CHAPTER 58 Care of Patients with Liver Problems

History: Cirrhosis

Age, gender, and employment history, especially history of exposure to alcohol, drugs (prescribed and illicit), and chemical toxins. Keep in mind that all exposures are important regardless of how long ago they occurred. Determine whether there has ever been a needle stick injury. Sexual history and orientation may be important in determining an infectious cause(men having sex with men (MSM) are at high risk for hepatitis A, hepatitis B, and hepatitis C). Inquire about whether there is a family history of alcoholism and/or liver disease. Is there a history of illicit drug use? Is there a history of tattoos? Has the patient been in the military or in prison? Is the patient a health care worker, firefighter, or police officer? Ask the patient about previous medical conditions, such as an episode of jaundice or acute viral hepatitis, biliary tract disorders (such as cholecystitis), viral infections, surgery, blood transfusions, autoimmune disorders, obesity, altered lipid profile, heart failure, respiratory disorders, or liver injury.

Preventing or Managing Hemorrhage: Cirrhosis

All patients with cirrhosis should be screened for esophageal varices by endoscopy to detect them early before they bleed. If acute bleeding occurs, early interventions are used to manage it. Because massive esophageal bleeding can cause rapid blood loss, emergency interventions are needed.

Liver Trauma

Common organ to be injured in patients with abdominal trauma. Damage or injury should be suspected whenever any upper abdominal or lower chest trauma is sustained. The liver is often injured by steering wheels. Common injuries include simple lacerations, multiple lacerations, avulsions (tears), and crush injuries. The liver is a highly vascular organ and receives almost a third of the body's cardiac output. When hepatic trauma occurs, blood loss can be massive. Observe for early signs of hypovolemic shock. An ultrasound or CT scan of the abdomen is often done to determine the presence of a hematoma (blood clot). A decreased hematocrit may confirm suspected blood loss. Clinical manifestations include right upper quadrant pain with abdominal tenderness, distention, guarding, and rigidity. Abdominal pain exaggerated by deep breathing and referred to the right shoulder may indicate diaphragmatic irritation. Managed through new diagnostic and therapeutic modalities such as enhanced critical care monitoring and damage control surgery. May require multiple blood products such as packed red blood cells and fresh frozen plasma, as well as massive volume infusion to maintain adequate hydration. Monitor the patient for persistent or new bleeding. Closely monitor complete blood count and coagulation studies.

Cancer of the Liver

Cancers may be primary tumors (hepatocellular carcinoma) starting in the liver, or they may be metastatic cancers that spread from another organ to the liver. Affects Vietnamese men more than any other group. Chronic infection with HBV and HCV frequently lead to cirrhosis, which is a risk factor for developing liver cancer. It is important to remember that cirrhosis from any cause, including alcoholic liver disease, increases the risk for cancer.

Assessment: Cancer of the Liver

Early stage of cancer, most patients are without symptoms. Later in the disease, they report weight loss, anorexia, and weakness. Ask the patient if he or she has or has had recent abdominal pain. It is most often felt in the right upper quadrant before jaundice, bleeding, ascites, and edema develop. Palpation may reveal an enlarged, nodular liver. Elevated serum alpha-fetoprotein (AFP) (a tumor marker for cancers of the liver, testis, and ovary) and increased alkaline phosphatase are also common. Ultrasound (US) and contrast-enhanced CT are both useful in detecting metastasis. If the primary tumor site is not known, a CT- or ultrasound-guided liver biopsy can confirm the diagnosis.

Hemorrhage Endoscopic Therapies: Cirrhosis

Endoscopic therapies include ligation(closing of vessel,tube,duct) of the bleeding veins or sclerotherapy. Esophageal varices may be managed with endoscopic variceal ligation (EVL) (banding). This procedure involves the application of small "O" bands around the base of the varices. Endoscopic sclerotherapy (EST), also called injection sclerotherapy, may be done to stop bleeding. The varices are injected with a sclerosing agent via a catheter.

Complications of Hepatitis

Failure of the liver cells to regenerate, with progression of the necrotic process, results in a severe acute and often fatal form of hepatitis known as fulminant hepatitis. Chronic is > 6 mo. Chronic hepatitis usually occurs as a result of hepatitis B or hepatitis C. Superimposed infection with hepatitis D virus (HDV) in patients with chronic hepatitis B may also result in chronic hepatitis. Chronic hepatitis can lead to cirrhosis and liver cancer. Many patients have multiple.

Action Alert

For skin irritation and pruritus associated with jaundice, teach the patient to use cool rather than warm water on the skin and to not use an excessive amount of soap. Teach unlicensed assistive personnel to use lotion to soothe the skin. Assess for open skin areas from scratching, which could become infected.

Common Causes of Cirrhosis

• Alcoholic liver disease • Viral hepatitis • Autoimmune hepatitis • Steatohepatitis (from fatty liver) • Drugs and chemical toxins • Gallbladder disease • Metabolic/genetic causes • Cardiovascular disease

NANDA-I nursing diagnoses: Cirrhosis

1. Excess Fluid Volume related to third spacing of abdominal and peripheral fluid (NANDA-I) 2. Potential for hemorrhage due to portal hypertension 3. Potential for hepatic encephalopathy due to shunting of portal venous blood and/or increased serum ammonia levels

Fluid Nutrition Therapy: Cirrhosis

A low-sodium diet as an initial means of controlling fluid accumulation in the abdominal cavity. The amount of daily sodium (Na+) intake restriction varies, but a 1- to 2-gram (2000 mg) Na+ restriction may be tried first. Table salt should be completely excluded. Low-sodium diets may be distasteful, so suggest alternative flavoring additives such as lemon, vinegar, parsley, oregano, and pepper. Remind the patient that seasoned and salty food is an acquired taste; in time, he or she will become used to it. Vitamin supplements such as thiamine (due to alcohol withdrawal), folate, and multivitamin preparations are typically added to the IV fluids because the liver cannot store vitamins. For patients with biliary cirrhosis, bile may not be available for fat-soluble vitamin transport and absorption. Oral vitamins are prescribed post-IV.

Community-Based Care: Hepatitis

A primary focus in any case is preventing the spread of the infection. For hepatitis transmitted by the fecal-oral route, careful handwashing and sanitary disposal of feces are important. Encourage the patient to increase activity gradually to prevent fatigue. Suggest that he or she eat small, frequent meals of high-carbohydrate foods

Ascites and Gastroesophageal Varices: Cirrhosis

Ascites is the collection of free fluid within the peritoneal cavity caused by increased hydrostatic pressure from portal hypertension. This reduces the amount of circulating plasma protein in the blood, and with the inability of the liver to produce albumin the serum colloid osmotic pressure is decreased in the circulatory system. The result is a fluid shift from the vascular system into the abdomen, a form of "third spacing." Massive ascites may cause renal vasoconstriction, triggering the renin-angiotensin system. This results in sodium and water retention, which increases hydrostatic pressure and the vascular volume and leads to more ascites. Esophageal varices occur when fragile, thin-walled esophageal veins become distended and tortuous from increased pressure. Bleeding esophageal varices is a life-threatening medical emergency. Severe blood loss may occur, resulting in shock from hypovolemia. The bleeding may be either hematemesis (vomiting blood) or melena (black, tarry stools). Any activity that increases abdominal pressure may increase the likelihood of a variceal bleed, including heavy lifting or vigorous physical exercise. In addition, chest trauma or dry, hard food. Portal hypertensive gastropathy, is slow gastric mucosal bleeding, which may result in chronic slow blood loss, occult-positive stools, and anemia. Splenomegaly (enlarged spleen) results from the backup of blood into the spleen. The enlarged spleen destroys platelets, causing thrombocytopenia (low serum platelet count) and increased risk for bleeding. Thrombocytopenia is often the first clinical sign.

History: Hepatitis

Ask the patient whether he or she has had known exposure to a person with hepatitis. With few or no symptoms of liver disease but has abnormal laboratory tests (e.g., elevated alanine aminotransferase [ALT] or aspartate aminotransferase [AST] level), the history may need: • Exposure to either inhaled or ingested chemical • Use of herbal supplements • Use of any new prescribed drug or over-the-counter (OTC) medication • Recent ingestion of shellfish • Exposure to a possibly contaminated water source • Travel to another country • Sexual activities with men, women, or both and whether it was protected or unprotected • Illicit drug use, IV or intranasal • For health care workers, recent needle stick exposure • Body piercing or tattooing • Close living accommodations (e.g., military barracks, correctional institutions, overcrowded dormitories, long-term care facilities, day-care centers) or employment in any such setting • Blood or blood products or organ transplants received before 1992 • Military service • Place of birth (United States or other country) and parents' place of birth • History of alcohol use (how many drinks each day or week) • Human immune deficiency virus (HIV)

Physical Assessment/Clinical Manifestations: Cirrhosis

Assess for early signs: • Fatigue • Significant change in weight • GI symptoms, such as anorexia and vomiting • Abdominal pain and liver tenderness (both of which may be ignored by the patient) GI bleeding, jaundice, ascites, and spontaneous bruising indicate poor liver function and complications of cirrhosis. Thoroughly assess the patient with liver dysfunction or failure because it affects every body system. Assess for: • Obvious yellowing of the skin (jaundice) and sclerae (icterus) • Dry skin • Rashes • Purpuric lesions, such as petechiae (round, pinpoint, red-purple lesions) or ecchymoses (large purple, blue, or yellow bruises) • Warm and bright red palms of the hands (palmar erythema) • Vascular lesions with a red center and radiating branches, known as "spider angiomas" (telangiectases, spider nevi, or vascular spiders), on the nose, cheeks, upper thorax, and shoulders • Ascites (abdominal fluid) • Peripheral dependent edema of the extremities and sacrum • Vitamin deficiency (especially fat-soluble vitamins A, D, E, and K)

Physical Assessment/Clinical Manifestations: Hepatitis

Assess whether the patient has: • Abdominal pain • Changes in skin or sclera (icterus) • Arthralgia (joint pain) or myalgia (muscle pain) • Diarrhea/constipation • Changes in color of urine or stool • Fever • Lethargy • Malaise • Nausea/vomiting • Pruritus (itching) Lightly palpate the right upper abdominal quadrant to assess for liver tenderness. The patient may report right upper quadrant pain with jarring movements. Inspect the skin, sclerae, and mucous membranes for jaundice. Jaundice in hepatitis results from intrahepatic obstruction and is caused by edema of the liver's bile channels. Dark urine and clay-colored stools are often reported by the patient. If possible, obtain a urine and stool specimen for visual inspection and laboratory analysis. The patient may also have skin abrasions from scratching

Cirrhosis

Cirrhosis is extensive, irreversible scarring of the liver, usually caused by a chronic reaction to hepatic inflammation and necrosis. The most common causes for cirrhosis in the United States are chronic alcoholism, chronic viral hepatitis, nonalcoholic steatohepatitis (NASH), bile duct disease, and genetic diseases. As cirrhosis develops, the tissue becomes nodular. These nodules can block bile ducts and normal blood flow throughout the liver. In early disease, the liver is usually enlarged, firm, and hard. As the pathologic process continues, the liver shrinks in size, resulting in decreased liver function, which can occur in weeks to years. The impaired liver function results in elevated serum liver enzymes. Types: • Postnecrotic cirrhosis (caused by viral hepatitis [especially hepatitis C] and certain drugs or other toxins) • Laennec's or alcoholic cirrhosis (caused by chronic alcoholism) • Biliary cirrhosis (also called cholestatic; caused by chronic biliary obstruction or autoimmune disease)

Hepatic Encephalopathy Drug Therapy: Cirrhosis

Drugs are used sparingly because they are difficult for the failing liver to metabolize. In particular, opioid analgesics, sedatives, and barbiturates should be restricted. May eliminate or reduce ammonia levels in the body. These include lactulose (e.g., Evalose, Heptalac) or lactitol and nonabsorbable antibiotics. May prescribe lactulose (or lactitol) to promote the excretion of ammonia in the stool. Cleansing the bowels may rid the intestinal tract of the toxins. Observe for response to lactulose. The patient may report intestinal bloating and cramping. Hypokalemia and dehydration may result from excessive stools. Remind unlicensed nursing personnel to help the patient with skin care. Several nonabsorbable antibiotics may be given if lactulose does not help the patient. These drugs should not be given together. Older adults can become weak and dehydrated from having multiple stools. Neomycin sulfate (Mycifradin) or rifaximin (Xifaxan), both broad-spectrum antibiotics, may be given to act as an intestinal antiseptic. These drugs destroy the normal flora in the bowel, diminishing protein breakdown and decreasing the rate of ammonia production. Long-term use has the potential for kidney toxicity. Metronidazole (Flagyl, Novonidazol image) is another broad-spectrum antibiotic with similar action to neomycin, but it can cause peripheral neuropathy. Vancomycin (Vancocin) may also be given, but its long-term use can lead to resistance. Frequently assess for changes in level of consciousness and orientation. Check for asterixis (liver flap) and fetor hepaticus (liver breath). These signs suggest worsening encephalopathy. Thiamine supplements and benzodiazepines may be needed if the patient is at risk for alcohol withdrawal.

Managing Fluid Volume: Cirrhosis

Early interventions are aimed at preventing the accumulation of additional fluid and moving the existing fluid collection. Nonsurgical treatment measures are used to treat ascites in most cases. Supportive measures to control abdominal ascites include nutrition therapy, drug therapy, paracentesis, and respiratory support. The patient's fluid and electrolyte balance is also carefully monitored. If the patient is jaundiced, he or she will likely scratch the skin because the excess bilirubin products cause irritation and pruritus (itching).

Fluid-Respiratory Support: Cirrhosis

Excessive ascitic fluid volume may cause the patient to have respiratory problems. He or she may develop hepatopulmonary syndrome. Dyspnea develops as a result of increased intra-abdominal pressure. Auscultate lungs every 4 to 8 hours for crackles. Laboratory tests, such as blood urea nitrogen (BUN), serum protein, hematocrit, and electrolytes, help determine fluid and electrolyte status. An elevated BUN, decreased serum proteins, and increased hematocrit may indicate hypovolemia. If medical management fails to control ascites, the physician may choose to divert ascites into the venous system by creating a shunt. The transjugular intrahepatic portal-systemic shunt (TIPS) is a nonsurgical procedure that is used to control long-term ascites and to reduce variceal bleeding.

Action Alert

For the patient who has had a liver transplantation, monitor the temperature frequently per hospital protocol, and report elevations, increased abdominal pain, distention, and rigidity, which are indicators of peritonitis. Nursing assessment also includes monitoring for a change in neurologic status that could indicate encephalopathy from a nonfunctioning liver. Report signs of clotting problems (e.g., bloody oozing from a catheter, petechiae, ecchymosis) to the surgeon immediately because they may indicate impaired function of the transplanted liver.

Action Alert

For the patient who has undergone liver transplantation, monitor for clinical manifestations of rejection, which may include tachycardia, fever, right upper quadrant or flank pain, decreased bile pigment and volume, and increasing jaundice. Laboratory findings include elevated serum bilirubin, rising ALT and AST levels, elevated alkaline phosphatase levels, and increased prothrombin time/international normalized ratio (PT/INR).

Action Alert

For the patient with hepatopulmonary syndrome, monitor his or her oxygen saturation with pulse oximetry. If needed, apply oxygen therapy to ease breathing. Elevate the head of the bed to at least 30 degrees or as high as the patient wants to improve breathing. This position, with his or her feet elevated to decrease dependent ankle edema, often relieves dyspnea. Weigh the patient daily, or delegate and supervise this activity.

Psychosocial Assessment: Hepatitis

General malaise, inactivity, and vague symptoms contribute to depression. Some patients often feel guilty and are remorseful about decisions made that caused the disease. These feelings are most likely to occur when the source of infection is from drug use. Family members may be angry that the patient caused the disease. The patient may feel embarrassed by the precautions that are imposed in the hospital and continue to be necessary at home. This embarrassment may cause the patient to limit social interactions. Patients may be afraid that they will spread the virus. Family members are sometimes afraid of getting the disease and may distance themselves from the patient. Allow them to verbalize these feelings, and explore the reasons for these fears. Educate the patient and family members about modes of transmission, and clarify information as needed. Patients may be unable to return to work for several weeks during the acute phases of illness. The loss of wages and the cost of hospitalization for a patient without insurance coverage may produce great anxiety and financial burden.

Other Diagnostic Assessment: Hepatitis

Liver biopsy may be used to confirm the diagnosis of hepatitis and to establish the stage and grade of liver damage. If coagulation is abnormal, however, it may be done using either a CT-guided or transjugular route to reduce the risk for pneumothorax or hemothorax. Ultrasound also may be used.

Hepatic Encephalopathy: Cirrhosis

Hepatic encephalopathy (also called portal-systemic encephalopathy [PSE]) is a complex cognitive syndrome that results from liver failure and cirrhosis. Patients report sleep disturbance, mood disturbance, mental status changes, and speech problems early. Later neurologic symptoms include an altered level of consciousness, impaired thinking processes, and neuromuscular problems. Symptoms develop rapidly in acute liver dysfunction. Are the result of the shunting of portal venous blood into the central circulation so that the liver is bypassed. As a result, substances absorbed by the intestine are not broken down or detoxified and may lead to metabolic abnormalities, such as elevated serum ammonia and gamma-aminobutyric acid (GABA). Factors that may lead to hepatic encephalopathy in patients with cirrhosis include: • High-protein diet • Infection • Hypovolemia (decreased fluid volume) • Hypokalemia (decreased serum potassium) • Constipation • GI bleeding (causes a large protein load in the intestines) • Drugs (e.g., hypnotics, opioids, sedatives, analgesics, diuretics, illicit drugs)

Etiology and Genetic Risk: Cirrhosis

Hepatitis C is the second leading cause of cirrhosis and liver failure in the U.S. Hepatitis B and hepatitis D are the most common causes of cirrhosis worldwide. Cirrhosis may also occur as a result of nonalcoholic fatty liver disease (NAFLD), a rapidly growing health care concern. NAFLD is associated with obesity, diabetes mellitus type 2, and metabolic syndrome. Hispanics have this gene more often than other ethnic groups. Another common cause of cirrhosis is excessive and prolonged alcohol use. The long-term use of illicit drugs, such as cocaine, has similar effects on the liver.

Hepatitis D

Hepatitis D (delta hepatitis) is caused by a defective RNA virus that needs the helper function of HBV. It occurs only with HBV to cause viral replication. This usually develops into chronic disease. The disease is transmitted primarily by parenteral routes, especially in patients who are IV drug users. Having sexual contact with a person with HDV is also a high risk factor.

Hepatic Encephalopathy Nutrition Therapy: Cirrhosis

High-carbohydrate, moderate-fat, and high-protein foods needed. Diet may be changed for those who have elevated serum ammonia levels with signs of encephalopathy. Patients should have a moderate amount of protein and fat foods and simple carbohydrates. Strict protein restrictions are not required because patients need protein for healing. Brief, simple directions regarding dietary dos and don'ts are recommended. Keep in mind any allergies, financial, cultural, or personal preferences.

Complications of Cirrhosis

In compensated cirrhosis, the liver is scarred but can still perform essential functions without causing major symptoms. In decompensated cirrhosis, liver function is impaired with obvious manifestations of liver failure. The loss of hepatic function contributes to the development of metabolic abnormalities. Hepatic cell damage may lead to these common complications: • Portal hypertension • Ascites and esophageal varices • Coagulation defects • Jaundice • Portal-systemic encephalopathy (PSE) with hepatic coma • Hepatorenal syndrome • Spontaneous bacterial peritonitis

Hepatitis B

It is a double-shelled particle containing DNA composed of a core antigen (HBcAg), a surface antigen (HBsAg), and another antigen found within the core (HBeAg) that circulates in the blood. HBV may be spread through these common modes of transmission: • Unprotected sexual intercourse with an infected partner • Sharing needles • Accidental needle sticks or injuries from sharp instruments primarily in health care workers (low incidence) • Blood transfusions (that have not been screened for the virus, before 1992) • Hemodialysis • Close person-to-person contact by open cuts and sores In addition, patients who are immunosuppressed susceptible. Symptoms usually occur within 25 to 180 days of exposure and include: • Anorexia, nausea, and vomiting • Fever • Fatigue • Right upper quadrant pain • Dark urine with light stool • Joint pain • Jaundice Blood tests confirm the disease. Most adults who get hepatitis B recover, clear the virus from their body, and develop immunity. Hepatitis carriers can infect others even though they are not sick and have no obvious signs of hepatitis B. Chronic carriers are at high risk for cirrhosis and liver cancer.

Abdominal Assessment: Cirrhosis

Massive ascites can be detected as a distended abdomen with bulging flanks. The umbilicus may protrude, and dilated abdominal veins (caput medusae) may radiate from the umbilicus. Orthopnea and dyspnea from increased abdominal distention can interfere with lung expansion. Difficulty maintaining an erect body posture, and problems with balance. Inspect and palpate for the presence of inguinal or umbilical hernias. Minimal ascites is often more difficult to detect, especially in the obese. Keep in mind that hepatomegaly (liver enlargement) occurs in many cases of early cirrhosis. Splenomegaly is common in nonalcoholic causes of cirrhosis. Measure the patient's abdominal girth to evaluate the progression of ascites. To measure abdominal girth, the patient lies flat while the nurse or other examiner pulls a tape measure around the largest diameter (usually over the umbilicus) of the abdomen. The girth is measured at the end of exhalation. Mark the abdominal skin and flanks to ensure the same tape measure placement on subsequent readings. Taking daily weights, however, is the most reliable indicator of fluid retention.

Psychosocial Assessment: Cirrhosis

May undergo subtle or obvious personality, cognitive, and behavior changes, such as agitation. He or she may experience sleep pattern disturbances or may exhibit signs of emotional lability (fluctuations in emotions), euphoria (a very elevated mood), or depression. Part of the psychosocial assessment is determining if the patient is alcohol-dependent. If this is the case, observe and prepare for alcohol withdrawal. Care of the patient experiencing withdrawal can be a medical emergency.

Health Promotion and Maintenance: Hepatitis

Measures for preventing hepatitis A in adults include: • Proper handwashing, especially after handling shellfish • Avoiding contaminated food or water (including tap water in countries with high incidence) • Receiving immunoglobulin within 14 days if exposed to the virus • Receiving the HAV vaccine before traveling to areas where the disease is common (e.g., Mexico, Caribbean) • Receiving the vaccine if living or working in enclosed areas with others, such as college dormitories, correctional institutions, day-care centers, and long-term care facilities Examples of groups for whom immunization against HBV should be used include: • People who have sexual intercourse with more than one partner • People with sexually transmitted disease (STD) or a history of STD • Men having sex with men (MSM) • People with any chronic liver disease (such as hepatitis C or cirrhosis) • Patients with human immune deficiency virus (HIV) infection • People who are exposed to blood or body fluids in the workplace, including health care workers, firefighters, and police • People in correctional facilities • Patients needing immunosuppressant drugs • Family members, household members, and sexual contacts of people with HBV infection

Other Physical Assessment: Cirrhosis

Observe vomitus and stool for blood. Gastritis, stomach ulceration, or oozing esophageal varices may be responsible. Note the presence of fetor hepaticus, which is the distinctive breath odor of chronic liver disease and hepatic encephalopathy and is characterized by a fruity or musty odor. Amenorrhea (no menstrual period) may occur. Men may exhibit testicular atrophy, gynecomastia (enlarged breasts), and impotence. May have bruising and petechiae (small, purplish hemorrhagic spots on the skin). Continually assess the patient's neurologic function. Often progress to coma—a late complication of encephalopathy. Monitor for asterixis—a coarse tremor characterized by rapid, nonrhythmic extensions and flexions in the wrists and fingers (hand-flapping).

Action Alert

One of the most important aspects of ongoing care for the patient with cirrhosis is to stress the need to avoid acetaminophen (Tylenol), alcohol, and illicit drugs. By avoiding these substances, the patient may: • Prevent further fibrosis of the liver from scarring • Allow the liver to heal and regenerate • Prevent gastric and esophageal irritation • Reduce the incidence of bleeding • Prevent other life-threatening complications

TABLE 58-2 Stages of Hepatic Encephalopathy

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TABLE 58-3 Assessment of Abnormal Laboratory Findings in Liver Disease

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Chart 58-1 The Patient with Paracentesis

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Chart 58-2 Patient and Family Education: Preparing for Self-Management Cirrhosis

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Chart 58-3 Prevention of Viral Hepatitis in Health Care Workers

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Chart 58-4 Health Practices to Prevent Viral Hepatitis

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Clinical Judgment Challenge

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TABLE 58-4 Drug Therapy for Chronic Hepatitis B and Hepatitis C

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Chart 58-6 Key Features Liver Trauma

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TABLE 58-5 Assessment and Prevention of Common Postoperative Complications Associated with Liver Transplantation

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Hemorrhage Other Interventions: Cirrhosis

Patients usually have a nasogastric tube (NGT) inserted to detect any new bleeding episodes. Patients often receive packed red blood cells, fresh frozen plasma, dextran, albumin, and platelets through large-bore IV catheters. Monitor vital signs every hour, and check coagulation studies, including prothrombin time (PT), partial thromboplastin time (PTT), platelet count, and international normalized ratio (INR).

Liver Transplantation

Patients who are not considered candidates for transplantation are those with: • Severe cardiovascular instability with advanced cardiac disease • Severe respiratory disease • Metastatic tumors • Inability to follow instructions regarding drug therapy and self-management Donor livers are obtained primarily from trauma victims who have not had liver damage. The donor liver is transported to the surgery center in a solution that preserves the organ for up to 8 hours. The diseased liver is removed through an incision made in the upper abdomen. The new liver is carefully put in its place and is attached to the patient's blood vessels and bile ducts. Living donors have also been used and are usually close family members or spouse. This is done on a voluntary basis after careful psychological and physiologic preparation and testing. The donor's liver is resected (usually removal of one lobe) and implanted into the recipient after removal of the diseased liver. In both the donor and the recipient, the liver regenerates and grows in size to meet the demands of the body.

Imaging Assessment: Cirrhosis

Plain x-rays of the abdomen may show hepatomegaly, splenomegaly, or massive ascites. A CT scan may be. MRI is another test used to diagnose the patient with liver disease. It can reveal mass lesions, giving additional specific information.

Portal Hypertension: Cirrhosis

Portal hypertension, a persistent increase in pressure within the portal vein greater than 5 mm Hg, is a major complication. From increased resistance to or obstruction (blockage) of the flow of blood through the portal vein and its branches. Blood flow backs into the spleen, causing splenomegaly (spleen enlargement). Veins in the esophagus, stomach, intestines, abdomen, and rectum become dilated. Portal hypertension can result in ascites (excessive abdominal [peritoneal] fluid), esophageal varices (distended veins), prominent abdominal veins (caput medusae), and hemorrhoids.

Fluid Drug Therapy: Cirrhosis

Prescribes a diuretic to reduce fluid accumulation and to prevent cardiac and respiratory problems. Monitor the effect of diuretic therapy by weighing the patient daily, measuring daily intake and output, measuring abdominal girth, documenting peripheral edema, and assessing electrolyte levels. Serious fluid and electrolyte imbalances, such as dehydration, hypokalemia (decreased potassium), and hyponatremia (decreased sodium), may occur with loop diuretic therapy. May prescribe an oral or IV potassium supplement. Some clinicians prescribe furosemide (Lasix) and spironolactone (Aldactone) as a combination diuretic therapy for the treatment of ascites. Because these drugs work differently, they are used for maintenance of sodium and potassium balance. For example, furosemide causes potassium loss, whereas spironolactone conserves it in the body. For spontaneous bacterial peritonitis (SBP); mild symptoms such as low-grade fever and loss of appetite occur. In others, there may be abdominal pain, fever, and change in mental status. Quinolones such as norfloxacin (Noroxin) are the drugs of choice for SBP. If the patient is allergic to this class of antibiotics, combination antibiotics like trimethoprim-sulfamethoxazole (Bactrim) are given.

Home Care Management: Cirrhosis

Referrals for physical therapy, nutrition therapy, and transportation for physician and laboratory follow-up may be needed. The patient's rest area needs to be close to a bathroom because diuretic and/or lactulose therapy increases the frequency of urination and stools. BSC may be needed. Incontinence pads or briefs may be helpful. Elevating the head of the bed and maintaining the patient in a semi-Fowler's to high-Fowler's position may help alleviate respiratory distress. Alternatively, a reclining chair with an elevated foot rest.

Laboratory Assessment: Cirrhosis

Serum levels of aspartate aminotransferase (AST), alanine aminotransferase (ALT), and lactate dehydrogenase (LDH) are typically elevated because these enzymes are released into the blood. The hepatocytes may be unable to create an inflammatory response and the AST and ALT may be normal. ALT levels are more specific to the liver, whereas AST can be found in muscle, kidney, brain, and heart. An AST/ALT ratio greater than 2 is usually found in alcoholic liver disease. Increased alkaline phosphatase and gamma-glutamyl transpeptidase (GGT) levels are caused by biliary obstruction and therefore may increase in patients with cirrhosis. Alkaline phosphatase is a nonspecific bone, intestinal, and liver enzyme. However, alkaline phosphatase also increases when bone disease, such as osteoporosis, is present. Total serum bilirubin levels also rise. Indirect bilirubin levels increase in patients with cirrhosis because of the inability of the failing liver to excrete bilirubin. Therefore bilirubin is present in the urine (urobilinogen) in increased amounts. Fecal urobilinogen concentration is decreased in patients with biliary tract obstruction. These patients have light- or clay-colored stools. Total serum protein and albumin levels are decreased in patients with severe or chronic liver disease. Prothrombin time/international normalized ratio (PT/INR) is prolonged because the liver decreases the production of prothrombin. The platelet count is low, resulting in a characteristic thrombocytopenia of cirrhosis. Anemia may be reflected by decreased red blood cell (RBC), hemoglobin, and hematocrit values. The white blood cell (WBC) count may also be decreased. Ammonia levels are usually elevated. Serum creatinine may be elevated in patients with deteriorating kidney function. Dilutional hyponatremia (low serum sodium) may occur in patients with ascites.

Interventions: Cancer of the Liver

Surgical resection and liver transplantation offer the only treatments for long-term survival from liver cancer. Unfortunately, most patients are not candidates for surgical removal because their tumors are unresectable. Tunneled abdominal drains, such as the PleurX drainage system, may be used at home by the patient and family to remove excess ascitic fluid. Teach them how to empty the drain and maintain the system. Remind them not to remove more than 2000 mL of fluid at one time to prevent hypovolemic shock. Selective internal radiation therapy (SIRT) has been successful for some patients. Other palliative approaches include hepatic artery embolization, ablation techniques, and drug therapy. Hepatic artery embolization causes cell death by blocking blood supply to the tumor in the liver. It is performed under moderate sedation by an interventional radiologist who threads a catheter through the femoral artery to inject small beads into the hepatic artery to block blood flow. May be followed by infusing a chemotherapy agent directly into the hepatic artery (chemoembolization). Common ablation(removal) procedures include radiofrequency ablation (RFA), percutaneous ethanol injection, and cryotherapy. RFA uses energy waves to heat cancer cells and kill them. Chemotherapy may be administered, however, it is not effective in many cases. Examples of drugs used are doxorubicin (Adriamycin), 5-fluorouracil (5-FU), and cisplatin. Sorafenib (Nexavar) is a kinase inhibitor that is approved for inoperable liver cancer. Another drug route is a catheter-directed method directly into the hepatic artery, a procedure called hepatic arterial infusion (HAI). The interventional radiologist places a catheter into the artery that supplies the tumor and injects a mixture of chemotherapy and contrast agent into the tumor. This procedure has the unique effect of depositing chemotherapeutic drugs directly into the tumor without causing major systemic effects.

Action Alert

Teach the patient with viral hepatitis and the family to use measures to prevent infection transmission (see Chart 58-4). In addition, instruct the patient to avoid alcohol and to check with the health care provider before taking any medication or vitamin, supplement, or herbal preparation.

Gender Health Considerations

The amount of alcohol necessary to cause cirrhosis varies widely from person to person, and there are gender differences. In women, it may take as few as two or three drinks per day over a minimum of 10 years. In men, perhaps six drinks per day over the same time period may be needed to cause disease. However, a smaller amount of alcohol over a long period of time can increase memory loss from alcohol toxicity of the cerebral cortex. Binge drinking can increase risk for hepatitis and fatty liver.

Hepatitis A

The causative agent of hepatitis A, hepatitis A virus (HAV), is a ribonucleic acid (RNA) virus of the enterovirus family. It is a hardy virus and survives on human hands. The virus is resistant to detergents and acids but is destroyed by chlorine (bleach) and extremely high temperatures. Spread most often by the fecal-oral route by fecal contamination either from person-to-person contact (e.g., oral-anal sexual activity) or by consuming contaminated food or water. Common sources of infection include shellfish.

Hepatitis C

The causative virus of hepatitis C (HCV) is an enveloped, single-stranded RNA virus. Transmission is blood to blood. The rate of sexual transmission is very low in a single-couple relationship but increases with multiple partners. HCV is spread most commonly by: • Illicit IV drug needle sharing (highest incidence) • Blood, blood products, or organ transplants received before 1992 • Needle stick injury with HCV-contaminated blood (health care workers at high risk) • Unsanitary tattoo equipment • Sharing of intranasal cocaine paraphernalia The disease is NOT transmitted by casual contact or by intimate household contact. Advised not to share razors, toothbrushes, or pierced earrings. Unlike with hepatitis B, most people infected with hepatitis C do not clear the virus and a chronic infection develops. HCV usually does its damage over decades by causing a chronic inflammation in the liver.

Other Complications: Cirrhosis

The development of hepatorenal syndrome (HRS) indicates a poor prognosis. This syndrome is manifested by: • A sudden decrease in urinary flow (<500 mL/24 hr) (oliguria) • Elevated blood urea nitrogen (BUN) and creatinine levels with abnormally decreased urine sodium excretion • Increased urine osmolarity Patients with cirrhosis and ascites may develop acute spontaneous bacterial peritonitis (SBP). The bacteria responsible for SBP are typically from the bowel and reach the ascitic fluid after migrating through the bowel wall and transversing the lymphatics. Clinical manifestations vary but may include fever, chills, and abdominal pain and tenderness. The diagnosis of SBP is made when a sample of ascitic fluid is obtained by paracentesis for cell counts and culture. An ascitic fluid leukocyte count of more than 250 polymorphonuclear (PMN) leukocytes may indicate the need for treatment.

Hepatitis E

The hepatitis E virus (HEV) causes a waterborne infection associated with epidemics. Many large outbreaks have occurred after heavy rains and flooding. Like hepatitis A, hepatitis E is caused by fecal contamination of food and water. In the United States, hepatitis E has been found only in international travelers. There is no evidence at this time of a chronic form of the disease. The disease tends to be self-limiting and resolves on its own.

Self-Management Education: Cirrhosis

The patient who has a tunneled ascites drain (e.g., PleurX drain) will need to be taught how to access the drain and remove excess fluid. Review the home care instructions that are provided with the drainage system with both the patient and family/caregiver. Remind them to not remove more than 2000 mL from the abdomen at one time to prevent hypovolemic shock. Patient with encephalopathy often finds that small, frequent meals are best. Multivitamin supplements and supplemental liquid feedings (e.g., Ensure, Boost) are usually needed. Teach patients to avoid excessive vitamins and minerals that can be toxic(fat-soluble, iron, niacin). The patient is often discharged while receiving diuretics. Teach about side effects of therapy, such as hypokalemia. The patient may need to take a potassium supplement. Problems with bleeding from gastric ulcers, the primary care provider may prescribe an H2-receptor antagonist agent or proton pump inhibitor to reduce acid reflux (see Chapter 55). Patients who have had episodes of spontaneous bacterial peritonitis (SBP) may be on a daily maintenance antibiotic. Teach family members how to recognize signs of encephalopathy and to contact the HCP. Reinforce that constipation, bleeding, and infections can increase the risk for encephalopathy. Advise the patient to avoid all over-the-counter drugs, especially NSAIDs and hepatic toxic herbs, vitamins, and minerals. Remind the patient and family to notify the health care provider immediately if any GI bleeding (overt bleeding or melena) is noted.

Interventions: Hepatitis

The plan of care for all patients with viral hepatitis is based on measures to rest the liver, promote cellular regeneration, and prevent complications. Interventions are aimed at resting the inflamed liver to promote hepatic cell regeneration. Rest is an essential intervention to reduce the liver's metabolic demands and increase its blood supply. Patient is usually tired and expresses feelings of general malaise. Complete bedrest is usually not required. The diet should be high in carbohydrates and calories with moderate amounts of fat and protein after nausea and anorexia subside. Small, frequent meals are often preferable. High-calorie snacks may be needed. Supplemental vitamins are often prescribed. Drugs of any kind are used sparingly. An antiemetic to relieve nausea may be prescribed. However, due to the life-threatening nature of chronic hepatitis B and hepatitis C, a number of drugs are given, including antiviral and immunomodulating drugs.

Preventing or Managing Hepatic Encephalopathy: Cirrhosis

The poorly functioning liver cannot convert ammonia and other by-products of protein metabolism to a less toxic form. Interventions are planned around the management of slowing or stopping the accumulation of ammonia in the body. Because ammonia is formed in the GI tract by the action of bacteria on protein, nonsurgical treatment measures to decrease ammonia production include dietary limitations and drug therapy to reduce bacterial breakdown.

Fluid-Paracentesis: Cirrhosis

The procedure is performed at the bedside, in an interventional radiology department, or in an ambulatory care setting. The physician inserts a trocar catheter or drain into the abdomen to remove the ascitic fluid from the peritoneal cavity. This procedure is done using ultrasound for added safety. If SBP is suspected, a sample of fluid is withdrawn and sent for cell count and culture. If the patient has symptoms of infection, the physician may prescribe antibiotics.

Biliary Obstruction: Cirrhosis

The production of bile in the liver is decreased. This prevents the absorption of fat-soluble vitamins (e.g., vitamin K). Without vitamin K, clotting factors II, VII, IX, and X are not produced in sufficient quantities and the patient is susceptible to bleeding and easy bruising. Jaundice (yellowish coloration of the skin) in patients with cirrhosis is caused by one of two mechanisms: hepatocellular disease or intrahepatic obstruction. Hepatocellular jaundice develops because the liver cells cannot effectively excrete bilirubin. Intrahepatic obstructive jaundice results from edema, fibrosis, or scarring of the hepatic bile channels and bile ducts, which interferes with normal bile and bilirubin excretion. Patients with jaundice often report pruritus (itching).

Hemorrhage Drug Therapy: Cirrhosis

The role of early drug therapy is to prevent bleeding and infection in patients who have varices. A nonselective beta-blocking agent such as propranolol (Inderal) is usually prescribed. By decreasing heart rate and the hepatic venous pressure gradient, the chance of bleeding may be reduced. Infection is one of the most common indicators that patients will have an acute variceal bleed (AVB). Therefore cirrhotic patients with GI bleeding should receive antibiotics. If bleeding, controled by combining vasoactive drugs with endoscopic therapies. Vasoactive drugs, such as vasopressin and octreotide acetate (Sandostatin), reduce blood flow through vasoconstriction to decrease portal pressure. Octreotide also suppresses secretion of gastrin, serotonin, and intestinal peptides, which decreases GI blood flow to help with pressure reduction within the varices.

Transplantation Complications

The two most common complications are acute graft rejection and infection. The success rate for transplantations has greatly improved since the introduction many years ago of cyclosporine(cyclosporin A), an immunosuppressant drug. Transplant rejection is treated aggressively with immunosuppressive drugs. As with all rejection treatments, the patient is at a greater risk for infection. Multi-system organ failure, including respiratory and renal involvement, develops along with diffuse coagulopathies and portal-systemic encephalopathy (PSE). The only alternative for treatment is emergency retransplantation. Vaccinations and prophylactic antibiotics are helpful in prevention. Immunosuppressant therapy, which must be used to prevent and treat organ rejection, significantly increases the patient's risk for infection. Other risk factors include the presence of multiple tubes and intravascular lines, immobility, and prolonged anesthesia. Common infections include pneumonia, wound infections, and urinary tract infections. Opportunistic infections usually develop after the first postoperative month and include cytomegalovirus, mycobacterial infections, and parasitic infections. Latent infections such as tuberculosis and herpes simplex may be reactivated. The physician prescribes broad-spectrum antibiotics for prophylaxis during and after surgery. Obtain culture specimens from all lines and tubes and collect specimens for culture. The biliary anastomosis is susceptible to breakdown, obstruction, and infection. If leakage occurs or if the site becomes necrotic or obstructed, an abscess can form or peritonitis, bacteremia, and cirrhosis may develop.

Hemorrhage Rescue Therapies: Cirrhosis

These procedures include a second endoscopic procedure, balloon tamponade and esophageal stents, and shunting procedures. Short-term esophagogastric balloon tamponade using a Minnesota or Sengstaken-Blakemore tube with esophageal stents is a very effective way to control bleeding. However, the procedure can cause potentially life-threatening complications, such as aspiration, asphyxia, and esophageal perforation. Tube is placed through the nose and into the stomach. An attached balloon is inflated to apply pressure to the bleeding variceal area. Before this tamponade, the patient is usually intubated and placed on a mechanical ventilator.

Hemorrhage Transjugular Intrahepatic Portal-Systemic Shunt: Cirrhosis

This procedure is used for patients who have not responded to other modalities for hemorrhage or long-term ascites. If time permits, patients have a Doppler ultrasound to assess jugular vein anatomy and patency. The patient receives heavy IV sedation or general anesthesia. The radiologist places a large sheath through the jugular vein. A needle is guided through the sheath and pushed through the liver into the portal vein. A balloon enlarges this tract, and a stent keeps it open. Most patients also have a Doppler ultrasound study of the liver after the TIPS procedure to record the blood flow.

Patient-Centered Collaborative Care: Liver Transplantation

Transplant complications cause patients to be very anxious. In collaboration with the members of the health care team, assure them and their families that these problems are common and usually successfully treated. After the patient is identified as a candidate and a donor organ is procured, the actual liver transplantation surgical procedure usually takes many hours. The length of the procedure can vary greatly. In the immediate postoperative period, the patient is managed in the critical care unit and requires aggressive monitoring and care. Assess for signs and symptoms of complications of surgery, and immediately report them. Teach patients to be aware of side effects of immunosuppressive drugs, such as hypertension, nephrotoxicity, and gastrointestinal disturbances. Remind them that long-term management of care includes surveillance for malignancy, metabolic syndrome, and diabetes. Teaching the patient self-examination for skin, breast, and testicular malignancies is important as well as reminders for annual Papanicolaou (Pap) smears and other cancer screening tests. Post-transplant patients need to maintain lifestyle changes to increase their longevity after surgery.

Other Diagnostic Assessment: Cirrhosis

Ultrasound (US) of the liver is often the first assessment for a person with suspected liver disease to detect ascites, hepatomegaly, and splenomegaly. It can also determine the presence of biliary stones or biliary duct obstruction. Liver US is useful in detecting portal vein thrombosis. Biopsy procedure can be problematic because a large number of patients are at risk for bleeding. Even a percutaneous (through the skin) biopsy. A radioisotope liver scan may be used to identify cirrhosis or other diffuse disease. The physician may request arteriography if US is not conclusive in finding portal vein thrombosis. To evaluate the portal vein and its branches, a portal venogram may be performed instead, by passing a catheter into the liver and into the portal vein. The physician may perform an esophagogastroduodenoscopy (EGD) to directly visualize the upper GI tract to detect complications of liver failure. An endoscopic retrograde cholangiopancreatography (ERCP) uses the endoscope to inject contrast material via the sphincter of Oddi to view the biliary tract and allow for stone removals, sphincterotomies, biopsies, and stent placements if required.

Laboratory Assessment: Hepatitis

Usually confirmed by acute elevations in levels of liver enzymes, indicating liver cellular damage, and by specific serologic markers. Levels of ALT and AST may possibly rise into the thousands in acute or fulminant cases of hepatitis. Alkaline phosphatase levels may be normal or elevated. Serum total bilirubin levels are elevated and are consistent with the clinical appearance of jaundice. Elevated levels of bilirubin are also present in the urine. The presence of hepatitis A is established when hepatitis A virus (HAV) antibodies (anti-HAV) are found in the blood. HAV is indicated by the presence of immunoglobulin M (IgM) antibodies. Previous infection is identified by the presence of immunoglobulin G (IgG) antibodies. The presence of the hepatitis B virus (HBV) is established when serologic testing confirms the presence of hepatitis B antigen-antibody systems in the blood and a detectable viral count (HBV polymerase chain reaction [PCR] DNA). The patient is infectious as long as hepatitis B surface antigen (HBsAg) is present in the blood. The presence of antibodies to HBsAb in the blood indicates recovery and immunity to hepatitis B. People who have been vaccinated against HBV have a positive HBsAg because they also have immunity to the disease. Enzyme-linked immunosorbent assay (ELISA) is the initial screening test for patients suspected of being infected with hepatitis C virus (HCV). A more specific assay called the recombinant immunoblot assay (RIBA) can be used as a confirmatory test. To identify the actual circulating virus, the HCV PCR RNA test is used. The presence of hepatitis D virus (HDV) can be confirmed by the identification of intrahepatic delta antigen or, more often, by a rise in the hepatitis D virus antibodies (anti-HDV) titer. Hepatitis E virus (HEV) testing is usually reserved for travelers in whom hepatitis is present but the virus cannot be detected. Hepatitis E antibodies (anti-HEV) are found in people infected.

Hepatitis

Viral hepatitis is the most common type and can be either acute or chronic. Less common types of hepatitis are caused by chemicals, drugs, and some herbs. Viral hepatitis results from an infection caused by one of five major categories of viruses: • Hepatitis A virus (HAV) • Hepatitis B virus (HBV) • Hepatitis C virus (HCV) • Hepatitis D virus (HDV) • Hepatitis E virus (HEV) • Non-A-E hepatitis Toxic and drug-induced hepatitis can result from exposure to hepatotoxins (e.g., industrial toxins, alcohol, and drugs). Hepatitis may also occur as a secondary infection during the course of infections with other viruses, such as Epstein-Barr, herpes simplex, varicella-zoster, and cytomegalovirus. Liver becomes enlarged and congested with inflammatory cells, lymphocytes, and fluid, resulting in right upper quadrant pain and discomfort. As the disease progresses, the liver's normal lobular pattern becomes distorted as a result of widespread inflammation, necrosis, and hepatocellular regeneration. This distortion increases pressure within the portal circulation, interfering with the blood flow into the hepatic lobules. Edema of the liver's bile channels results in obstructive jaundice (yellowing of the skin).

Fatty Liver (Steatosis)

atty liver is caused by the accumulation of fats in and around the hepatic cells. It may be caused by alcohol use or other factors. Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) are types of fatty liver disease. Causes include: • Diabetes mellitus • Obesity • Elevated lipid profile Fatty infiltration of the liver may result from faulty fat metabolism in the liver and the movement of fatty acids from adipose tissue (fat). The most common and typical finding is an elevated ALT and AST or normal ALT and elevated AST (part of a group of liver function tests [LFTs]). MRI, ultrasound, and nuclear medicine examinations can be used to confirm excessive fat in the liver. A percutaneous biopsy can also confirm the diagnosis. Interventions are aimed at removing the underlying cause of the infiltration. Weight loss, glucose control, and aggressive treatment using lipid-lowering agents are recommended. Monitoring liver function tests is essential.

Respond by:

• Applying oxygen to assist in ease of breathing • Keeping head of bed elevated to at least 30 degrees • Maintaining rest • Collaborating with dietitian and pharmacist as needed • Prioritizing and pacing activities to prevent fatigue • Monitoring patient closely for complications, such as bleeding; calling the Rapid Response Team if bleeding occurs

Perform and interpret physical assessment findings, including:

• Assessing respiratory status to check for dyspnea or shallow breathing • Checking level of consciousness and cognition • Taking vital signs (looking for fever or decreased BP) and oxygen saturation • Checking for blood in the vomitus • Performing an abdominal assessment, including measuring girth • Checking urine for dark color and stool for clay-colored appearance • Taking current weight, and comparing with previous weight • Assessing skin for open areas • Checking most recent laboratory values for coagulation studies and LFTs

Chart 58-5 Patient and Family Education: Preparing for Self-Management Viral Hepatitis

• Avoid all medications, including over-the-counter drugs such as acetaminophen (Tylenol, Exdol image), unless prescribed by your physician. • Avoid all alcohol. • Rest frequently throughout the day, and get adequate sleep at night. • Eat small, frequent meals with a high-carbohydrate, moderate-fat, and moderate-protein content. • Avoid sexual intercourse until antibody testing results are negative. • Follow the guidelines for preventing transmission of the disease (see Chart 58-4).

Key Points: Physiological Integrity

• Be aware that cirrhosis has many causes other than alcohol use (see Table 58-1). • Observe for clinical manifestations of hepatic encephalopathy (PSE) as listed in Table 58-2. • Monitor laboratory values of patients suspected of or diagnosed with cirrhosis of the liver as listed in Table 58-3. • Monitor the patient with cirrhosis for bleeding and neurologic changes. • Provide care for the patient having a paracentesis as described in Chart 58-1. • Administer drug therapy to decrease ammonia levels (which cause PSE) in patients with cirrhosis, such as lactulose and nonabsorbable antibiotics. • Differentiate the five major types of hepatitis: A, B, C, D, and E. Hepatitis D occurs only with Hepatitis B and is transmitted most commonly by blood and body fluid exposure. Hepatitis A is transmitted via the fecal-oral route. Hepatitis C is the most common type and is also transmitted via blood and body fluids. • Be aware that patients with chronic viral hepatitis often develop cirrhosis and cancer of the liver. • Recognize that potent immunomodulators and antivirals are given to treat hepatitis B and hepatitis C; teach patients on immunomodulators to avoid large crowds and people who have infections. • Monitor for bleeding in the patient with liver trauma; assume that any abdominal trauma has damaged the liver. • Monitor the patient having a liver transplantation for complications, such as those described in Table 58-5. • Report and document elevated temperature, increased abdominal pain and rigidity, bleeding, and/or neurologic status changes as possible indicators of liver transplantation complications.

Key Points: Health Promotion and Maintenance

• Follow the guidelines listed in Chart 58-3 to prevent viral hepatitis in the workplace. • Teach patients to take precautions to prevent viral hepatitis in the community as described in Chart 58-4. • For patients with viral hepatitis, instruct them to follow the guidelines listed in Chart 58-5. • Teach patients to avoid alcohol and illicit drugs to prevent or slow the progression of alcohol-induced cirrhosis; remind them not to take any medication (including over-the-counter drugs) without checking with their health care provider.

What might you NOTICE if the patient is experiencing inadequate digestion, nutrition, and metabolism as a result of impaired liver function?

• Jaundice • Icterus • Report of nausea and anorexia • Vomiting • Weight loss • Bruising or bleeding • Ascites

Key Points: Psychosocial Integrity

• Recognize that patients with cirrhosis have mental and emotional changes due to hepatic encephalopathy. • Be aware that patients with cirrhosis and/or chronic hepatitis may feel guilty about their disease because of past habits such as drug and alcohol use. • Be aware that family members and friends may fear getting hepatitis from the patient. • Be aware that patients having liver transplantation have major concerns about the possibility of complications, such as organ rejection.

Key Points: Safe and Effective Care Environment

• When caring for patients with cirrhosis, collaborate with the dietitian, physician, and pharmacist. • Refer patients with liver disorders to the American Liver Foundation; refer dying patients to hospice and other community resources as needed.