Ch. 53 M/S Liver problems

. A nurse assesses a client who is recovering from a paracentesis 1 hour ago. Which assessment finding requires action by the nurse?

. Urine output via indwelling urinary catheter is 20 mL/hr

Itching tx

Avoid too warm NO soap Moisturize skin Steroids Cool compresses

Jaundice

Yellow skin, sclera Causd by -Hepatocellular disease (liver cannot excrete bilirubin) -Intrahepatic obstruction (edema/fibrosis/duct scars)

. A nurse cares for a client who has cirrhosis of the liver. Which action should the nurse take to decrease the presence of ascites?

. Provide a low-sodium diet.

Ascites

Orthopnea, dyspnea, can't stand up straight Measure girth at end of respiration/exhalation Daily weights- most reliable indication of fluid retention

A nurse delegates hygiene care for a client who has advanced cirrhosis to an unlicensed nursing personnel (UAP). Which statements should the nurse include when delegating this task to the UAP? (Select all that apply.)

. Apply lotion to the clients dry skin areas For the clients oral care, use a soft toothbrush Provide clippers so the client can trim the fingernails.

. An emergency room nurse assesses a client after a motor vehicle crash. The nurse notices a steering wheel mark across the clients chest. Which action should the nurse take?

. Assess the client by gently palpating the abdomen for tenderness.

. A nurse assesses a client who is prescribed an infusion of vasopressin (Pitressin) for bleeding esophageal varices. Which clinical manifestation should alert the nurse to a serious adverse effect?

. Mid-sternal chest pain

A nurse assesses clients on the medical-surgical unit. Which client is at greatest risk for the development of carcinoma of the liver?

A 66-year-old who has a history of cirrhosis

A nurse cares for a client who is hemorrhaging from bleeding esophageal varices and has an esophagogastric tube. Which action should the nurse take first?

Assess the client for airway patency

Cirrhosis labs

AST/ALT, LDH: <1/0 Elevated bilirubin levels PT/INR prolonged Low platelet, anemia, elevated ammonia XR, CT- -megalies, US, Arteriography, EGD

Cirrhosis hx

Age Gender Sex orientation Healthcare worker, police officer, firefighter? ETOH? RX use? Herbs? Needlestick injury? Tattoo? Military/prison? Men-men sex higher risk

Splenomegaly

Backup blood into spleen *Destroys platelets*- causes thrombocytopenia - Increased risk for bleeding, easy bruising

Biliary obstruction

Bile breaks down fat, fat soluble vitamins can't be absorbed -Prevents Vit. K absorption, clotting factors not produced -Pt easily bruise/ bleed

Esophageal varices

Causes bleeding, AEB hematemesis and melena Rupture? -Pt may lose consciousness before bleeding is noticed Life-threatening EMERGENCY!!! CODE FAST!!! - Hypovolemic shock Cause of bleeding: exercise, heavy lifting, chest trauma, dry/hard food in esophagus

Cirrhosis causes

Chronic ETOH abuse Chronic, viral hepatitis Bile duct disease Genetic diseases

. A nurse cares for a client who is prescribed lactulose (Heptalac). The client states, I do not want to take this medication because it causes diarrhea. How should the nurse respond?

Diarrhea is expected; thats how your body gets rid of ammonia

Hep B

Double-shelled particle Antigens can circulate in blood Causes: Needlesticks, sharing syringes, razors, toothbrushes, needles, Direct blood contact, blood transfusions, Hemodialysis, Birth, lots sex partners Blood test confirms Chronic carriers have higher risk for cirrhosis and liver CA Healthcare workers, cops, firefighters, prisoners, immunosuppressed pts, contact with HBV pts- vax *Blood-blood transmission* Extrahepatic sx: Depression, polyarthritis, myalgia, renal insufficiency, cognitive impairments, cardiac problems

Cirrhosis s/s

Early: fatigue, wt changes, GI sx Late: jaundice, ascites, GI bleed, spontaneous bruising

Cirrhosis sx

Enlarged liver, then shrinks in size and function, becomes *necrotic*

Cirrhosis

Fibrotic bands of connective tissue that changes the liver's make up and affects cellular regulation. -Inflammation damages hepatocytes -Liver becomes *nodular*- blocks ducts -*Blood/lymph flow impaired* *Extensive, irreversible scarring d/t hepatic inflammation*

Cx of Hepatitis

Fulminant- liver cells don't regenerate, necrotic progression- fatal Chronic inflammation lasts >6mos- usually result of B/C *B/C- asx with CANCER

Risk factors for Cirrhosis

Hepatitis C- 2nd leading cause U.S. Hep B+D- most common worldwide ETOH excessive + prolonged use

Cause of hepatic encephalopathy

High protein diet Infection Hypovolemia Hypokalemia Constipation GI bleed Drugs- illicit use

A nurse assesses a male client who has symptoms of cirrhosis. Which questions should the nurse ask to identify potential factors contributing to this laboratory result? (Select all that apply.)

How frequently do you drink alcohol? Have you ever had sex with a man? Were you previously incarcerated?

. A nurse obtains a clients health history at a community health clinic. Which statement alerts the nurse to provide health teaching to this client?

I take a lot of Tylenol for my arthritis pain

Late-stage cirrhosis s/sx

Jaundice Dry skin Rashes Petechiae Ecchymoses Vascular lesions-spider angiomas Ascites Peripheral dependent edema Vitamin deficiency ADEK

Cirrhosis RX

Lactulose- removes ammonia via stool Causes diarrhea- watch elytes, dehydration, skin breakdown Abx- Neomycin sulfate, rifixamin (Flagyl)- toxic to kidneys- use if lactulose doesn't work

First sign of liver dysfunction

Thrombocytopenia

Stage 4 Hepatic Encephalopathy

Unresponsive Unarousable No response pain Positive Babinkski sign Muscle rigidity Liver breath- fetor hepaticus- sweet, musty odor Seizures

Hep C

Unsanitary needlestick Men-sex-men IV needle sharing Boomers Hemodialysis Does not clear, becomes chronic, causes swelling/scarring

. A nurse cares for a client with hepatitis C. The clients brother states, I do not want to contract this infection, so I will not go into his hospital room. How should the nurse respond?

Viral hepatitis is not spread through casual contact

. A nurse assesses clients at a community health fair. Which client is at greatest risk for the development of hepatitis B?

20-year-old college student who has had several sexual partners

Portal HTN

Increase in *5mm/Hg* pressure in portal vein d/t constriction/reduction of blood flow -Backs into spleen, causes *splenomegaly*, *esophageal varices*

Hepatitis

Inflammation/infection of the liver -Develops after exposure to drugs/chemicals, ETOH Liver- enlarged, RUQ pain Secondary to EBV, CMV, herpes, varicella-zoster

Liver CA

Most fatal d/t circulatory involvement Cirrhosis increases risk LABS *Serum AFP*

Acetaminophen

NO MORE THAN 3,000 MG/24 HRS!!!

Nonalcoholic fatty liver disease (NAFLD)

NO alcohol, but lots of fat consumption ASx with obesity, T2DM, Metabolic sydrome Latinos- highest risk

Hep D

Needs Hep B to function Primarily IV drug users, also sexual contact

Hemorrhage occurs

Ocreotide acetate and vasopressin- reduce blood flow0

A nurse plans care for a client who has hepatopulmonary syndrome. Which interventions should the nurse include in this clients plan of care? (Select all that apply.)

Oxygen therapy Feet elevated on pillows Daily weights

Hepatic Encephalopathy

Shunting of portal venous blood into circulation-liver bypassed- stuff not detoxed- leads to *elevated serum ammonia* Results from *liver failure and cirrhosis* *reversible if caught early* Develops into liver dysfunction

Hepatic encephalopathy s/sx

Sleep/ mood disturbances, speech problems

Hepatitis education

Small, frequent meals, high cal Rest periods Potential for infection

Cirrhosis home health

Stay close to bathroom Simple carbs, moderate fat/protein DO not drain more than 2,000 mL at one time Small, frequent meals Avoid herbs, NSAIDS, ETOH

Hepatitis labs

Increased AST/ALT

A nurse teaches a client with hepatitis C who is prescribed ribavirin (Copegus). Which statement should the nurse include in this clients discharge education?

. Use a pill organizer to ensure you take this medication as prescribed.

. A nurse cares for a client who is scheduled for a paracentesis. Which intervention should the nurse delegate to an unlicensed assistive personnel (UAP)?

Assist the client to void before the procedure.

Stage 2 Hepatic Encephalopathy

Continuing mental changes Mental confusion Disorientation time place person Aterixis (hand flapping)

Hep E

Fecal contamination *Waterborne*, esp 3rd world countries Self-limiting

Hep A

Fecal-PO route Usually *contaminated food* Hardy, survives on human hands Flu-like sx, resolves on own *Shellfish* *PROPER HANDWASHING!!!* Destroyed by *Bleach* and *high temps* *Immunoglobulins within 14 days exposure* Vax before travel or close living quarters, deltoid

Hepatitis s/sx

Abd pain Sclera changes Joint/muscle pain Diarrhea or constipation Urine/stool color changes Fever Lethargy Malaise (flu-like sx) N/V Itching

A nurse cares for a client with hepatopulmonary syndrome who is experiencing dyspnea with oxygen saturations at 92%. The client states, I do not want to wear the oxygen because it causes my nose to bleed. Get out of my room and leave me alone! Which action should the nurse take?

. Instruct the client to sit in as upright a position as possible.

. A nurse cares for a client with hepatic portal-systemic encephalopathy (PSE). The client is thin and cachectic in appearance, and the family expresses distress that the client is receiving little dietary protein. How should the nurse respond?

. Less protein in the diet will help prevent confusion associated with liver failure.

. After teaching a client who has been diagnosed with hepatitis A, the nurse assesses the clients understanding. Which statement by the client indicates a correct understanding of the teaching?

. I may have been exposed when we ate shrimp last weekend

After teaching a client who has alcohol-induced cirrhosis, a nurse assesses the clients understanding. Which statement made by the client indicates a need for additional teaching?

. I need to avoid protein in my diet.

After teaching a client who has plans to travel to a non-industrialized country, the nurse assesses the clients understanding regarding the prevention of viral hepatitis. Which statement made by the client indicates a need for additional teaching?

. I should eat plenty of fresh fruits and vegetables.

A nurse cares for a client who has chronic cirrhosis from substance abuse. The client states, All of my family hates me. How should the nurse respond?

. I will help you identify a support system

Varicosities Tx

Banded (EVL) or Sclerosed (EST) -"Stent" to stop -TIPS- shunt is placed to control bleeding, unless hx Right HF Blakemore tube- balloon puts pressure on varices

Bleeding or clotting

Liver has all clotting factors

Manage ascites- fluid overload

Low Na+ 1-2 g/day NO TABLE SALT!!! Low fluid intake Fresh veggies, no sodium Banana bag- thiamine, folate, multivitamins Diuretics-daily weights, e-lytes, I+Os - Lasix + Aldactone Assess lung sounds q 4-8 hrs for crackles

Hepatitis psych

Malaise Fatigue Inactivity Depression Stigma

. An infection control nurse develops a plan to decrease the number of health care professionals who contract viral hepatitis at work. Which ideas should the nurse include in this plan? (Select all that apply.)

Policies related to consistent use of Standard Precautions Implementation of a needleless system for intravenous therapy Number of sharps used in client care reduced where possible Postexposure prophylaxis provided in a timely manner

Hepatorenal syndrome

Poor prognosis Sudden decreased urine output Increased BUN/creatinine -Usually occurs *after GI bleed from liver failure*

Cirrhosis cx

Portal HTN Esophageal varices Hepatic encephalopathy Jaundice Bleeding or clotting issues

Stage 3 Hepatic Encephalopathy

Progressive deterioration Marked mental confusion Stuporous, drowsy but arousable Abnormal electroencephalogram tracing Muscle twitching Hyperrreflexia Asterixis

Hemorrhage prevention

Propanolol + Abx

Prevent hepatitis spread

Standard precautions Needleless systems Prophylactic tx stat post needlestick

Stage 1 Hepatic Encephalopathy

Subtle manifestations Personality/behavior changes Emotional labile Impaired thinking Inability to concentrate Fatigue, drowsiness Slurred/slowed speech Sleep disturbances

. An emergency room nurse assesses a client with potential liver trauma. Which clinical manifestations should alert the nurse to internal bleeding and hypovolemic shock? (Select all that apply.)

Tachycardia Confusion

Paracentesis tx

Void before procedure Monitor vitals after, decreased UO Measure output, document Drain? Vacuum bottles to drain fluid from abdomen

. A nurse assesses a client who has liver disease. Which laboratory findings should the nurse recognize as potentially causing complications of this disorder? (Select all that apply.)

Elevated international normalized ratio (INR) Elevated serum ammonia Elevated prothrombin time (PT)

. A telehealth nurse speaks with a client who is recovering from a liver transplant 2 weeks ago. The client states, I am experiencing right flank pain and have a temperature of 101 F. How should the nurse respond?

You should go to the hospital immediately to have your new liver checked out.