Nurse 405B: Liver Issues
Treatment: Ascites
•Treatment focuses on sodium restriction, diuretics, & fluid removal •Albumin infusion •Diuretics •Spironolactone (Aldactone) •Furosemide (Lasix): increase osmotic pressure in vessels •Tolvaptan (Samsca) 15-60 mg PO daily •Correct hyponatremia •Paracentesis •Relieve pain, pressure, or SOB in patients not responding to diuretics •Temporary and palliative •TIPS (discuss with varices): shunting blood from portal system directly into circulation, bypassing portal system all together
Liver Cancer Diagnostics
•Ultrasound •CT •MRI •Liver biopsy •Increased serum alpha-fetoprotein (AFP) •Protein made by the liver & produced when cells regenerating •Tumor marker •Normal < 10-40 ng/ml •Possible tumor > 500 ng/ml
Nursing Assessment
Subject: •PMH •Medications: Tylenol •Alcohol abuse •Weight loss •Bleeding / bruising •Urine & bowel elimination changes •RUQ or epigastric pain •Pruritis Objective: •Altered mental status, asterixis •Cachexia / wasting •Jaundice, petechiae, ecchymosis, spider angiomas, palmar erythema, alopecia, peripheral edema •Shallow, rapid respirations •Epistaxis •Abd distention, ascites, palpable liver and spleen, hemorrhoids •Hematemesis or melena •Hemorrhoids: varices in the lower part of recutm
The nurse is caring for a patient who has cirrhosis. Which data obtained by the nurse during the assessment will be of most concern? A.The patient complains of right upper-quadrant pain with palpation. B.The patient's hands flap back and forth when the arms are extended. C.The patient has ascites and a 2-kg weight gain from the previous day. D.The patient's abdominal skin has multiple spider-shaped blood vessels.
B.The patient's hands flap back and forth when the arms are extended.
To detect possible complications in a patient with severe cirrhosis who has bleeding esophageal varices, it is most important for the nurse to monitor A.bilirubin levels B.ammonia levels C.potassium levels D.prothrombin time
B.ammonia levels Number one complication is the hepatic encephalopathy-->ammonia would trend up RBC in tract and liver cant break it down to excrete
Which response by the nurse best explains the purpose of pantoprazole (Protonix) for a patient admitted with bleeding esophageal varices? A.The medication will reduce the risk for aspiration. B.The medication will inhibit development of gastric ulcers. C.The medication will prevent irritation of the enlarged veins. D.The medication will decrease nausea and improve the appetite.
C.The medication will prevent irritation of the enlarged veins.
Liver Cancer: Clinical Manifestations
•Absent or subtle changes early stages •Usually due to cirrhosis rather than a tumor •Hepatomegaly, splenomegaly, fatigue, edema, ascites, portal HTN •Late manifestations include fever, chills, jaundice, anorexia, weight loss, palpable mass, RUQ pain
Risk Factors & Prevention
•Alcoholism •Malnutrition •Viral hepatitis •Biliary obstruction •Obesity: •~~Steatohepatitis: fatty liver; fat deposits cause liver not to work •Right sided heart failure: fluid overload; inflammatory process •Adequate nutrition •Identify & treat acute hepatitis •Weight loss and/or bariatric surgery for morbid obesity
Hepatic Encephalopathy: Clinical Manifestations
•Asterixis: hands flapping up and down when they hold their hands out •Impaired writing: not able to write the way they had been before--> unable to process and write left to right •Apraxia: unable to recognize objects in hand •Tongue fasciculations: muscle movements of tongue, grimacing, grasping reflexes •Hyperventilation •Hypothermia •Fetor hepaticus: distinct sweet smell of their breath
Nursing Care for Cirrhosis: Bleeding Varices
•Bleeding Varices •Monitor for hematemesis and melena •Balloon tamponade: •Monitor for rupture/erosion of esophagus, regurgitation/aspiration of gastric contents, & airway occlusion •Suction & keep in semi-Fowler's position •If gastric balloon breaks or deflates esophageal balloon moves up & restricts airway •Cut tube or deflate esophageal balloon - MUST have scissors at bedside
Cirrhosis: Patient Education
•Chronic illness & need for ongoing healthcare •Symptoms of complications & when to seek care •Avoid hepatotoxic OTC medications •Alcohol abstinence •Avoid ASA & NSAIDS with varices •Avoid straining to defecate, cough, sneeze, belching, or vomiting
Liver Cancer Nursing Care
•Prevention •Identify & treat chronic hepatitis B & C •Treat alcohol abuse •Screen patients at high risk •Obtain AFP & liver imaging •Treatment based on stage of liver cancer, patient age, co-morbidities
Nursing Care for Cirrhosis: Skin, Resp., MSK
•Skin •Bleeding / ecchymosis •Pruritis from jaundice •bilirubin irritates peripheral nerves = intense itching sensation •Hydroxyzine, antihistamines, moisturizing baths, calamine lotion, temp control •Edematous tissue prone to breakdown •Turn & reposition Q2 hours, support with pillows •Respiratory •Dyspnea with ascites & pleural effusions •Cough & deep breathing •MSK •ROM
Cirrhosis Treatment Goals
•Slow progression •Prevent & treat any complications •Ascites •Esophageal & gastric varices •Hepatic encephalopathy
Treatment: Bleeding Esophageal & Gastric Varices contin.
•Stop the bleeding, identify source, & prevent further bleeding •octreotide (Sandostatin) or vasopressin •Vasoconstriction decreases portal blood flow & portal HTN •UGI •Band ligation - endoscopic variceal ligation (EVL) •Sclerotherapy •Balloon tamponade •When bleeding cannot be controlled •Mechanical compression of varices •Different tubes available
Liver Cancer Treatment
•Surgical resection •Partial hepatectomy •Best cure but only 15% have healthy liver tissue •Liver transplant •With early stages & impaired liver function •Good prognosis •Non-surgical •Percutaneous ablation •Chemoembolization •Radioembolization •Sorafenib (Nexavar): cuts off blood supply to tumor; angiogenesis inhibitorà prevents tumor form creating massive blood supply
Cirrhosis: Nursing Diagnoses and Goals of Care
1.Imbalanced nutrition: less than body requirements •Anorexia, nausea, impaired nutrient use & storage 2.Impaired skin integrity •Peripheral edema, ascites, pruritus 3.Excess fluid volume •Portal HTN, hyperaldosteronism 4.Ineffective health management •Ineffective coping, alcohol abuse 5.Altered thought process •Elevated ammonia level 6.Potential for injury Return to near normal lifestyle relief of discomfort minimal to no complicaitons
During change-of-shift report, the nurse learns about the following four patients. Which patient requires assessment first? A.A 40-yr-old patient with chronic pancreatitis who has gnawing abdominal pain B.A 58-yr-old patient who has compensated cirrhosis and is complaining of anorexia C.A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C) D.A 36-yr-old patient recovering from a laparoscopic cholecystectomy who has severe shoulder pain
A.A 55-yr-old patient with cirrhosis and ascites who has an oral temperature of 102° F (38.8° C)
Types of Cirrhosis
Alcoholic: number one cause, most common, 30% of cirrhosis cases; 8-16oz of hard liquor for 15 years Biliary: not as common; primary cause or secondary cause; typically happens to women--> usually an autoimmune disorder that affects the liver; secondary: obstruction in the liver--> gall stones blocking biliary drainage movement Post-necrotic: drug or toxin causes damage; hepatitis; rare
A patient with advanced cirrhosis who has ascites is short of breath and has an increased respiratory rate. The nurse should: A. Initiate oxygen therapy at 2 L/min to increase gas exchange. B. Notify the health care provider so that a paracentesis can be performed. C. Ask the patient to cough and breathe deeply to clear respiratory secretions. D. Place the patient in Fowler's position to relieve pressure on the diaphragm.
D. Place the patient in Fowler's position to relieve pressure on the diaphragm. ways to relieve pressure on diaphragm is making sure they sit up
A serum potassium level of 3.2 mEq/L (3.2 mmol/L) is reported for a patient with cirrhosis who has scheduled doses of spironolactone (Aldactone) and furosemide (Lasix) due. Which action should the nurse take? A.Withhold both drugs B.Administer both drugs C.Administer the furosemide D.Administer the spironolactone
D.Administer the spironolactone
Hepatic Encephalopathy: Grading Scale
Grade 0: Normal/minimal change Grade 1: Lack of awareness, sleep disturbances Grade 2: lethargy, drowsiness Grade 3: somnolent, arousable Grade 4: Comatose
Laboratory findings
•Elevated Liver Function Studies (LFTs): •Alanine Aminotransferase (ALT) - enzyme made by cells in liver (5-30 U/L) •Aspartate aminotransferase (AST) - enzyme in liver, heart, skeletal muscles, kidney, brain, and RBC (5-30 U/L) •Alkaline Phosphatase (Alk Phos) - enzyme found along bile ducts (50-100 U/L) •AST/ALT Ratio: •Usually < 1 •ALT > AST most liver injury •AST > ALT - consider muscle ratio •Not good measures of liver function - other sources may increase these levels •Consider also: obesity or DM •Bilirubin gives bile it's color: •Serum bilirubin (total) 0.1 to 1.2 mg/dl •Direct bilirubin - < 0.3 mg/dl •Free bilirubin - < 1.1 mg/dl •Ammonia: (15-50 mmol/L) •Creatinine: (0.5 - 1.1 mg/dl) •Prolonged PT/INR Decreased albumin (35-50 g/L
Cirrhosis
•Extensive degeneration & destruction of hepatocytes •Liver cells attempt to regenerate •Regeneration is disorganized •Overgrowth of new & fibrous connective tissue •Disturbs normal lobular structure = irregular •Decades of chronic liver disease = cirrhosis •8th leading cause of death in US •Males > Females
Supportive Measures for Bleeding Varices
•FFP or PRBCs •Vitamin K: 2.5-25 mg PO daily PRN or 10 mg SQ/IM/IV Q6-8 hours PRN based on INR level •Helps with clotting •PPI •Prevent hepatic encephalopathy •lactulose: 30-45 ml PO TID to QID •Increases stool water content and stool acidity •Traps ammonia ions and they pass it out in BM •AE: flatulence, intestinal cramps, abd distension, n/v---à all on top of what they have •Monitor electrolytes •rifaximin (Xifaxan): 550 mg PO BID •Poorly absorbed antibiotic that eliminates ammonia producing bacteria in intestines •C. diff, superinfection, nausea, dizziness, abd pain, pruritus •About $2000 per month
Nursing Care for Cirrhosis: Fluid Status, Labs, Paracentesis
•Fluid status •Accurate I/O, daily weights, measure abd girth, monitor peripheral edema •Labs •Monitor LFTs, electrolytes, renal function, anemia, bleeding indices •Paracentesis •Void prior to prevent bladder puncture •High Fowler's position after •Monitor for hypovolemia and electrolyte imbalances •Monitor BP, HR, dressing
Treatment: Hepatic Encephalopathy
•Goal is to decrease ammonia formation •Decrease ammonia with lactulose •Rifaximin option if no response to lactulose •Avoid constipation •Want regular & frequent bowel movements •Treat precipitating causes •GI bleed, constipation, hypokalemia, hypovolemia, infection, cerebral depressants, metabolic alkalosis, paracentesis, dehydration, increased metabolism, uremia
Treatment: Esophageal & Gastric Varices
•Goal: prevent bleeding & rupture by decreasing portal pressure •Avoid alcohol, ASA, NSAIDS: acetaminophen •All patients with cirrhosis need UGI to screen for varices •Varices present & risk for bleeding: •Non-selective beta-blocker (nadolol or propranolol) •decrease high portal pressure which decreases risk for rupture and won't affect systemic system as much •Varices present & bleeding: •Stabilize & maintain airway •Treat with blood, drugs, & endoscopic procedures together
Paracentesis
•Have patient void first •Trocar catheter inserted into abdomen to drain ascitic fluid from peritoneal cavity •More commonly used to examine fluid & send samples to the lab •If used to relieve acute symptoms (respiratory and/or abdominal distress), then fluid slowly drained (1 to 3 L) •Rapid removal causes vasodilation & potentially hypovolemic shock •Patient has adjusted to excess abdominal volume & pressure
Nursing Care for Cirrhosis: Hepatic Encephalopathy
•Hepatic encephalopathy •Confusion, increased fall risk •Assess frequently •LOC, sensory & motor function, fluids, electrolytes, acid-base balance, response to treatments •Neuro checks Q2 hours •Fall prevention •Decrease/avoid constipation •Rx = laxatives & enemas •Encourage fluids if appropriate/tolerated
Cirrhosis Causes
•Hepatitis C* •20% with hepatitis C •10-20% with hepatitis B •Alcohol* •Nutrition related •Extreme dieting, malabsorption, obesity •Environmental factors •Genetic predisposition •Biliary causes: obstruction •Cardiac cirrhosis: long standing right sided HF •*Most common causes: Hep c and alcohol
Cirrhosis Clinical Manifestations
•Jaundice: unable to conjugate bilirubin and it's picked up into circulation •Skin: trunk, upper extremities, face, palms •Spider angiomas •Palmar erythema •See these because estrogen is not being metabolized in the liver so we have more circulating in system •Hematology •Thrombocytopenia, leukopenia, anemia, and coagulation disorders: live runnable to make clotting factors •Endocrinology •Estrogen increase, testosterone increase, and aldosterone: hyperaldosteronism--> why we use spironolactone for these patients May not feel bad early on Can see portal hypertension
Liver Cancer
•Liver cancer most common cause of death with cirrhosis •Hepatocellular carcinoma (HCC) - 75% of cases •Cirrhosis due to Hep C & alcohol most common cause in US •Intrahepatic cholangiocarcinoma - bile duct cancer •35,660 diagnosed with liver cancer annually in US •24,550 deaths annually •5th most common cancer worldwide •2nd most common cause of death •Males > Females •Common site of metastasis is liver
Diagnostics
•Liver ultrasound •Fibroscan: done in GI office, soundwaves transport through liver and they grade 0-4; how much fibrous tissue is inside •CT or MRI •Biopsy: for definitive diagnosis •Percutaneous risky due to increased risk of bleeding •Interventional radiologist: sheath through jugular vein into hepatic vein •Esophagogastroduodenoscopy (EGD): looking for varices, SI issues, duct blocked
Recurrent Bleeding Varices
•Non-surgical & surgical shunting •Usually done after second major bleed •Transjugular intrahepatic portosystemic shunt (TIPS)
Liver Cancer Prognosis
•Poor prognosis •Rapidly progressing cancer •6-12-month survival without treatment •Hepatic encephalopathy or GI bleed
Cirrhosis Complications
•Portal HTN: not equivalent to BP in arm •Varices •Ruptured esophageal varices most life-threatening complication •Peripheral edema •Ascites •Spontaneous bacterial peritonitis •Hepatic encephalopathy: -•Neuro-psych manifestation -•Multifactorial -•Factors that increase ammonia may precipitate •Hepatorenal syndrome: bleeds out to kidney's and leads to loss of kidney function--> they try to vasoconstrict to hold on to fluid and put more in the system since all the fluid is in the gut Confusion to comatose Ammonia building up in bloodstream
