dark amber - soluble bilirubin in the urine

decrease

bleeding esophageal varices result in an increase or decrease in renal perfusion due to loss of blood?

hep b transmission

blood, saliva, semen, and vaginal secretions; sexually transmitted; transmitted to infant at the time of birth *major worldwide cause of cirrhosis & liver cancer

jaundice

caused by bilirubin levels >2 mg/dL 3 kinds: Hemolytic, hepatocellular, obstructive *Hepatocellular and obstructive jaundice are most associated with liver disease

toxic hepatitis

caused by exposure to hepatotoxins (industrial toxins, alcohol, drugs)

portosystemic shunting

collateral vessels develop allowing elements of the portal blood (laden with potentially toxic substances usually extracted by the liver) to enter the systemic circulation

hepatic encephalopathy assessment

▪ EEG▪ Changes in LOC ▪ Potential seizures ▪ Fetor hepaticus ▪ Monitor fluid, electrolyte, and ammonia levels

ascites results

❖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

ascites assessment

* Record abdominal girth and weight daily * 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

liver function tests

- serum amniotransferase - ALT - AST - GGT

GGT (gamma glutamyl transferase)

0-30 IU/L levels are associated with cholestasis; alcoholic liver disease

Phytonadione (Vitamin K)

A client with advanced cirrhosis has a prothrombin time (PT) of 15 seconds, compared with a control time of 11 seconds. The nurse expects to administer: eased blood volume

AST (aspartate aminotransferase)

5-40 units/L not specific to liver diseases; however, levels of AST may be increased in cirrhosis, hepatitis, and liver cancer

ALT (alanine aminotransferase)

8-20 units/L levels increase primarily in liver disorders; used to monitor the course of hepatitis, cirrhosis, the effects of treatments that may be toxic to the liver

hep c (occurs primarily through injection of drugs and through transfusion of blood products prior to 1992.)

A 33-year-old male patient with a history of IV heroin and cocaine use has been admitted to the medical unit for the treatment of endocarditis. The nurse should recognize that this patient is also likely to test positive for which of the following hepatitis viruses?

fatty liver disease

A buildup of lipids that are deposited in the liver tissue. 2 types: - Nonalcoholic fatty liver disease (NAFLD) -Nonalcoholic steatohepatitis (NASH)

clay colored pool (Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results)

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?

liver function decreasing (The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction.)

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?

hep c increase risk for liver cancer

A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include?

Alcoholic cirrhosis

A nurse is teaching a client about the types of chronic liver disease. The teaching is determined to be effective when the client correctly identifies which type of cirrhosis as being caused by scar tissue surrounding portal areas?

bleeding esophageal varices

A patient is brought to the emergency department by ambulance. He has hematemesis and alteration in mental status. The patient has tachycardia, cool clammy skin, and hypotension. The patient has a history of alcohol abuse. What would the nurse suspect the patient has?

low platelet count (Prolonged prothrombin time (PT) and low platelet count place the client at high risk for hemorrhage.)

A physician has ordered a liver biopsy for a client with cirrhosis whose condition has recently deteriorated. The nurse reviews the client's recent laboratory findings and recognizes that the client is at risk for complications due to:

1 mo, 6 mo

A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor?

minimize social isolation

A young client with anorexia, fatigue, and jaundice is diagnosed with hepatitis B and has just been admitted to the hospital. The client asks the nurse how long the stay in the hospital will be. In planning care for the client, the nurse identifies impaired psychosocial issues and assigns the highest priority to which client outcome?

Right lateral decubitus position

After undergoing a liver biopsy, a client should be placed in which position?

dietary and blood proteins (The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. Ammonia from these sources increases as a result of GI bleeding (i.e., bleeding esophageal varices, chronic GI bleeding), a high-protein diet, bacterial infection, or uremia.)

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from:

primary liver tumors

Associated with hepatitis B and C Hepatocellular carcinoma (HCC)

postnecrotic cirrhosis

Cirrhosis that occurs after massive liver necrosis. Cirrhosis results as a complication of hepatitis or exposure to hepatotoxins. Scar tissue causes destruction of liver lobules and entire lobes. broad bands of scar tissue

hypotension (cool, clammy skin; tachycardia; hypotension, and decreased urine output)

Clients diagnosed with esophageal varices are at risk for hemorrhagic shock. Which is a sign of potential hypovolemia?

scurvy

Clients with chronic liver dysfunction have problems with insufficient vitamin intake. Which may occur as a result of vitamin C deficiency?

hep d

Co-infection with Hep B *only ppl w hep b are at risk of contracting

obstructive jaundice s/s

Dark orange-brown urine, clay-colored stools Dyspepsia and intolerance of fats, impaired digestion Pruritus

mental changes, motor disturbances

Early signs of hepatic encephalopathy

esophageal varices s/s

If ruptured-->Hematemesis, melon, hematochezia, dizziness Sx of cirrhosis and portal HTN

hep c

MOST COMMON BLOODBORNE INFECTION Transmitted by blood and sexual contract, including needle sticks and sharing of needles - causes 1/3 liver cancer - most common reason for liver transplant

preicteric phase (prodromal phase)

Phase in which malaise, fatigue, nausea, and loss of appetite are commonly seen; elevated liver enzymes s/s: urticaria; nausea; vomiting; anorexia; fever; malaise; arthralgia; headache; right upper quadrant (RUQ) discomfort; enlargement of the spleen, liver, and lymph nodes; weight loss; and rash.

diuretics

Spironolactone and furosemide are what kind of drugs?

bleeding varices tx

TX for shock - admin O2 - ❖IV fluids, electrolytes, volume expanders, blood and blood products ❖Vasopressin, somatostatin, octreotide to decrease bleeding ❖Nitroglycerin in combination with vasopressin to reduce coronary vasoconstriction ❖Propranolol and nadolol to decrease portal pressure; used in combination with other treatment ❖Balloon tamponade ❖Endoscopic sclerotherapy ❖Endoscopic variceal ligation (esophageal banding therapy) ❖Transjugular intrahepatic portosystemic shunt

hep c s/s

may be asymptomatic rash, angioedema, arthritis, fever, malaise, jaundice

fecal-oral

The mode of transmission of hepatitis A virus (HAV) includes which of the following?

Hemolytic

The nurse identifies which type of jaundice in an adult experiencing a transfusion reaction?

lactulose

The nurse is administering medications to a client that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent?

rash

The nurse is caring for a client with hepatitis. Which of the following would lead the nurse to suspect that the client is in the prodromal phase?

drug induced hepatitis

Usually caused by Acetaminophen (tylenol)-- most common cause of acute liver failure increased AST(ALT is viral)

change in handwriting/ cognition (include mental status changes and motor disturbances. The client will appear confused and unkempt and have altered mood and sleep patterns. Neurologic status should be assessed frequently. Mental status is monitored by the nurse keeping the client's daily record of handwriting and arithmetic performance. The nurse should report any change in mental status immediately)

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately?

Spironolactone

Which diuretic medication would most often be used for a patient with ascites?

Vasopressin

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?

Paracentesis

Which term describes the passage of a hollow instrument into a cavity to withdraw fluid?

esophageal varices

happens in 30% of pt w cirrhosis first bleed= mortality of 10-30% if pt has cirrhosis, recommended to have endoscopy every 2-3yrs

2-6 wks

hep a incubation

4-8 wks

hep a period of illness

1-6 mo

hep b incubation period

15-160 days

hep c incubation period

Hepatocellular jaundice

inability of damaged liver cells to clear normal amounts of bilirubin from the blood

30-150 days

incubation period for hep d

Serum aminotransferase levels

indicators of injury to the liver cells; useful in detecting hepatitis

hep a and e

infection through fecal-oral

hep a s/s

mild flu-like symptoms, low-grade fever, anorexia, later jaundice and dark urine, indigestion and epigastric distress, enlargement of liver and spleen

Propranolol (Inderal)

most common medications used both to prevent a first bleeding episode in clients with known varices and to prevent rebleeding

interferon alfa

only licensed drug available in tx for hep d infection

cirrhosis complications

portal hypertension, esophageal varices, ascites ❖Bleeding and hemorrhage ❖Hepatic encephalopathy ❖Fluid volume excess

hep a tx

prevention= handwashing, VACCINE, immunoglobulin if exposed - bed rest - nutritional support

alcoholic hepatic cirrhosis

scar tissue characteristically surrounds the portal areas

biliary hepatic cirrhosis

scarring occurs in the liver around the bile ducts

cholelithiasis pain

severe abdominal pain that presents several hours after a large meal.

pruritus

severe itching

Fulminant hepatic failure

sudden, severe onset of acute liver failure that occurs within 8 weeks after the first symptoms of jaundice

portal vein

supplies the majority of blood to the liver - it is rich in nutrients from the GI tract

Paracentesis

surgical puncture to remove fluid from the abdomen

paracentesis

surgical puncture to remove fluid from the abdomen

hep b tx

tenofovir and entecavir - bed rest & nutritional support - VACCINE

Hepatic insufficiency

the inability of the liver to detoxify toxic by-products of metabolism

nonobstructive jaundice

the type of jaundice that is on a cellular level, no associated with biliary obstruction associated w hepatitis

Nonviral Hepatitis

toxic and drug induced hepatitis Usually recovery possible May develop liver failure, liver cancer, or cirrhosis Not contagious

hep E

transmitted by fecal-oral route could be contaminated food/ water - resembles hep A - self limiting, abrupt onset hand hygiene can prevent infection