MedSurg Ch. 49
A nurse is preparing a presentation for a local community group about hepatitis. Which of the following would the nurse include?
Hepatitis C increases a person's risk for liver cancer. Infection with hepatitis C increases the risk of a person developing hepatic (liver) cancer. Hepatitis A is transmitted primarily by the oral-fecal route; hepatitis B is frequently spread by sexual contact and infected blood. Hepatitis E is similar to hepatitis A whereas hepatitis G is similar to hepatitis C.
Patients with chronic liver dysfunction have problems with insufficient vitamin intake. Which of the following 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.
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. Potassium would be given only if the client's serum potassium levels were low. Oral bile acids are not prescribed for a client with carcinoma of the head of the pancreas; they are given to dissolve gallstones. Vitamin B has no implications in the surgery.
Which type of jaundice is the result of increased destruction of red blood cells?
Hemolytic Hemolytic jaundice is the result of an increased destruction of the red blood cells. Hepatocellular jaundice is caused by the inability of damaged liver cells to clear normal amounts of bilirubin from the blood. Obstructive jaundice resulting from extrahepatic obstruction may be caused by occlusion of the bile duct form a gall stone, inflammatory process, a tumor, or pressure from an enlarged organ. Nonobstructive jaundice occurs with hepatitis.
The nurse is assessing a patient with hepatic cirrhosis for mental deterioration. For what clinical manifestations will the nurse monitor? Select all that apply.
• Alterations in mood • Agitation • Insomnia The earliest symptoms of hepatic encephalopathy include both mental status changes and motor disturbances. The patient appears confused and unkempt and has alterations in mood and sleep patterns. The patient tends to sleep during the day and has restlessness and insomnia at night. To assess for mental deterioration, the nurse will assess general behavior, orientation, and speech as well as cognitive abilities and speech patterns
The nurse is educating a patient who has been treated for hepatic encephalopathy about dietary restrictions to prevent ammonia accumulation. What should the nurse include in the teaching?
Decrease the amount of protein in the diet. Patients with hepatic encephalopathy and their families are advised about foods that are high in protein (e.g., meat, eggs), which may need to be limited in the diet for the short term to reduce production of ammonia • Minimize the formation and absorption of toxins, principally ammonia, from the intestine. • Keep daily protein intake between 1.2 and 1.5 g/kg body weight per day. • Avoid protein restriction if possible, even in those with encephalopathy. • For patients who are truly protein intolerant, provide additional nitrogen in the form of an amino acid supplement. The use of branched-chain amino acids should be a consideration in patients with cirrhosis. It has improved outcomes in varied populations with the disease. • Provide small, frequent meals and 3 small snacks per day in addition to a late-night snack before bed.
The nurse identifies which of the following types 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 patients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive jaundice is the result of liver disease. Nonobstructive jaundice occurs with hepatitis. Hepatocellular jaundice is the result of liver disease.
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
Which of the following terms describes the passage of a hollow instrument into a cavity for the withdrawal of fluid?
Paracentesis Paracentesis may be used to withdraw ascitic fluid if the fluid accumulation is causing cardiorespiratory compromise. Asterixis refers to involuntary flapping movements of the hands associated with metabolic liver dysfunction. Ascites refers to accumulation of serous fluid within the peritoneal cavity. Dialysis refers to a form of filtration to separate crystalloid from colloid substances.
A client is admitted with increased ascites related to cirrhosis. Which nursing diagnosis should receive top priority?
Ineffective breathing pattern In ascites, accumulation of large amounts of fluid causes extreme abdominal distention, which may put pressure on the diaphragm and interfere with respiration. If uncorrected, this problem may lead to atelectasis or pneumonia. Although fluid volume excess is present, the diagnosis Ineffective breathing pattern takes precedence because it can lead more quickly to life-threatening consequences. The nurse can deal with fatigue and altered nutrition after the client establishes and maintains an effective breathing pattern.
A patient with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade therapy is used temporarily to control hemorrhage and stabilize the patient. In planning care, the nurse gives the highest priority to which of the following goals?
Maintaining the airway Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Maintaining the airway is the highest priority because oxygenation is essential for life. The airway is compromised by possible displacement of the tube and the inflated balloon into the oropharynx, which can cause life-threatening obstruction of the airway and asphyxiation.
Connie, a 60-year-old retired financial planner, is recently diagnosed with carcinoma of the pancreas. She has just met with her surgeon and feels overwhelmed by all the information she was given. She tells you that she is having the head of the pancreas removed; additionally, the surgeon is also removing the duodenum and stomach and redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the middle section of the small intestine. What procedure is Connie having performed?
Radical pancreatoduodenectomy This surgical procedure involves removing the head of the pancreas, resecting the duodenum and stomach, and redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the jejunum. This surgical procedure is a rerouting of the pancreatic and biliary drainage systems, which may be done to relieve obstructive jaundice. This measure is considered palliative only. A pancreatectomy is the surgical removal of the pancreas. A pancreatectomy may be total, in which case the entire organ is removed, usually along with the spleen, gallbladder, common bile duct, and portions of the small intestine and stomach. A distal pancreatectomy is a surgical procedure to remove the bottom half of the pancreas.
A client is suspected of having cirrhosis of the liver. What diagnostic procedure will the nurse prepare the client for in order to obtain a confirmed diagnosis?
A liver biopsy A liver biopsy, which reveals hepatic fibrosis, is the most conclusive diagnostic procedure. It can be performed in the radiology department with ultrasound or CT to identify appropriate placement of the trocar or biopsy needle. A prothrombin time and platelet count will assist with determining if the client is at increased risk for bleeding.
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. Ascites present in liver failure contain albumin; therefore, if the bladder ruptured, ascites containing albumin would drain from the indwelling urinary catheter because the catheter is no longer contained in the bladder. Creatinine, urobilinogen, and chloride are normally found in urine.
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 (Fig. 49-13).
When inspecting the abdomen of a client with cirrhosis, the nurse observes that the veins over the abdomen are dilated. The nurse documents this finding as which of the following?
Caput medusae Caput medusa is a term used to denote the appearance of dilated veins over the client's abdomen. Gynecomastia refers to enlarged breasts in a male, which may occur because the dysfunctional liver is unable to metabolize estrogen. Palmer erythema refers to the bright pink appearance of the palms and cutaneous spider angiomata refers to tiny, spider-like blood vessels that may be apparent in a client with cirrhosis due to the liver's inability to inactivate estrogen.
When caring for a patient with cirrhosis, which of the following symptoms should the nurse report immediately?
Change in mental status When caring for a patient with cirrhosis, the nurse should report any change in mental status immediately because they indicate secondary complications. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation with accompanying weight loss are regular symptoms of cirrhosis.
When caring for a patient with advanced cirrhosis and hepatic encephalopathy, which of the following assessment findings should the nurse report immediately?
Change in the patient's handwriting and or cognitive performance The earliest symptoms of hepatic encephalopathy include mental status changes and motor disturbances. The patient appears confused and unkempt and has alterations in mood and sleep patterns. Neurologic status should be assessed frequently. Mental status is monitored by the nurse keeping the patient's daily record of handwriting and arithmetic performance. The nurse should report any change in mental status immediately. Chronic fatigue, anorexia, dyspepsia, nausea, vomiting, and diarrhea or constipation with accompanying weight loss are regular symptoms of cirrhosis.
When assessing a client with cirrhosis of the liver, which of the following stool characteristics is the client likely to report?
Clay-colored or whitish Many clients report passing clay-colored or whitish stools as a result of no bile in the gastrointestinal tract. The other stool colors would not be absolute indicators of cirrhosis of the liver but may indicate other GI tract disorders.
Which of the following is an age-related change of the hepatobiliary system?
Decreased blood flow Age-related changes of the hepatobiliary system include decreased blood flow, decreased drug clearance capability, increased presence of gall stones, and a steady decrease in size and weight of the liver.
The mode of transmission of hepatitis A virus (HAV) includes which of the following?
Fecal-oral The mode of transmission of hepatitis A virus (HAV) occurs through fecal-oral route, primarily through person to person contact and/or ingestion of fecal contaminated food or water. Hepatitis B virus (HBV) is transmitted primarily through blood. HBV can be found in blood, saliva, semen, and can be transmitted through mucous membranes and breaks in the skin.
Which type of deficiency results in macrocytic anemia?
Folic acid Folic acid deficiency results in macrocytic anemia. Vitamin C deficiency results in hemorrhagic lesions of scurvy. Vitamin A deficiency results in night blindness and eye and skin changes. Vitamin K deficiency results in hypoprothrombinemia, which is characterized by spontaneous bleeding and ecchymosis.
A patient has an elevated serum ammonia level and is exhibiting mental status changes. The nurse should suspect which of the following conditions?
Hepatic encephalopathy Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with elevated ammonia levels that produce changes in mental status, altered level of consciousness, and coma. Portal hypertension is an elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.
A nurse is gathering equipment and preparing to assist with a sterile bedside procedure to withdraw fluid from a patient's abdomen. The procedure tray contains the following equipment: trocar, syringe, needles, and drainage tube. The patient is placed in a high Fowler's position and a BP cuff is secured around the arm in preparation for which of the following procedures?
Paracentesis Paracentesis is the removal of fluid (ascites) from the peritoneal cavity through a puncture or a small surgical incision through the abdominal wall under sterile conditions. Paracentesis may be used to withdraw ascitic fluid if the fluid accumulation is causing cardiorespiratory compromise.
Gynecomastia is a common side effect of which of the following diuretics?
Spironolactone (Aldactone) Gynecomastia is a common side effect caused by spironolactone. Pitressin is used for bleeding esophageal varices and is not a diuretic. Nitroglycerin (IV) may be used with vasopressin to counteract the effects of vasoconstriction from the vasopressin.
The nurse is concerned about potassium loss when a diuretic is prescribed for a patient with ascites and edema. What diuretic may be ordered that spares potassium and prevents hypokalemia?
Spironolactone (Aldactone) Potassium-sparing diuretic agents such as spironolactone or triamterene (Dyrenium) may be indicated to decrease ascites, if present; these diuretics are preferred because they minimize the fluid and electrolyte changes commonly seen with other agents.
Which of the following is the most effective strategy to prevent hepatitis B infection?
Vaccine The most effective strategy to prevent hepatitis B infection is through vaccination. Recommendations to prevent transmission of hepatitis B include vaccination of sexual contacts of individuals with chronic hepatitis, use of barrier protection during sexual intercourse, avoidance of sharing toothbrushes, razors with others, and covering open sores or skin lesions.
A patient with end-stage liver disease who is scheduled to undergo a liver transplant tells the nurse, "I am worried that my body will reject the liver." Which of the following statements is the nurse's best response to the patient?
"You will need to take daily medication to prevent rejection of the transplanted liver. The new liver has a good chance of survival with the use of these drugs." Rejection is a primary concern. A transplanted liver is perceived by the immune system as a foreign antigen. This triggers an immune response, leading to the activation of T lymphocytes that attack and destroy the transplanted liver. Immunosuppressive agents are used as long-term therapy to prevent this response and rejection of the transplanted liver. These agents inhibit the activation of immunocompetent T lymphocytes to prevent the production of effector T cells. Although the 1- and 5-year survival rates have increased dramatically with the use of new immunosuppressive therapies, these advances are not without major side effects. The other statements are inaccurate or will not decrease the patient's anxiety.
A client and spouse are visiting the clinic. The client recently experienced a seizure and says she has been having difficulty writing. Before the seizure, the client says that for several weeks she was sleeping late into the day but having restlessness and insomnia at night. The client's husband says that he has noticed the client has been moody and slightly confused. Which of the following problems is most consistent with the client's clinical manifestations?
Hepatic encephalopathy The earliest symptoms of hepatic encephalopathy include minor mental changes and motor disturbances. The client appears slightly confused and unkempt and has alterations in mood and sleep patterns. The client tends to sleep during the day and have restlessness and insomnia at night. As hepatic encephalopathy progresses, the client may become difficult to awaken and completely disoriented with respect to time and place. With further progression, the client lapses into frank coma and may have seizures. Simple tasks, such as handwriting, become difficult.
The nurse is administering medications to a patient 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 (Cephulac) Lactulose (Cephulac) is administered to detoxify ammonium and to act as an osmotic agent, drawing water into the bowel, which causes diarrhea in some clients. Potassium-sparing diuretics such as spironolactone (Aldactone) are used to treat ascites. Cholestyramine (Questran) is a bile acid sequestrant and reduces pruritus. Kanamycin (Kantrex) decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.
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 Daily weight measurement is the most accurate indicator of fluid status; a loss of 2.2 lb (1 kg) indicates loss of 1 L of fluid. Because spironolactone is a diuretic, weight loss is the best indicator of its effectiveness. This client's serum potassium and sodium levels are normal. A blood pH of 7.25 indicates acidosis, an adverse reaction to spironolactone.
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 scheduled to have a laparoscopic cholecystectomy as an outpatient. The client asks the nurse when he will be able to resume normal activities. What information should the nurse provide?
Normal activities may be resumed in 1 week. A prolonged recovery period usually is unnecessary. Most clients resume normal activities within 1 week.
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. Dyspnea and fatigue suggest anemia. Ascites and orthopnea are unrelated to vitamin K absorption. Gynecomastia and testicular atrophy result from decreased estrogen metabolism by the diseased liver.
The nurse is providing care to a patient with gross ascites who is maintaining a position of comfort in the high semi-Fowler's position. What is the nurse's priority assessment of this patient?
Respiratory assessment related to increased thoracic pressure If a patient with ascites from liver dysfunction is hospitalized, nursing measures include assessment and documentation of intake and output (I&O;), abdominal girth, and daily weight to assess fluid status. The nurse also closely monitors the respiratory status because large volumes of ascites can compress the thoracic cavity and inhibit adequate lung expansion. The nurse monitors serum ammonia, creatinine, and electrolyte levels to assess electrolyte balance, response to therapy, and indications of encephalopathy
After undergoing a liver biopsy, a client should be placed in which position?
Right lateral decubitus position After a liver biopsy, the client is placed on the right side (right lateral decubitus position) to exert pressure on the liver and prevent bleeding. Semi-Fowler's position and the supine and prone positions wouldn't achieve this goal.
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. If the client didn't take his morning dose of lactulose, he wouldn't have elevated ammonia levels and decreased level of consciousness this soon. These assessment findings don't indicate that the client is relaxed or avoiding the nurse.
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. Circumstances that increase serum ammonia levels tend to aggravate or precipitate hepatic encephalopathy. The largest source of ammonia is the enzymatic and bacterial digestion of dietary and blood proteins in the GI tract. Ammonia from these sources increases as a result of GI bleeding (ie, bleeding esophageal varices, chronic GI bleeding), a high-protein diet, bacterial infection, or uremia.
A client is actively bleeding from esophageal varices. Which of the following medications would the nurse most expect to be administered to this client?
Vasopressin (Pitressin) In an actively bleeding client, medications are administered initially because they can be obtained and administered quicker than other therapies. Vasopressin (Pitressin) may be the initial mode of therapy in urgent situations, because it produces constriction of the splanchnic arterial bed and decreases portal pressure. Propranolol (Inderal) and nadolol (Corgard), beta-blocking agents that decrease portal pressure, are the most common medications used both to prevent a first bleeding episode in clients with known varices and to prevent rebleeding. Beta-blockers should not be used in acute variceal hemorrhage, but they are effective prophylaxis against such an episode. Spironolactone (Aldactone), an aldosterone-blocking agent, is most often the first-line therapy in clients with ascites from cirrhosis. Lactulose (Cephulac) is administered to reduce serum ammonia levels in clients with hepatic encephalopathy.
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 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. Explanation: In acute liver failure, serum ammonia levels increase because the liver can't adequately detoxify the ammonia produced in the GI tract. In addition, serum glucose levels decline because the liver isn't capable of releasing stored glucose. Elevated serum ammonia and subnormal serum glucose levels depress the level of a client's consciousness. Elevated liver enzymes, low serum protein level, subnormal clotting factors and platelet count, elevated blood urea nitrogen and creatine levels, and hyperglycemia aren't as directly related to the client's level of consciousness.
A client is given a diagnosis of hepatic cirrhosis. The client asks the nurse what findings led to this determination. Which of the following clinical manifestations would the nurse correctly identify? Select all that apply.
• Enlarged liver size • Ascites • Hemorrhoids Early in the course of cirrhosis, the liver tends to be large, and the cells are loaded with fat. The liver is firm and has a sharp edge that is noticeable on palpation. Portal obstruction and ascites, late manifestations of cirrhosis, are caused partly by chronic failure of liver function and partly by obstruction of the portal circulation. The obstruction to blood flow through the liver caused by fibrotic changes also results in the formation of collateral blood vessels in the GI system and shunting of blood from the portal vessels into blood vessels with lower pressures. These distended blood vessels form varices or hemorrhoids, depending on their location. Because of inadequate formation, use, and storage of certain vitamins (notably vitamins A, C, and K), signs of deficiency are common, particularly hemorrhagic phenomena associated with vitamin K deficiency. Additional clinical manifestations include deterioration of mental and cognitive function with impending hepatic encephalopathy and hepatic coma, as previously described.