Module 1 Chapter 58: Care of Patients with Liver Problems

2 Frequent vital signs 4 Red blood cell transfusion 5 Sengstaken-Blakemore tube 6 Beta-adrenergic blocking agent Frequent vital signs are necessary during bleeding episodes to assess for shock and evaluate therapies. Red blood cells are given to replace fluid volume and oxygen-carrying capacity lost during hemorrhage. Esophageal balloon tamponade with a Minnesota or Sengstaken-Blakemore tube is used to control bleeding through direct pressure. Beta-adrenergic blockers are used to reduce portal pressure and therefore bleeding. Platelets, rather than antiplatelet medications which can cause bleeding, are usually administered. A liver biopsy is done to diagnose the cause of the cirrhotic process, but it is not a treatment for bleeding esophageal varices.

A client is admitted with bleeding esophageal varices. The nurse anticipates which factors may be included in the client's plan of care? Select all that apply. 1 Liver biopsy 2 Frequent vital signs 3 Antiplatelet medication 4 Red blood cell transfusion 5 Sengstaken-Blakemore tube 6 Beta-adrenergic blocking agent

Answer: 3. "Not eating salt is an acquired taste, which you can become used to." Table salt should be completely excluded from the diet. The client should be made aware that humans are not born craving salt, so in time, the client can become used to a low-sodium diet. Agreeing the diet is restrictive does not help promote adherence nor offer hope to the client that the situation can improve. While it is true that adding sodium will promote fluid retention and worsen ascites, it is not a cause of encephalopathy/confusion.

A client with ascites says, "This diet is terrible. I don't know how anyone can survive with no salt on their food." What is the best response by the nurse? 1. "You can add just one teaspoon of salt to your food each day." 2. "This is a terribly restrictive diet, but you must adhere to it." 3. "Not eating salt is an acquired taste, which you can become used to." 4. "Adding salt to your food will make you more confused than you already are.

2 Discuss this early sign of serious complications with the provider. A change in sleep patterns in clients with cirrhosis is an early indicator of hepatic encephalopathy and may be reversible with early intervention. The nurse should notify the provider so that intervention may begin. Sedatives may or may not be ordered, but evaluation of the cause is necessary. Difficulty getting to sleep and staying asleep is not transient, and at this stage is reversible.

A client with cirrhosis reports having difficulty getting to sleep and staying asleep. Which action by the nurse is correct? 1 Contact the provider to discuss ordering a sedating medication. 2 Discuss this early sign of serious complications with the provider. 3 Reassure the client that this is a transient disease side effect. 4 Tell the client that this indicates irreversible encephalopathy.

3 Intrahepatic obstruction Clients with hepatitis may develop intrahepatic obstruction, which will cause clay-colored stools and dark urine when the bile ducts are blocked. These findings may occur with hepatic obstruction in cirrhosis or carcinoma, but do not necessarily indicate that these have occurred. Obstructive jaundice is another sign of intrahepatic obstruction.

A client with viral hepatitis has clay-colored stools and dark urine. These findings are typically characteristic of which complication of hepatitis? 1 Cirrhosis of the liver 2 Hepatic carcinoma 3 Intrahepatic obstruction 4 Obstructive jaundice

4 Noting the presence of bloody emesis or stool. Clients with esophageal varices are at risk for hemorrhage, which is a life-threatening medical emergency. Unconsciousness may occur prior to observable bleeding, so the client who is unconscious should be evaluated for this. Splenomegaly, jaundice, and ascites are all complications of cirrhosis, but are not life-threatening and not the priority assessment in this case.

An unconscious client brought to the emergency department has a history of Laennec's cirrhosis and esophageal varices. What is the priority assessment for this client? 1 Assessing the size of the spleen. 2 Determining the presence of jaundice. 3 Evaluating the abdomen for ascites. 4 Noting the presence of bloody emesis or stool.

Answer: 1. Potassium chloride Spironolactone is a potassium-sparing diuretic; additional potassium may result in potassium intoxication. Cephulac and neomycin are used to control hepatic encephalopathy, which is part of the expected treatment plan. Propranolol is used to prevent gastrointestinal hemorrhage secondary to portal hypertension and gastroesophageal varices, which is an expected treatment for portal hypertension.

The nurse is administering spironolactone (Aldactone) to a client with portal hypertension and portal systemic encephalopathy. Which additional medication order does the nurse question? 1. Potassium chloride 2. Lactulose (Cephulac) 3. Neomycin (Mycifradin) 4. Propranolol (Inderal)

2 Decreased fluid volume 4 Constipation 5 Gastrointestinal bleeding Decreased fluid volume, constipation, and gastrointestinal bleeding may cause hepatic encephalopathy in clients with cirrhosis. Other causes include a high-protein diet and decreased serum potassium levels.

The nurse is caring for a client with cirrhosis. What factors may lead to hepatic encephalopathy in the client? Select all that apply. 1 Low-protein diet 2 Decreased fluid volume 3 Increased serum potassium 4 Constipation 5 Gastrointestinal bleeding

Answer: 2. Client with severe ascites who has a temperature of 101.4° F (38° C) The client with ascites and an elevated temperature may have spontaneous bacterial peritonitis; the nurse should call this client first. Itching is anticipated with jaundice, this client may be called last. Weight gain with cirrhosis is not uncommon owing to low albumin levels. Cirrhosis may cause mild right upper quadrant pain; this client should be called after the client with severe ascites.

The nurse is caring for clients in the outpatient clinic. Which of these phone calls should the nurse return first? 1. Client with hepatitis A reporting severe and ongoing itching 2. Client with severe ascites who has a temperature of 101.4° F (38° C) 3. Client with cirrhosis who has had a 3-pound weight gain over 2 days 4. Client with esophageal varices and mild right upper quadrant pain

3 Client with end-stage cirrhosis who needs teaching about a low-sodium diet The RN is responsible for client teaching; therefore, the client with end-stage cirrhosis should be assigned to the RN. Assisting a client with toileting and recording stool number and amount can be accomplished by nonprofessional staff. The LPN/LVN can provide dressing changes. Ancillary staff can perform venipuncture.

The nursing team consists of an RN, an LPN/LVN, and a nursing assistant. Which client should be assigned to the RN? 1 Client who is taking lactulose and has diarrhea 2 Client with hepatitis C who requires a dressing change 3 Client with end-stage cirrhosis who needs teaching about a low-sodium diet 4 Obtunded client with alcoholic encephalopathy who needs a blood draw

4 Alkaline phosphatase In clients with obstructive jaundice, the serum alkaline phosphatase level is elevated. Levels of serum aspartate aminotransferase, serum alanine aminotransferase, and lactate dehydrogenase are elevated in case of clients with hepatic cell destruction.

The serum level of what enzyme is elevated in clients with obstructive jaundice? 1 Aspartate aminotransferase 2 Alanine aminotransferase 3 Lactate dehydrogenase 4 Alkaline phosphatase

1 Postnecrotic The hepatitis C virus causes postnecrotic cirrhosis. Laennec's cirrhosis is caused by chronic alcoholism. Biliary cirrhosis is also called cholestatic cirrhosis; it is caused by chronic biliary obstruction or autoimmune disease.

What type of cirrhosis is caused by hepatitis C? 1 Postnecrotic 2 Laennec's 3 Biliary 4 Cholestatic

Brown stool 3 Tea-colored urine 4 Right upper quadrant tenderness 5 Itching The urine may be brown, tea-, or cola-colored in clients with hepatitis. Inflammation of the liver may cause right upper quadrant pain. Deposits of bilirubin on the skin, secondary to high bilirubin levels, and jaundice irritate the skin and cause itching. Hepatitis B virus, not the influenza virus, causes hepatitis B, which is spread by blood and body fluids. The stool in hepatitis may be tan or clay-colored.

When assessing a client with hepatitis B, the nurse anticipates which assessment findings? Select all that apply. 1 Recent influenza infection 2 Brown stool 3 Tea-colored urine 4 Right upper quadrant tenderness 5 Itching

1 Kidney failure The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and should not be taken by the client with hepatic encephalopathy. Cirrhosis and hepatic failure cause both ascites and encephalopathy; no contraindication for neomycin is known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels. The client may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.

When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)? 1 Kidney failure 2 Refractory ascites 3 Fetor hepaticus 4 Paracentesis scheduled for today

1 Do not consume any alcohol. 5 Avoid medications containing acetaminophen. The client with hepatitis should avoid all alcohol as well as hepatotoxic medications such as acetaminophen unless instructed otherwise by the provider. The diet should be high in carbohydrates with moderate fat and moderate protein content. The client may drive if he or she feels well. As hepatitis does not directly affect the cardiovascular system, there is no need to monitor vital signs. While carbonated beverages may contribute to a sense of fullness, it is not required that they be absolutely excluded.

When teaching a client with viral hepatitis, which instructions does the nurse include in the plan of care? Select all that apply. 1 Do not consume any alcohol. 2 Consume a high-protein diet. 3 Do not drive a car for 1-2 weeks. 4 Monitor blood pressure and pulse daily. 5 Avoid medications containing acetaminophen. 6 Avoid carbonated beverages

2. Gastrointestinal bleeding 3 Hypokalemia 5 High-protein diet The development of hepatic encephalopathy is believed to be the result of the shunting of portal venous blood into the central circulation so that the liver is bypassed. A buildup of ammonia and gamma aminobutyric acid (GABA) results. Factors that may precipitate hepatic encephalopathy include a high-protein diet, infections, hypovolemia, hypokalemia, and constipation. GI bleeding that causes a large protein load in the intestine, and medications such as hypnotics, opioids, sedatives, analgesics, and diuretics also contribute to encephalopathy. Diarrhea, hypertension, and hypermagnesemia are not known to be contributing factors for hepatic encephalopathy.

Which factors may lead to the development of hepatic encephalopathy in a client with cirrhosis? Select all that apply. 1 Diarrhea 2 Gastrointestinal bleeding 3 Hypokalemia 4 Hypertension 5 High-protein diet 6 Hypermagnesemia

1 Never miss a dose. Clients being treated with Ribavirin for hepatitis C are instructed to never miss a dose of the drug. The nurse should assist the client in methods to use for reminders such as setting an alarm or alert. Exposure to sun is not contraindicated with ribavirin; this restriction pertains to sulfonamides or antipsychotic medications. This medication is often taken with food.

Which instruction is essential for the nurse to include when teaching a client who is undergoing treatment for hepatitis with ribavirin? 1 Never miss a dose. 2 Avoid going out in the sun. 3 Take the medication on an empty stomach. 4 Take the medication at the same time each day.

2 Employment in the health care field Risk factors for hepatitis C include illicit drug use by IV or intranasal route, unsanitary tattoo equipment, and current or former employment in the health care field (because health care workers can easily be exposed to blood and body fluids). Hepatitis A can be contracted by consuming contaminated shellfish. Hepatitis E can be contracted by individuals who travel to countries with poor sanitation. Chronic alcohol consumption is a risk factor for cirrhosis, not hepatitis.

Which is a risk factor for the development of hepatitis C? 1 Consuming shellfish 2 Employment in the health care field 3 Traveling internationally 4 Chronic alcohol consumption