Concept Synthesis: Liver Disease
Viral hep infection continued
Hepatitis C- No vaccine -Prevention: Clean needles, safe sex -Tx: Antiviral shown to cure subset Hep C= Ledipasvir/Harvoni -Labs: Positive Hepatitis C antibody, PCR for qualitative & quantitative. Hepatitis D- No vaccine -Prevention Vaccination against Hep B, Tx: Antivirals -Labs: Positive HDAg - infection, -Positive Anti-HD - immunity Hepatitis E- No vaccine. -Prevention: Handwashing, Tx: Immunoglobulins, Interferon Labs: - Positive HEVag - infection, -Positive Anti HD - immunity -If third trimester give immunoglobulins
Liver and Kidney
-Azotemia: increase BUN -Oliguria: -Intractable ascites
A client is about to have a blood transfusion and asks the nurse which type of hepatitis is most frequently transmitted through food. Which type of hepatitis should the nurse teach the client about being most associated with food? A B C D
A Hepatitis A, also known as infectious hepatitis, is caused by an RNA virus that is transmitted via the fecal-oral route and is most frequently transmitted though food. Hepatitis B is transmitted parenterally, sexually, and by direct contact with infected body secretions. Hepatitis C is caused by an RNA virus that is transmitted parenterally. Hepatitis D is a complication of hepatitis B.
Spiralactone
-Pulls aldosterone out -Watch BP before giving
Asterixis is a late sign of hepatic encephalopathy
-True -Ammonia levels will be high -Hand flapping -Will be confused
Which lab value is most important to monitor in your Pt with ascetics in decompensated liver failure
-Albumin -ALT not important since the pt is already in decompensated and the values may be false -Replace IV albumin.
Vitamin Deficiency that result in Wernickie
-B1 Thiamine -WernickiL LOC changes -Wernikcie-Korsokoff: permeant damage
Respiratory effort
-Not supine= increases intraabdominal pressure -Fowlers preferred
Nursing implementation
Ambulatory Care -Community support programs -Symptoms of complications -When to seek medical attention -Written instructions with adequate explanations for patient/family -Referral to community or home health nurse
A nurse is caring for a client with cirrhosis of the liver. Which laboratory test should the nurse monitor that, when abnormal, might identify a client who may benefit from neomycin enemas? Ammonia level Culture and sensitivity White blood cell count Alanine aminotransferase (ALT) level
Ammonia Level Increased ammonia levels indicate that the liver is unable to detoxify protein by-products. Neomycin reduces the amount of ammonia-forming bacteria in the intestines. Culture and sensitivity testing is unnecessary; cirrhosis is an inflammatory, not infectious, process. Increased white blood cell count may indicate infection; however, this will have no relationship to the need for neomycin enemas. ALT, also called serum glutamic-pyruvic transaminase (SGPT), assesses for liver disease but has no relationship to the need for neomycin enemas.
A nurse educator of a college health course is discussing tattoos with the class. Which type of hepatitis associated with tattoos should the nurse include in the teaching plan? A C D E
C Hepatitis C is a blood-borne pathogen that can be transmitted via contaminated tattoo needles. Hepatitis A is not a blood-borne pathogen; it is spread through contaminated food or water. Although hepatitis D is a blood-borne pathogen, it can be produced only when the hepatitis B virus is present. Also, hepatitis D is not the main virus associated with contaminated tattoo needles. Hepatitis E is believed to be transmitted via the fecal-oral route; it is spread through contaminated food or wate
A client is diagnosed with hepatitis A. The nurse provides the client with information about untoward signs and symptoms related to hepatitis. The nurse instructs the client to contact the primary healthcare provider if the client develops what symptom? Fatigue Anorexia Yellow urine Clay-colored stools
Clay-colored stools Clay-colored stools are indicative of hepatic obstruction because bile is prevented from entering the intestines. It is unnecessary to call the healthcare provider because fatigue and anorexia are characteristic of hepatitis from the onset of clinical manifestations. Yellow is the expected color of urine.
Clinical Manifestations
Early Manifestations: -Relatively few symptoms in early stage disease -Fatigue and enlarged liver may be early symptoms -Blood tests may be normal- compensated cirrhosis won't show elevated ALT and AST Late manifestations -Result from liver failure and portal hypertension - Other -Skin lesions, hematologic disorders , endocrine disturbances , and peripheral neuropathies
Best goal for pt with ascetics and fluid overload
Have a decrease in abdominal girth
Viral hepatitis
Hepatitis A - Acute- Transmitted fecal oral route (dirty hands) -can resolve on own Hepatitis B - Acute/Chronic Blood, blood products, sexual contact, and perinatal transmission Hepatitis C -Acute/chronic Blood, blood products, sexual contact, and perinatal transmission. (dialysis) Hepatitis D - Acute/Chronic: HBV must precede HDV Hepatitis E - Acute: Transmitted fecal oral route in developing countries due to poor sanitation.
Iron metabolism
Hepcidin is a key regulator of the entry of iron into the circulation in mammals. During conditions in which the hepcidin level is abnormally high, such as inflammation, serum iron falls due to iron trapping within macrophages and liver cells and decreased gut iron absorption.
Diagnostic
Liver enzyme tests Total protein, albumin levels Serum bilirubin, globulin levels Cholesterol levels Prothrombin time Ultrasound elastography (Fibroscan) Liver biopsy Endoscopy -ALT, AST and GCT Increase because of their relationship with liver cells -In end stage liver disease ALT and AST may be normal due death of hepatic cites (labs not necessary then) -Decrease serum protein and albumin -Increase serum bilirubin, increase glubulin=carrier proteins made in liver -Increase in PT -Decrease cholesterol levels: helps in fats and vitamin D synthesis Liver biopsy is the gold standard -put pt on right side to put pressure and decrease chance of bleeding -Elastography: fiber scan
Alcohol withdrawal
Management begins with identifying high-risk patients -Clinical Institute Withdrawal Assessment of Alcohol Scale (CIWA) -CM: Agitation, anxiety, hypertension, tachycardia, diaphoresis, tremors to disorientation, visual & auditory hallucinations, seizures to death. Treatment: Benzodiazepines, thiamine, Vitamins, Mg, IV glucose, Beta blockers, -Tegretol/Depakote to prevent seizures, Librium or Haldol for psychosis.
A client is admitted to the hospital with a diagnosis of cirrhosis of the liver. For which assessment signs of hepatic encephalopathy should the nurse assess this client? Select all that apply. Mental confusion Increased cholesterol Brown-colored stools Flapping hand tremors Musty, sweet breath odor
Mental confusion Musty, sweet breath odor Flapping hand tremors An accumulation of nitrogenous wastes affects the central nervous system, causing mental confusion. An accumulation of nitrogenous wastes in hepatic encephalopathy affects the nervous system. Flapping tremors and generalized twitching occur in the second and third stages, respectively. Fetor hepaticus is the musty, sweet odor of the client's breath. Increased cholesterol levels are not necessarily present. Stool is often clay-colored because of lack of bile caused by biliary obstruction.
A client is admitted to the hospital with a history of cancer of the liver and jaundice. In relation to the jaundice, the nurse expects the client to report the presence of what symptom? Pruritus Diarrhea Blurred vision Bleeding gums
Pruritis itching associated with jaundice is believed to be caused by accumulating bile salts in the skin. Diarrhea, blurred vision, and bleeding gums are not related to jaundice.
Role of liver Pt 2: Meta of toxins and aldosterone and estrogen
Role of liver -Metabolize drugs: -Metabolize aldosterone and estrogen Cirrhosis -Decrease in metabolism of drugs, stays in the system longer. - Increase levels of aldosterone and estrogen -Red hands: flushed palmer= estrogen can't metabolize in body CM -Toxicity of medications - varied by the drug -Aldosterone - causes increase in water and sodium retention -Estrogen causes palmer erythema, spider angiomas, gynecomastia in men, impotence, testicular atrophy, amenorrhea (no bleeding), or bleeding. Interventions -Give spironolactone to pull aldosterone and decrease H20 and sodium
A nurse is caring for a client who is positive for hepatitis A. Which precautions should the nurse take? Wear a gown when entering the client's room. Use caution when bringing in the client's food. Use gloves when removing the client's bedpan. Wear a protective mask when entering the client's room.
Use gloves when removing the client's bedpan.
Causes
Viral (most common) Alcohol Medications Chemicals Autoimmune Metabolic abnormalities
Long term management
Long-term management -Nonselective βB -Repeated band ligation -Portosystemic shunts Shunting procedures -Used more after second major bleeding episode - Nonsurgical: transjugular intrahepatic portosystemic shunt (TIPS) -Surgical: portacaval and distal splenorenal shunt
Role of Liver 3: Vitamins and clotting factors
Role of liver -Storage of glycogen, fat soluble vitamins A,D,E,K, and water soluble vitamins B,C -Minerals such as Copper & Iron. -Breaks down old RBC's and recycles iron and heme. -Production of clotting factors; clotting facets, fibrinogen, prothrombin, Factors, protein C and S and anti-thrombin Cirrhosis -decrease in Vitamin D, K, B1 Thiamine (Vitamin B1) -we need it to breakdown glucose -we need thiamine before we give glucose -can turn into a condition if deficiency persists -Decrease in clotting factors CM -Vit D: Increase risk for bone fractures -Bleeding tendencies -Wernicke-Korsokoff Syndrome -Bleeding Esophageal Gastric, Rectal & due to high Portal vein pressure Interventions -Don't give IM injections: risk of bleeding -Give beta blocker for esophageal varicose to decrease portal hypertension
Nursing Assessment
Subjective Data -PMH -Last time/day of alcohol -Intake. Objective Data -Physical Assessment -Vital Signs -Labs -Diagnostics
Inflammation
Cirrohis: end stage disease of liver -fibrous nodules C-irrhosis is an inflammatory condition that occurs in the liver that can lead to cell death • From this inflammatory issue, scar tissue begins to form on the liver which creates nodules which affect the perfusion coming into the liver • As blood flow to the liver continues to be alter it leads to further scar tissue and nodules-forming which can lead to liver failure
The parent of a newborn asks a nurse why, except for hepatitis B vaccine, the immunization schedule does not start until the infant is 2 months old. How should the nurse respond? "A newborn's spleen can't produce efficient antibodies." "Infants younger than 2 months are rarely exposed to infectious disease." "The immunization will attack the infant's immature immune system and cause the disease." "Maternal antibodies interfere with the development of active antibodies by the infant when immunized."
"Maternal antibodies interfere with the development of active antibodies by the infant when immunized." Passive antibodies received from the mother will be diminished by age 8 weeks and will no longer interfere with the development of active immunity to most communicable diseases. -The spleen does not produce antibodies. Infants often are exposed to infectious diseases. The viruses in immunizations are inactivated or attenuated; they may cause irritability and fever but will not cause the related disease.
Liver Pt develop agitation, fine tremors and tachycardia
-Alcohol withdrawal -Watch within 24 hours -Occurs when alcohol use abruptly stops -Variable course -Peaks at 24-96 hours after last drink (usually around 48 hours) -May progress to alcohol withdrawal delirium Clinical manifestations of withdrawal: -Agitation -Anxiety -↑ Heart rate -↑ BP -Diaphoresis -Nausea -Tremors -Insomnia -Hyperactivity IPE Management of care for withdrawal -Benzodiazepines or barbiturates: to prevent seizures and delirium -Lorazepam (Ativan) -Chlordiazepoxide (Librium) long acting benzo: with liver disease be cautious with giving it takes longer to metabolize -Phenobarbital (Luminal): not as bad at depressing Resp Depp. Sedation to control hyperactivity -Dexmedetomidine (Precedex): SE: Hypotension, Brady doesn't effect Resp. -Thiamine to prevent Wernicke-Korsakoff syndrome -Multivitamins -Magnesium sulfate -IV glucose solution to treat hypoglycemia Alpha/Beta -β-blockers (e.g., propranolol) -α2-agonists (e.g., clonidine) to stabilize VS: central acting alpha agonist to decrease BP -Respiratory support -Mechanical ventilation?
hepatorenal failure
-Azotemia: increase BUN and Urea -Oliguria -Intrattabile ascites Portal hepato renal failure -liver decomposition and portal hypertension results in splanchnic and systemic vasodilatation =Decreases arterial volume: renal vasoconstriction Increase Acities -translocation of bacteria in blood -Decrease Resp Esophageal varicies -Stabilize airway -O2 -Upright -IV therapy: blood constrict -IV therapy: blood constrict Splanchnic vasodilation is responsible for the hypoperfusion of the renal system which An increase in splanchnic blood flow in portal hypertension is the result of a marked vasodilation of arterioles in splanchnic organs, which drain blood into the portal venous system[35].
Portal hypertension: Decompansated lover
-Caput medusa -umbilica collateral venous system comes enlarged -Caused by damaged liver that increases pressure in the portal venous system and increases pressure in the inferior vena cava -Sleenomegaly: thrbombocytopenia, leukopenia, anemia: -causes the spleen to be encouraged with blood: decrease WBC, Platlets, RBC -Panconomia: spleen hold excess blood and splices cells -Bleeding in nose: epistaxis
Interventions with bleeding esophageal varicose: blood loss
-FFP -Blackmoter tube -Aquamephyton: Vitamin K to prevent further bleeding
Role of liver: F&E
-Hypokolemia due to hyperaldosternism -Lactulose will cause hypokalemia Cirrhosis -Hypokalemia due to hyperaldosteronism, nutritional intake, and diuretics. -Hypo or hypernatremia CM Cardiac dysrhythmias -Increase NA and Water retention -Decrease in NA (changes in LOC for too high or too low).
Esophageal varices
-If bleeding occurs, stabilize patient, manage airway, provide IV therapy and blood products -Drug therapy =Endoscopic therapy -Supportive measures for -Acute bleed -Varicies don't tolerate high pressure -Blackmore tube top decrease bleeding and esophageal varices (emergency only)
Vasopressin slows blood loss in GI bled by constricting splanchnic arteriolar bed by decreasing portal hypertension
-Octiatide IV (like vasopressin) -Beta blockers
Labs seen with decomposated liver failure
-Prolonged PT -Elevated bilirubin -Decreased Albumin Partial thromboplastin time (PTT) -Intrinsic and common pathways -A normal finding is 60-70 seconds. -Heparin Prothrombin time (PT) 11-12.5 seconds -Warfarin
Interventions esophageal varicose
-Sengten Blackmore tube (emergency) -Edoscopy with sclerotherapy -Octreotide infusion: vasopressin -Vitamin K: help with clotting Long term care: beta blockers Rifaxamin given with hepatic encephalopathy to decrease ammonia levels
In direct bilirubin is associated with hepatic disease
-True -Indirect bilirubin is not cogugated -itching of the body -Sclera covered eyes -urines: looks brown
A client is diagnosed as having the hepatitis B virus (HBV). The nurse reviews the client's health history for possible situations in which exposure may have occurred. Which event does the nurse determine is most likely the source of this infection? Had a small tattoo on the arm three months ago Assisted in the emergency birth of a baby two weeks ago Worked for a month in an undeveloped area in Mexico four months ago Attended an ecologic conference in a large urban center two months ago
Had a small tattoo on the arm three months ago Any situation in which a needle is inserted under the skin is a potential source of hepatitis; according to the Centers for Disease Control and Prevention, the range for the incubation period is 45 to 180 days; however, the average incubation period is 60 to 90 days. The range for the incubation period is 45 to 180 days. Hepatitis B is not transmitted via inadequate sanitation or a contaminated water supply. Hepatitis B is not transmitted by casual proximity to others.
Viral Hep: prevention
Hepatitis A - Vaccine -Prevention: Vaccination -Tx: Support, Immunoglobulins -Labs: Positive: Hep A IGM = acute infection -Positive: Hep A antibody IgG = immunity Hepatitis B- Vaccine -Prevention: Vaccination, clean needles and safe sex -Tx: Acute- Immunoglobulins. -Chronic PEG Interferon 2a/2b Labs -Positive HBsAg (hepatitis surface b antigen - infected -acute/chronic). -Positive HB Core Ab IgM = acute hepatitis -Positive Hepatitis B surface Antibody (Immunity from vaccine or infection) IgM: acute problem IgG: passive acute issue
When preparing a client for a liver biopsy, what should the nurse instruct the client to do? Turn onto the left side after the procedure Breathe normally throughout the procedure Hold the breath at the moment of the actual biopsy Bear down during the insertion of the biopsy needle
Hold the breath at the moment of the actual biopsy Holding the breath at the moment of the actual biopsy ensures that the liver does not move as it normally does with regular respiratory excursions; minimizing movement reduces potential injury to the liver. -Lying on the right side after the procedure applies pressure at the insertion site, preventing hemorrhage. Movement or breathing increases the danger of damage to the liver. -Bearing down (Valsalva maneuver) during the insertion of the biopsy needle is unnecessary; holding the breath at the moment of the actual biopsy is all that is necessary to help minimize injury to the liver.
A nurse is caring for a client who is admitted to the hospital with ascites and a diagnosis of cirrhosis of the liver. What does the nurse conclude is the probable cause of ascites? Impaired portal venous return Inadequate secretion of bile salts Excess production of serum albumin Decreased interstitial osmotic pressure
Impaired portal venous return An enlarged liver impairs venous return, leading to an increased portal vein hydrostatic pressure and a fluid shift into the abdominal cavity. Bile plays an important role in digestion of fats, but it is not a major factor in fluid balance. Increased serum albumin causes hypervolemia, not ascites. Ascites is not associated with the interstitial fluid compartment.
Other causes
Non-Alcoholic Fatty Liver and Non-Alcoholic Steatohepatitis Biliary cirrhosis: primary cholangitis -Affects bile ducts and backs up in liver causes inflammation Cardiac cirrhosis -RS HF -Hepatic venous congestion
Planning
Overall Goals -Relief of discomfort -Minimal to no complications -Reduce or eliminate risk factors -Treat alcoholism -Maintain adequate nutrition -Identify and treat acute hepatitis
Portal venous system
Rectal varicose (hemorrhoids) -Can cause bleeding Portal hypertension: Decompansated lover -poop medusa -umbilica
Role of Liver: Metabolism of Protein and Glucose
Role -Metabolize Protein, to AA, to ammonia, converted by the liver into BUN and excreted by kidneys. -Metabolize Glucose, stored in the liver as glycogen or gluconeogenesis (hemostasis of sugars). Cirrhosis -Increase levels of ammonia - crosses blood brain barrier.: Asiercixis (arm flapping and is a late sign of hepatic encephalopathy ; Give lactulose -When storage is impaired hyperglycemia occurs, -when breakdown is impaired hypoglycemia occurs. Insulin resistance and clearance. CM -Hepatic Encephalopathy (changes in LOC, behavior, and coma). -Asterixis - flapping hands, unable to write or draw. -Hyperglycemia and or hypoglycemia. Interventions -Give rifaximin antibiotic to kill bacteria in gut flora; decreases ammonia level since gut bacteria produce ammonia -Give high carb, low fat normal protein -Encourage fluids -Hepatic Encephalopathy begins to occur when liver cells become damaged which can be a result from cirrhosis. -The accumulation of toxins accumulate in the bloodstream and travel to the braincauses encephalopathy
Role of the liver 4: Production of albumin and digestion of bilirubin
Role of Liver -Production: Albumin for oncotic pressures -Aides in Digestion -Bilirubin and production of bile, secreted into the GB stored and release into small intestine when fats are present Cirrhosis -Hypoalbuminemia, changes in oncotic pressure and movement of fluid to third and other space. -Primary cause due to portal hypertension )peripheral and sacral edema) -GET ABDOMINAL GIRTH DAILY -Decrease in bile production. -Hyperbilirubinemia (decrease in hepatic clearance of bilirubin and hemolysis). CM -Ascites (primary cause from portal hypertension) Peripheral and sacral edema -Jaundice of the skin and sclera of the eyes. -Urine is dark in color- brownish -Clay/pale colored stools.: secreting fats -Extreme fatigue N/V -Before Pericentisis have them use the restroom -High fowls -After look for bleeding -Hyperbiliruben= hemolysis -Serum bilirubin is a specific marker for liver disease but sensitivity is low for detecting liver damage
A nurse is teaching a client about prophylactic measures that minimize the risk of contracting hepatitis B. Which actions should be included in this teaching plan? Select all that apply.
Screening of blood donors Maintaining a monogamous sexual relationship
The nurse is providing care to a client with ascites secondary to liver failure. What is appropriate to include in this client's care? Select all that apply. High protein diet Low sodium diet Daily abdominal girth measurements Encourage increased by mouth fluid intake Daily weights
Daily weights Low Na Abdominal girth In the client with liver failure and ascites, the liver has lost its ability to synthesize proteins. This leads to hypoalbuminemia and decreased oncotic pressure in the vessels. This decrease in oncotic pressure leads to fluids leaking out of the vessels and into the interstitial spaces and peritoneum, causing edema and ascites. A low sodium and low protein diet is recommended. A high protein diet will worsen the symptoms, and often these clients are on a fluid restriction. Taking daily weights is the most reliable indicator of fluid retention. High protein diet increases ammonia levels!