Chapter 49: Assessment and Management of Patients With Hepatic Disorders

A nurse is responsible for monitoring the diet of a client with hepatic encephalopathy. Which daily protein intake should this 185-pound (84-kilogram) male consume?

100 to 126 grams Daily protein intake should be maintained at 1.2 to 1.5 g/kg per day. To calculate protein intake, multiply the 84 kg by the low and high ranges: (84 kg × 1.2 = 100 g; 84 kg × 1.5 = 126 g). This client would require a daily protein range from 100 to 126 grams.

A nurse is caring for a client newly diagnosed with hepatitis A. Which statement by the client indicates the need for further teaching?

"How did this happen? I've been faithful my entire marriage."

A client with hepatic cirrhosis questions the nurse about the possible use of an herbal supplement—milk thistle—to help heal the liver. Which is the most appropriate response by the nurse?

"Silymarin from milk thistle has anti-inflammatory and antioxidant properties that may have beneficial effects, especially in hepatitis. However, you should always notify your primary care provider of any herbal remedies being used so drug interactions can be evaluated."

A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor?

"You must have the second one in 1 month and the third in 6 months."

A client with liver and renal failure has severe ascites. On initial shift rounds, his primary nurse finds his indwelling urinary catheter collection bag too full to store more urine. The nurse empties more than 2,000 ml from the collection bag. One hour later, she finds the collection bag full again. The nurse notifies the physician, who suspects that a bladder rupture is allowing the drainage of peritoneal fluid. The physician orders a urinalysis to be obtained immediately. The presence of which substance is considered abnormal?

Albumin Albumin is an abnormal finding in a routine urine specimen.

The nurse is caring for a patient with cirrhosis of the liver and observes that the patient is having hand-flapping tremors. What does the nurse document this finding as?

Asterixis Asterixis, an involuntary flapping of the hands, may be seen in stage II encephalopathy

A client with a history of IV drug use is being treated for hepatitis, and presents today with jaundice and arthralgias. This client most likely has hepatitis:

B. The client's presentation is most similar to hepatitis B. Mode of transmission is from infected blood or plasma, needles, syringes, surgical or dental equipment contaminated with infected blood; also sexually transmitted through vaginal secretions and semen of carriers or those actively infected.

When caring for a client with advanced cirrhosis and hepatic encephalopathy, which assessment finding should the nurse report immediately?

Change in the client's handwriting and/or cognitive performance The earliest symptoms of hepatic encephalopathy include mental status changes and motor disturbances. The client will appear confused and unkempt and have altered mood and sleep patterns.

When assessing a client with obstructive jaundice, which of the following stool characteristics is the client likely to report?

Clay-colored or whitish

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct?

Endoscopic retrograde cholangiopancreatography (ERCP) ERCP locates stones that have collected in the common bile duct.

The mode of transmission of hepatitis A virus (HAV) includes which of the following?

Fecal-oral

The nurse identifies which type of jaundice in an adult experiencing a transfusion reaction?

Hemolytic Hemolytic jaundice occurs because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. This type of jaundice is encountered in clients with hemolytic transfusion reactions and other hemolytic disorder

Which of the following symptoms would indicate that a client with chronic pancreatitis has developed secondary diabetes?

Increased appetite and thirst When secondary diabetes develops in a client with chronic pancreatitis, the client experiences increased appetite, thirst, and urination. Vomiting, diarrhea, low blood pressure and pulse, and constipation do not indicate the development of secondary diabetes.

The nurse is administering medications to a client that has elevated ammonia due to cirrhosis of the liver. What medication will the nurse give to detoxify ammonium and to act as an osmotic agent?

Lactulose

A client is being prepared to undergo laboratory and diagnostic testing to confirm the diagnosis of cirrhosis. Which test would the nurse expect to be used to provide definitive confirmation of the disorder?

Liver biopsy A liver biopsy which reveals hepatic fibrosis is the most conclusive diagnostic procedure. Coagulation studies provide information about liver function but do not definitively confirm the diagnosis of cirrhosis. Magnetic resonance imaging and radioisotope liver scan help to support the diagnosis but do not confirm it.

A physician orders spironolactone (Aldactone), 50 mg by mouth four times daily, for a client with fluid retention caused by cirrhosis. Which finding indicates that the drug is producing a therapeutic effect?

Loss of 2.2 lb (1 kg) in 24 hours

When performing a physical examination on a client with cirrhosis, a nurse notices that the client's abdomen is enlarged. Which of the following interventions should the nurse consider?

Measure abdominal girth according to a set routine. If the abdomen appears enlarged, the nurse measures it according to a set routine. The nurse reports any change in mental status or signs of gastrointestinal bleeding immediately. It is not essential for the client to take laxatives unless prescribed. The client's food intake does not affect the size of the abdomen in case of cirrhosis.

A client is actively bleeding from esophageal varices. Which medication would the nurse mostexpect to be administered to this client?

Octreotide In an actively bleeding client, medications are administered initially because they can be obtained and administered quicker than other therapies. Octreotide (Sandostatin) causes selective splanchnic vasoconstriction by inhibiting glucagon release and is used mainly in the management of active hemorrhage.

A patient who had a recent myocardial infarction was brought to the emergency department with bleeding esophageal varices and is presently receiving fluid resuscitation. What first-line pharmacologic therapy does the nurse anticipate administering to control the bleeding from the varices?

Octreotide (Sandostatin) Octreotide (Sandostatin), a synthetic analogue of the hormone somatostatin, is effective in decreasing bleeding from esophageal varices, and lacks the vasoconstrictive effects of vasopressin.

The nurse is caring for a client with cirrhosis. Which assessment findings indicate that the client has deficient vitamin K absorption caused by this hepatic disease?

Purpura and petechiae A hepatic disorder, such as cirrhosis, may disrupt the liver's normal use of vitamin K to produce prothrombin (a clotting factor). Consequently, the nurse should monitor the client for signs of bleeding, including purpura and petechiae.

A client with cirrhosis has portal hypertension, which is causing esophageal varices. What is the goal of the interventions that the nurse will provide?

Reduce fluid accumulation and venous pressure. Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective.

In what location would the nurse palpate for the liver?

Right upper quadrant

The nurse is preparing a care plan for a client with hepatic cirrhosis. Which nursing diagnoses are appropriate? Select all that apply.

Risk for injury related to altered clotting mechanisms Activity intolerance related to fatigue, general debility, muscle wasting, and discomfort Disturbed body image related to changes in appearance, sexual dysfunction, and role

Clients with chronic liver dysfunction have problems with insufficient vitamin intake. Which may occur as a result of vitamin C deficiency?

Scurvy Scurvy may result from a vitamin C deficiency. Night blindness, hypoprothrombinemia, and beriberi do not result from a vitamin C deficiency.

Which of the following medications would the nurse expect the physician to order for a client with cirrhosis who develops portal hypertension?

Spironolactone (Aldactone) For portal hypertension, a diuretic usually an aldosterone antagonist such as spironolactone (Aldactone) is ordered.

A nurse is caring for a client with cirrhosis. The nurse assesses the client at noon and discovers that the client is difficult to arouse and has an elevated serum ammonia level. The nurse should suspect which situation?

The client's hepatic function is decreasing. The decreased level of consciousness caused by an increased serum ammonia level indicates hepatic disfunction.

Ammonia, the major etiologic factor in the development of encephalopathy, inhibits neurotransmission. Increased levels of ammonia are damaging to the body. The largest source of ammonia is from:

The digestion of dietary and blood proteins.

A patient with bleeding esophageal varices has had pharmacologic therapy with Octreotide (Sandostatin) and endoscopic therapy with esophageal varices banding, but the patient has continued to have bleeding. What procedure that will lower portal pressure does the nurse prepare the patient for?

Transjugular intrahepatic portosystemic shunting (TIPS) A TIPS procedure (see Fig. 49-8) is indicated for the treatment of an acute episode of uncontrolled variceal bleeding refractory to pharmacologic or endoscopic therapy. In 10% to 20% of patients for whom urgent band ligation or sclerotherapy and medications are not successful in eradicating bleeding, a TIPS procedure can effectively control acute variceal hemorrhage by rapidly lowering portal pressure.

The nurse is caring for a patient with ascites due to cirrhosis of the liver. What position does the nurse understand will activate the renin-angiotensin aldosterone and sympathetic nervous system and decrease responsiveness to diuretic therapy?

Upright

Which of the following is the most effective strategy to prevent hepatitis B infection?

Vaccine

Which medication is used to decrease portal pressure, halting bleeding of esophageal varices?

Vasopressin

A client with severe and chronic liver disease is showing manifestations related to inadequate vitamin intake and metabolism. He reports difficulty driving at night because he cannot see well. Which of the following vitamins is most likely deficient for this client?

Vitamin A Problems common to clients with severe chronic liver dysfunction result from inadequate intake of sufficient vitamins. Vitamin A deficiency results in night blindness and eye and skin changes. Thiamine deficiency can lead to beriberi, polyneuritis, and Wernicke-Korsakoff psychosis. Riboflavin deficiency results in characteristic skin and mucous membrane lesions. Vitamin K deficiency can cause hypoprothrombinemia, characterized by spontaneous bleeding and ecchymoses.

A client with carcinoma of the head of the pancreas is scheduled for surgery. Which of the following should a nurse administer to the client before surgery?

Vitamin K Clients with carcinoma of the head of the pancreas typically require vitamin K before surgery to correct a prothrombin deficiency.

Which condition indicates an overdose of lactulose?

Watery diarrhea The client receiving lactulose is monitored closely for the development of watery diarrheal stool, which indicates a medication overdose.

What is the recommended dietary treatment for a client with chronic cholecystitis?

low-fat diet The bile secreted from the gallbladder helps the body absorb and break down dietary fats. If the gallbladder is not functioning properly, then it will not secrete enough bile to help digest the dietary fat. This can lead to further complications; therefore, a diet low in fat can be used to prevent complications.

A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. What is an important education topic regarding ingestion of medications?

metabolism of medications Careful evaluation of the client's response to drug therapy is important because the malfunctioning liver cannot metabolize many substances.

A client with acute liver failure exhibits confusion, a declining level of consciousness, and slowed respirations. The nurse finds him very difficult to arouse. The diagnostic information which best explains the client's behavior is:

subnormal serum glucose and elevated serum ammonia levels. n acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract.

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition?

Hepatic encephalopathy Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with an elevated ammonia concentration that produces changes in mental status, altered level of consciousness, and coma.