Cirrhosis

Signs and Symptoms of Cirrhosis

Early stages: patients may be asymptomatic, but in the late stages will have: Remember the mnemonic: "The Liver is Scarred" Tremors of hands (asterixis: hand-flapping due to increased toxins in the blood) Hepatic foetor or "fetor hepaticus": very late in the disease and is a pungent, sweet, musty smell. This is from the buildup of toxins (mercaptans) in the blood. Why in the breath? Portal hypertension shunts these toxins where they pass through the lungs allowing the smell to be noticed. Eye and skin yellowing (jaundice) Loss of appetite (spleen pushing on stomach...feel full) Increased Bilirubin (skin and urine....jaundice) and ammonia Varices (esophagus and gastric...at risk for bleeding...watching for activities that can increase rupture: coughing, vomiting, drinking ETOH, constipation) Edema in legs (low albumin and congestion of hepatic veins) Reduced platelets and WBCs (bleeding and infection risk) Itchy skin (toxins the blood) Spider angiomas (chest) (increased estrogen in the blood) Splenomegaly (low platelets and WBCs), stool clay-colored (no bilirubin in the stool...should be there not in the urine or blood) Confusion or coma (high toxin and ammonia level) Ascites (low albumin and venous congestion) Redness on the palms of the hands (increased estrogen in the blood) Renal failure (hepatorenal syndrome) Enlarged breast in men (decrease the metabolism of estrogen so there is more in the blood) Deficient in vitamins (B12, A, C, D, E, K, and iron) (no longer able to store and have bile to help absorb these fat-soluble vitamins)

How does the liver receive its blood supply to do its job?

First Source: Majority of the blood flow to the liver comes from the hepatic portal vein (remember this structure for complications seen in portal hypertension).This is a venous network that delivers blood high in nutrients (lipids, proteins, carbs, GLUCOSE etc.) from organs that aid in digestion of food, but this blood is very poor in oxygen. The organs connected to the hepatic portal vein are:small/large intestine, pancreas, spleen, stomachSecond Source: Hepatic artery: it delivers rich oxygenate blood that just came from the heart to the liver, but it's poor in nutrients. —-these two blood supplies mix together as they enter the functional units of the liver called the liver lobules (there are thousands of them in the liver). These lobules contain hepatocytes, which perform most of the liver's function and kupffer cells (macrophages that cleanse the blood coming from the hepatic portal vein and artery), and the blood will exit via the hepatic vein to go back to the heart to be re-oxygenated. As blood flows through the lobules there a two types of cells performing special jobs (as stated above): Kupffer cells: removing bacteria, debris, parasites, old RBCs (remember this because this plays a role with bilirubin) Hepatocytes: does most of the work of the liver by performing bile production, metabolism, storage, conjugating bilirubin, and detoxification.

Cirrhosis

It's a liver disease where liver cells become extremely damaged due to long term/severe damage. This leads to the damaged cells being replaced with fibrous tissue, hence, scarring of the liver.

diagnosed

Liver biopsy Labs: liver enzymes (albumin), platelet levels, PT/INR, hepatitis B or C, bilirubin levels

treatment

Liver transplant Shunting surgery (helps alleviate the ascites) Diuretics beta blockers (slows the heart rate..decreases force of contraction and also helps with the treatment of esophageal varices) and Nitrates (dilate vessels) to treat portal hypertension Administer blood products and vitamin K to help with clotting Lactulose (to decrease ammonia level) Paracentesis (to remove fluid from abdomen)

Functions of the liver

Metabolizes: All the fresh nutrient-rich blood entering into the hepatic lobule passes by the hepatocytes which METABOLIZES :Glucose: the excessive amounts will be synthesized and stored as glycogen (monitor blood glucose...in cirrhosis the liver can't synthesize glycogen properly and store it, so more hangs out in the blood, leading to hyperglycemia) AND converts glycogen into glucose when blood glucose levels are low to increase sugar levels (in cirrhosis, if the patient is sick or not eating the liver is unable to convert the glycogen to glucose so the patient can have episode of hypoglycemia)Lipids and Proteins. The liver converts ammonia, which is a byproduct of protein breakdown, into urea which is then excreted via the urine. Urea is much less toxic to the brain that ammonia. This doesn't happen in cirrhosis which is why the patient will have neuro change, asterixis, HEPATIC ENCEPHALOPATHY, etc. Storage:Stores vitamins (vitamin B12, A, E, D, and K) and minerals along with iron and glycogen. Remember bile is essential for the absorption of fat soluble vitamins. In cirrhosis, bile production is impaired which will lead to decreased absorption and storage of those fat soluble vitamins (vitamin A, D, E, and K) Digestion:hepatocytes produce bile to help with the absorption of fats (bile is stored in the gall bladder) and those fat soluble vitamins.In the bile and stool is a substance call BILIRUBIN. How does the bilirubin get there?Remember RBCs are removed by the Kupffer cells and components of the RBCs are recycled. The Kupffer cells break down the hemoglobin into heme and globin groups.Then hepatocytes metabolize heme into iron and bilirubin. The bilirubin is put into the bile and leaves via the stool (which is why stool is brown because bilirubin is a yellow brown substance).In cirrhosis, the hepatocytes are damaged and CAN'T do this so the hepatocytes leak bilirubin in the blood (rather than it entering the bile to leave the body in stool) and the levels increase in the blood and present in the urine. This is WHY the patient will have yellowing of the skin, sclera, mucous membranes, dark urine along with clay-colored stool... JAUNDICE! Production of blood plasma proteins: albumin (maintains oncotic pressure and water regulation within the interstitial tissue), fibrinogen, prothrombin (aids in clotting). Detoxifies: makes drugs less harmful to the body. In cirrhosis, the patient is very sensitive to drugs because the liver can't protect the patient from their harmful effects. It also removes toxins from the body (alcohol) and hormones produced by our glands. For example, estrogen is metabolized in the liver. However, in cirrhosis, it is unable to metabolize estrogen which leaves more of the hormone in the body. This can lead to enlarged breast tissue in men (gynecomastia).

Nursing Interventions for Cirrhosis:

Monitor for bleeding (PT and INR) limit invasive procedures and hold pressure at injection sites for 5 minutes or more, soft tooth brushes, safety, assessing stools, urine, petechiae Monitor Esophageal varices Monitor very closely for bleeding, darky tarry stools, vomiting blood, (bleeding is an emergency!!) Watch for activities that can increase rupture: coughing, vomiting, drinking ETOH, constipation Check reflexes, mental status very closely (mental status change, irritability, confusion), hepatic encephalopathy, and for flapping of the hands "asterixis" Diet: If neuro system is compromised: low protein diet: protein breaks down into ammonia If neuro system NOT compromised: high lean protein (fish, poultry) NO ETOH, or raw seafood (oysters....contain bacteria that the immune system is too weak to fight and detoxify from the body), fluid restriction, needs vitamin (administer PO vitamins per MD order) Monitor blood glucose levels (hyperglycemia and hypoglycemia) Assessing sclera and skin color for Jaundice along with urine color: very dark Monitor I's and O's very closely, daily weight, and measuring abdominal girth (monitor ascites) and swelling in extremities Activity intolerance, difficulty breathing (no supine), at risk for skin breakdown (turning every 2 hours), elevating feet Administering Lactulose per MD order: decreases ammonia levels

Complications of cirrhosis

Portal Hypertension: the portal vein becomes narrowed due to scar tissue in the liver. This restricts the flow of blood to the liver and increases pressure in the portal vein. This will affect the organs connected to the portal vein.....like the spleen, vessels to the GI structure (varices). Enlarged spleen: "splenomegaly" What does the spleen do? Stores platelets and WBCs. With portal HTN the platelets and WBCs are kept in the spleen. They can't leave and this leads to a low platelet and WBC count. Esophageal Varices (as well as gastric varices): due to the increased pressure via the portal vein. This increased pressure causes the veins to become weak, and they can RUPTURE! Life-threatening if the varices rupture: WHY? Remember the platelet count will be low along with clotting factors available AND levels of Vitamin-K...they are at risk for a total bleed out. Fluid overload in legs and abdomen: Ascites (fluid in the abdomen). If the patient has ascites, they are at risk for infection from bacteria in the GI system. Remember the immune system is compromised because of low WBC production. Swelling in the legs and ascites is happening due to venous congestion from the portal HTN and low albumin levels (the water is not being regulated in the body and is entering the interstitial tissue). Jaundice: yellowing of the sclera of the eyes, mucous membranes, and skin. This is due to the hepatocytes leaking bilirubin into the blood rather than the bile. Hepatic Encephalopathy: the liver is unable to detoxify. Ammonia builds up along with other toxins that collect in the brain. This leads to an altered mental system, coma, neuromuscular problems, asterixis (involuntary hand-flapping), hepatic foetor "fetor hepaticus" (late sign). What is Hepatic Foetor? A pungent, musty, sweet smell to the breath (discussed more below) Renal Failure: In severe cases known as Hepatorenal Syndrome. Miscellaneous: Liver Cancer, bone fractures (low vitamin D), diabetes

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

The answer are B, C, and E. Portal Hypertension is where the portal vein becomes narrow due to scar tissue in the liver, which is restricting the flow of blood to the liver. Therefore, pressure becomes increased in the portal vein and affects the organs connected via the vein to the liver. The patient may experience ascites, enlarged spleen "splenomegaly", and esophageal varices etc.

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). Therefore, the patient should consume foods LOW in protein until the encephalopathy subsides. Option A is very high in protein while the others are low in protein. Remember meats, legumes, eggs, broccoli rabe, certain grains etc. are high in protein.

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

The answer is 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.

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

The answer is B.

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

The answer is B. Majority of the blood flow to the liver comes from the hepatic portal vein. This vessel network delivers blood HIGH in nutrients (lipids, proteins, carbs etc.) from organs that aid in the digestion of food, but the blood is POOR in oxygen. The organs connected to the hepatic portal vein are: small/large intestine, pancreas, spleen, stomach. Rich oxygenated blood comes from the hepatic artery to the liver.

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

The answer is C. Based on the assessment findings and the fact the patient has cirrhosis, the patient is experiencing hepatic encephalopathy. This is due to the buildup of toxins in the blood, specifically ammonia. The flapping motion of the hands is called "asterixis". Therefore, an increased ammonia level would confirm these abnormal assessment findings.

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

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

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.

The answer is 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

The answer is 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.

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 cirrhos

The answer is E. All of these conditions can cause cirrhosis.

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

The answers are A, C, and D. A patient with an enlarged spleen (splenomegaly) due to cirrhosis can experience thrombocytopenia (low platelet count), increased PT/INR (means it takes the patient a long time to stop bleeding), and leukopenia (low white blood cells). The spleen stores platelets and WBCs. An enlarged spleen can develop due to portal hypertension, which causes the platelets and WBCs to become stuck inside the spleen due to the increased pressure in the hepatic vein (hence lowering the count and the body's access to these important cells for survival).

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

The answers are 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.)

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

The answers are B, C, and 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).

What causes cirrhosis?

Viral Infection: Hepatitis C*, B 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 in liver and damages cells Autoimmune

role of liver

the liver takes substances in our blood and metabolizes and detoxifies them along with storing and producing substances to help with digestion, clotting, and immune health