Cirrhosis

Preventing getting sick if exposed to Hep A

"An immunoglobulin injection will be given to prevent infection or limit symptoms." Rationale: Immunoglobulin provides temporary (1 to 2 months) passive immunity and is effective for preventing hepatitis A if given within 2 weeks after exposure. It may not prevent infection in all persons, but it will at least modify the illness to a subclinical infection. The hepatitis vaccine is only used for preexposure prophylaxis

The nurse provides discharge instructions for a patient with ascites and peripheral edema related to cirrhosis. Which patient statement indicates teaching was effective? "Lactulose should be taken every day to prevent constipation." "It is safe to take acetaminophen up to four times a day for pain." "Herbs and other spices should be used to season my foods instead of salt." "I will eat foods high in potassium while taking spironolactone (Aldactone)."

"Herbs and other spices should be used to season my foods instead of salt." Rationale: A low-sodium diet is indicated for patients with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided because these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.

The nurse provides discharge instructions for a patient with ascites and peripheral edema related to cirrhosis. Which patient statement indicates teaching was effective? "Lactulose should be taken every day to prevent constipation." "It is safe to take acetaminophen up to four times a day for pain." "Herbs and other spices should be used to season my foods instead of salt." "I will eat foods high in potassium while taking spironolactone (Aldactone)."

"Herbs and other spices should be used to season my foods instead of salt." Rationale: A low-sodium diet is indicated for patients with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices. Pain medications such as acetaminophen, aspirin, and ibuprofen should be avoided because these medications may be toxic to the liver. The patient should avoid potentially hepatotoxic over-the-counter drugs (e.g., acetaminophen) because the diseased liver is unable to metabolize these drugs. Spironolactone is a potassium-sparing diuretic. Lactulose results in the acidification of feces in bowel and trapping of ammonia, causing its elimination in feces.

When teaching the patient with acute hepatitis C (HCV), which statement demonstrates understanding of the disease process? "I will use care when kissing my wife to prevent giving it to her." "I will need to take adefovir (Hepsera) to prevent chronic HCV." "Now that I have had HCV, I will have immunity and not get it again." "I will need to be monitored for chronic HCV and other liver problems."

"I will need to be monitored for chronic HCV and other liver problems." Rationale: Many patients who acquire HCV develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva but by blood exposures such as sharing needles and high-risk sexual activity. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adefovir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. HCV is treated with oral direct-acting antivirals (DAAs). Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.

The patient with cirrhosis is being taught self-care. Which statement indicates the patient needs further teaching? "A scrotal support may be more comfortable when I have scrotal edema." "I need to take good care of my belly and ankle skin where it is swollen." "I can use pillows to support my head to help me breathe when I am in bed." "If I notice a fast heart rate or irregular beats, this is normal for cirrhosis."

"If I notice a fast heart rate or irregular beats, this is normal for cirrhosis." Rationale: If the patient with cirrhosis develops a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider because this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.

How is cholestyramine administered?

"The medication is a powder and needs to be mixed with milk or juice." Rationale: For treatment of pruritus, cholestyramine may provide relief. This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is in powder form and should be mixed with milk or juice before oral administration.

Functions of the liver

- production of bile, which helps carry away waste and break down fats in the small intestine during digestion; - production of certain proteins for blood plasma; - production of cholesterol and special proteins to help carry fats through the body; - conversion of excess glucose into glycogen for storage (This glycogen can later be converted back to glucose for energy.); - regulation of blood levels of amino acids, processing of hemoglobin for use of its iron content (The liver stores iron.); - conversion of poisonous ammonia to urea (Urea is one of the end products of protein metabolism that is excreted in the urine.); - clearing the blood of drugs and other poisonous substances; - regulating blood clotting; - resisting infections by producing immune factors and removing bacteria from the bloodstream

Pt Teaching for Cirrhosis patient with Ascites and Edema

A low-sodium diet is indicated for patients with ascites and edema related to cirrhosis. Table salt is a well-known source of sodium and should be avoided. Alternatives to salt to season foods include the use of seasonings such as garlic, parsley, onion, lemon juice, and spices.

Your patient with cirrhosis has severe splenomegaly. As the nurse you will make it priority to monitor the patient for signs and symptoms of? Select all that apply: A. Thrombocytopenia B. Vision changes C. Increased PT/INR D. Leukopenia

A, C, D

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, D, E, and F. Esophageal varices are dilated vessels that are connected from the throat to the stomach. They can become enlarged due to portal hypertension in cirrhosis and can rupture (this is a medical emergency). The patient should avoid activities that could rupture these vessels, such as excessive cough, vomiting, drinking alcohol, and constipation (straining increases thoracic pressure.)

Ascites pathophysiology in Cirrhosis

Ascites related to cirrhosis is caused by decreased colloid oncotic pressure. The liver does not produce albumin that holds fluid in the vascular space, so fluid shifts into interstitial and third spaces. Portal hypertension causes back pressure in the vessels, shifting protein and fluids into the peritoneal cavity. Decreased intravascular volume stimulates the release of aldosterone, which increases sodium and fluid retention. Oral intake of fluids and removal of blood cells by the spleen do not directly contribute to ascites.

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

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

The physician orders Lactulose 30 mL by mouth per day for a patient with cirrhosis. What findings below demonstrates the medication is working effectively? Select all that apply: A. Decrease albumin levels B. Decrease in Fetor Hepaticus C. Patient is stuporous. D. Decreased ammonia blood level E. Presence of asterixis

B and D. A patient with cirrhosis may experience a complication called hepatic encephalopathy. This will cause the patient to become confused (they may enter into a coma), have pungent, musty smelling breath (fetor hepaticus), asterixis (involuntary flapping of the hands) etc. This is due to the buildup of ammonia in the blood, which affects the brain. Lactulose can be prescribed to help decrease the ammonia levels. Therefore, if the medication is working properly to decrease the level of ammonia the patient would have improving mental status (NOT stuporous), decreased ammonia blood level, decreasing or absence of asterixis, and decreased ammonia blood level.

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? Select all that apply: 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, C, E High bilirubin levels are because the hepatocytes are no longer able to properly conjugate the bilirubin because they are damaged. This causes bilirubin to leak into the blood and urine (rather than entering the bile and being excreted in the stool). Therefore, the bilirubin stays in the blood and will enter the urine. This will cause the patient to experience yellowing of the skin, sclera of the eyes, and mucous membranes ("jaundice") and have dark brown urine. The stools would be CLAY-COLORED not dark brown (remember bilirubin normally gives stool it brown color but it will be absent).

A patient with late-stage cirrhosis develops portal hypertension. Which of the following options below are complications that can develop from this condition? Select all that apply: A. Increase albumin levels B. Ascites C. Splenomegaly D. Fluid volume deficient E. Esophageal varices

B, C, and E.

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 - Asterixis

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. The liver does not absorb water. The intestines are responsible for this function.

Contraindications for Liver Transfer

Contraindications for liver transplant include severe extrahepatic disease, advanced hepatocellular carcinoma or other cancer, ongoing drug or alcohol use, and the inability to comprehend or comply with the rigorous posttransplant course.

A patient with cirrhosis has increased abdominal girth from ascites. Which statements describe the pathophysiology of ascites? (Select all that apply.) Hepatocytes are unable to convert ammonia to urea. Osmoreceptors in the hypothalamus stimulate thirst. An enlarged spleen removes blood cells from the circulation. Portal hypertension causes leaking of protein and water into the peritoneal cavity. Aldosterone is released to stabilize intravascular volume by saving salt and water. Inability of the liver to synthesize albumin reducing intravascular oncotic pressure.

Correct Answer: Portal hypertension causes leaking of protein and water into the peritoneal cavity. Aldosterone is released to stabilize intravascular volume by saving salt and water. Inability of the liver to synthesize albumin reducing intravascular oncotic pressure. Rationale: Ascites related to cirrhosis is caused by decreased colloid oncotic pressure. The liver does not produce albumin that holds fluid in the vascular space, so fluid shifts into interstitial and third spaces. Portal hypertension causes back pressure in the vessels, shifting protein and fluids into the peritoneal cavity. Decreased intravascular volume stimulates the release of aldosterone, which increases sodium and fluid retention. Oral intake of fluids and removal of blood cells by the spleen do not directly contribute to ascites.

The nurse is aware of potential complications related to cirrhosis. Which interventions would be included in a safe plan of care? (Select all that apply.) a)Provide a high-protein, low-carbohydrate diet. b)Tell the patient to use soft-bristle toothbrush and electric razor. C)Teach the patient to avoid vigorous blowing of nose and coughing. d)Apply gentle pressure for the shortest possible time after venipuncture. e)Use the smallest gauge needle possible when giving injections or drawing blood. f) Teach the patient to avoid aspirin and nonsteroidal antiinflammatory (NSAIDs).

Correct Answer: Tell the patient to use soft-bristle toothbrush and electric razor. Teach the patient to avoid vigorous blowing of nose and coughing. Use the smallest gauge needle possible when giving injections or drawing blood. Teach the patient to avoid aspirin and nonsteroidal antiinflammatory (NSAIDs). Rationale: Using the smallest gauge needle for injections, using a soft bristle toothbrush and an electric razor will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding. A low-salt, low-protein, high-carbohydrate diet may be recommended.

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? A. The liver cells are removing too much estrogen from the body which causes the testicles to produce excessive amounts of estrogen, and this leads to gynecomastia. B. The liver is producing too much estrogen due to the damage to the liver cells, which causes the level to increase in the body, and this leads to gynecomastia. C. The liver cells are failing to recycle estrogen into testosterone, which leads to gynecomastia. 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.

D

_______ 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 perform this function and are one of the two types of cells found in the liver lobules (the functional units of the liver). These cells play a role in helping the hepatocytes turn parts of the old red blood cells into bilirubin.

The health care provider orders lactulose for a patient with hepatic encephalopathy. Which finding indicates the medication has been effective?

DECREASED AMMONIA LEVELS Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy. An additional finding may be an improvement in level of consciousness.

The health care provider orders lactulose for a patient with hepatic encephalopathy. Which finding indicates the medication has been effective? Relief of constipation Relief of abdominal pain Decreased liver enzymes Decreased ammonia levels

Decreased ammonia levels Rationale: Hepatic encephalopathy is a complication of liver disease and is associated with elevated serum ammonia levels. Lactulose traps ammonia in the intestinal tract. Its laxative effect then expels the ammonia from the colon, resulting in decreased serum ammonia levels and correction of hepatic encephalopathy. An additional finding may be an improvement in level of consciousness.

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

Pruritis treatment associated with gallbladder disease

For treatment of pruritus, cholestyramine may provide relief. This is a resin that binds bile salts in the intestine, increasing their excretion in the feces. Cholestyramine is in powder form and should be mixed with milk or juice before oral administration.

A patient with chronic hepatitis B is being discharged with pain medication after knee surgery. Which medication order should the nurse question? Tramadol Hydromorphone (Dilaudid) Hydrocodone with acetaminophen Oxycodone with aspirin (Percodan)

Hydrocodone with acetaminophen Rationale: The analgesic with acetaminophen should be questioned because this patient has chronic hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.

Who should receive an immunoglobulin (IG) injection in regards to a patient with Hep A?

IG is recommended for persons who do not have anti-HAV antibodies and are exposed because of close contact with persons who have HAV or foodborne exposure. Persons who have received a dose of HAV vaccine more than 1 month previously or who have a history of HAV infection do not require IG.

Cirrhosis Patient teaching

If the patient with cirrhosis develops a fast or irregular heart rate, it may be indicative of hypokalemia and should be reported to the health care provider because this is not normal for cirrhosis. Edematous tissue is subject to breakdown and needs meticulous skin care. Pillows and a semi-Fowler's or Fowler's position increase respiratory efficiency. A scrotal support may improve comfort if there is scrotal edema.

When planning care for a patient with cirrhosis, the nurse will give highest priority to which nursing diagnosis? Fluid imbalance Impaired tissue integrity Impaired nutritional status Ineffective breathing pattern

Ineffective breathing pattern Rationale: Although all these nursing diagnoses are appropriate and important in the care of a patient with cirrhosis, airway and breathing are always the highest priorities.

Disease process of Hep C

Many patients who acquire HCV develop chronic infection, which may lead to cirrhosis or liver cancer. HCV is not transmitted via saliva but by blood exposures such as sharing needles and high-risk sexual activity. The treatment for acute viral hepatitis focuses on resting the body and adequate nutrition for liver regeneration. Adefovir (Hepsera) is taken for severe hepatitis B (HBV) with liver failure. HCV is treated with oral direct-acting antivirals (DAAs). Immunity with HCV does not occur as it does with HAV and HBV, so the patient may be reinfected with another type of HCV.

A patient with cirrhosis has increased abdominal girth from ascites. Which statements describe the pathophysiology of ascites? (Select all that apply.) a) Hepatocytes are unable to convert ammonia to urea. b) Osmoreceptors in the hypothalamus stimulate thirst. c) An enlarged spleen removes blood cells from the circulation. d) Portal hypertension causes leaking of protein and water into the peritoneal cavity. e) Aldosterone is released to stabilize intravascular volume by saving salt and water. f) Inability of the liver to synthesize albumin reducing intravascular oncotic pressure.correct answer

Portal hypertension causes leaking of protein and water into the peritoneal cavity. Aldosterone is released to stabilize intravascular volume by saving salt and water. Inability of the liver to synthesize albumin reducing intravascular oncotic pressure. Rationale: Ascites related to cirrhosis is caused by decreased colloid oncotic pressure. The liver does not produce albumin that holds fluid in the vascular space, so fluid shifts into interstitial and third spaces. Portal hypertension causes back pressure in the vessels, shifting protein and fluids into the peritoneal cavity. Decreased intravascular volume stimulates the release of aldosterone, which increases sodium and fluid retention. Oral intake of fluids and removal of blood cells by the spleen do not directly contribute to ascites.

The nurse is aware of potential complications related to cirrhosis. Which interventions would be included in a safe plan of care? (Select all that apply.) Provide a high-protein, low-carbohydrate diet. Tell the patient to use soft-bristle toothbrush and electric razor. Teach the patient to avoid vigorous blowing of nose and coughing. Apply gentle pressure for the shortest possible time after venipuncture. Use the smallest gauge needle possible when giving injections or drawing blood. Teach the patient to avoid aspirin and nonsteroidal antiinflammatory (NSAIDs).

Tell the patient to use soft-bristle toothbrush and electric razor. Teach the patient to avoid vigorous blowing of nose and coughing. Use the smallest gauge needle possible when giving injections or drawing blood. Teach the patient to avoid aspirin and nonsteroidal antiinflammatory (NSAIDs). Rationale: Using the smallest gauge needle for injections, using a soft bristle toothbrush and an electric razor will minimize the risk of bleeding into the tissues. Avoiding straining, nose blowing, and coughing will reduce the risk of hemorrhage at these sites. The nurse should apply gentle but prolonged pressure to venipuncture sites to minimize the risk of bleeding. Aspirin and NSAIDs should not be used in patients with liver disease because they interfere with platelet aggregation, thus increasing the risk for bleeding. A low-salt, low-protein, high-carbohydrate diet may be recommended.

What medication is contraindicated with chronic Hepatitis B?

The analgesic with acetaminophen should be questioned because this patient has chronic hepatitis B and is likely to have impaired liver function. Acetaminophen is not suitable for this patient because it is converted to a toxic metabolite in the liver after absorption, increasing the risk of hepatocellular damage.

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

The answer is A. Patients who are experiencing hepatic encephalopathy are having issues with toxin build up in the body, specifically ammonia. Remember that ammonia is the byproduct of protein breakdown, and normally the liver can take the ammonia from the protein breakdown and turn it into urea (but if the cirrhosis is severe enough this can't happen).