Cirrhosis

Delirium tremens (DTs)

is the most severe form of alcohol withdrawal and occurs in about 5% of alcoholics. DTs begin approximately 40-48 hours after the cessation of drinking. DTs can be life-threatening. DTs is characterized by high blood pressure, tachycardia, fever, tremors, diaphoresis, disorientation, confusion, agitation, hallucinations, delusions, and seizures. DTs may last 1-3 days, and reoccurrence may continue for weeks.

Bell's HCP is called away, but tells you she will return shortly to write more prescriptions. You anticipate that she will prescribe which medications? A Heparin to prevent clotting B diazepam for sedation C propranolol or nadolol D Phenobarbital for sedation E Aspirin to prevent clotting

propranolol or nadolol By decreasing heart rate and the hepatic venous pressure gradient, the chance of bleeding may be reduced. She has an increased risk for bleeding because liver dysfunction results in a decreased production of clotting factors. Bell has evidence of bleeding, and her prothrombin time (PT) is prolonged. Heparin administration could result in hemorrhage.

How should you prepare a patient for the paracentesis?

- In a sitting position. During paracentesis, a needle is inserted through the abdomen into the peritoneal cavity. - Ask them to void; to reduce risk of perforation of a distended bladder when the needle is inserted. A insert a nasogastric (NG) tube

Bell has been hospitalized for less than a day. Assuming she was drinking heavily prior to admission, at this time she might exhibit signs and symptoms of early alcohol withdrawal. What are signs and symptoms of early alcohol withdrawal? A anxiety B agitation C tremors D delirium tremens (DTs) E irritability F diaphoresis

A Anxiety characterizes early alcohol withdrawal, which begins within 6-8 hours after the cessation of drinking. B agitation: Early signs of alcohol withdrawal begin within 6-8 hours after the cessation of drinking. Agitation and disturbed sleep are common as the brain inhibiting action of alcohol wears off. However, lethargy and fatigue may also be observed, usually when alcohol withdrawal is less severe. C tremors Early signs of alcohol withdrawal begin within 6-8 hours after the cessation of drinking. Tremors are common during this period. A subjective "shaking inside" is experienced. Tremors often continue throughout the later stages of alcohol withdrawal. E Irritability and emotional volatility are common signs of early alcohol withdrawal, which begins within 6-8 hours after the cessation of drinking. Individuals generally startle easily during this period F diaphoresis Early signs of alcohol withdrawal begin within 6-8 hours after the cessation of drinking. Sweating is common during this period. Delirium tremens (DTs) does not occur in the early hours of alcohol withdrawal. Delirium tremens characterizes the later stages of alcohol withdrawal, beginning approximately 40-48 hours after the cessation of drinking

When determining the extent of Bell's liver dysfunction, which blood tests are monitored? A Aspartate aminotransferase (AST) B Alanine aminotransferase (ALT) C Creatinine D Calcitonin E Albumin F Ammonia G Prothrombin time (PT)

A Aspartate aminotransferase (AST) B Alanine aminotransferase (ALT) C Creatinine E Albumin F Ammonia G Prothrombin time (PT)

Bleeding from esophageal varices can be abrupt and massive. If a client at risk for varices started vomiting blood, which actions are important for the nurse to take? A Assess vital signs B Turn the client on her side C Alert the cardiac arrest team D Prepare to administer oxygen E Prepare suctioning equipment F Insure an IV access G Prepare for insertion of a nasogastric tube

A Assess vital signs B Turn the client on her side D Prepare to administer oxygen E Prepare suctioning equipment F Insure an IV access G Prepare for insertion of a nasogastric tube

Magnesium sulfate per IV is prescribed for infusion over four hours. Which of the following are important with this drug administration? A Calcium gluconate IV should be available B Urine output should be adequate C Vital signs should be checked frequently D The patellar reflex should be checked E Observe for nausea and vomiting F A tracheotomy set should be available at the bedside

A Calcium gluconate IV should be available; If hypermagnesium occurred, the drug would be stopped and IV fluids would be prescribed to flush out excess drug (assuming normal kidney function). A calcium salt (e.g., calcium gluconate) might be given for treatment of magnesium toxicity. Calcium antagonizes the action of magnesium. B Urine output should be adequate; Magnesium sulfate is eliminated by the kidneys. Kidney function and urine output must be sufficient (greater than 25-30 mL per hour) to prevent drug toxicity and ensure adequate elimination of excess drug. C Vital signs should be checked frequently; Magnesium has a sedating effect in the body. Hypotension and respiratory depression occur with hypermagnesemia. Heart rate may slow and dysrhythmias may develop. Frequent monitoring of vital signs is indicated to help detect these problems. Cardiac monitoring is recommended and often required by agency protocol. D The patellar reflex should be checked; Magnesium has a sedating effect in the body. Depressed deep tendon reflexes occur with magnesium toxicity. Monitoring of reflex activity is indicated to detect signs of excess magnesium. E Observe for nausea and vomiting; Nausea and vomiting may occur with the presence of excess magnesium. Weakness, drowsiness, and flushing may also occur.

When a person with severe cirrhosis has esophageal or any other gastrointestinal (GI) bleeding, lactulose may be given. Which of the following are expected with administration of lactulose? A Onset of soft stools b Constipation C Reduction of serum ammonia level D Decrease in bleeding tendency

A Onset of soft stools Lactulose is a laxative which traps ammonia in the feces and hastens its elimination. It is expected to cause soft stools. Sufficient drug is administered to ensure 2-3 soft stools per day. C Reduction of serum ammonia level Lactulose causes rapid movement of stool through the intestine, decreasing the time for creation of ammonia. It also causes ammonia to become ionized and less absorbable from the bowel. With lactulose, serum ammonia level should decrease.

The medical procedure that removes excess fluid from the peritoneal cavity is called: A Paracentesis B Thoracentesis C Amniocentesis D Arthrocentesis

A Paracentesis is the procedure used to remove fluid from the peritoneal cavity.

In cirrhosis, which factors contribute to ascites? A Portal hypertension B Hypersecretion of aldosterone C Accumulation of antidiuretic hormone (ADH) D Increased secretion of gastric juices E Hyperbilirubinemia F Hypoproteinemia

A Portal hypertension In clients with cirrhosis, scar tissue replaces normal liver tissue. Fibrous scar tissue restricts blood flow from the portal veins (which drain the GI tract, pancreas, and spleen) from entering the liver. Blood backs up in the portal system. High portal venous pressure (portal hypertension) causes fluid to seep into the peritoneal cavity, resulting in ascites. C Accumulation of antidiuretic hormone (ADH) Antidiuretic hormone (ADH) accumulates in the serum of clients with cirrhosis, because the diseased liver is not able to metabolize ADH. ADH causes water to be reabsorbed by the kidneys. Urine output decreases. Excess water retention contributes to ascites. F Hypoproteinemia The liver normally produces proteins such as albumin, which help maintain normal osmotic pressure in the vascular compartment. With liver dysfunction and hypoalbuminemia, a hypotonic vascular compartment contributes to a fluid shift from the vascular compartment to extracellular spaces, including the peritoneal cavity.

You work on Bell's plan of care. At this time, what is the major goal of nursing care for Bell? A improve Bell's nutritional status B promote regeneration of liver cells C improve Bell's self-concept D convince Bell that lifestyle changes are necessary

A improve Bell's nutritional status

You work on Bell's plan of care. At this time, what is the major goal of nursing care for Bell? A improve Bell's nutritional status B promote regeneration of liver cells C improve Bell's self-concept D convince Bell that lifestyle changes are necessary

A improve Bell's nutritional status; Individuals who abuse alcohol often are seriously malnourished as a result of poor nutritional intake. Vitamin supplementation is usually indicated. Regeneration of liver cells is not a realistic goal. Cirrhosis is a progressive disease. Liver cell necrosis and subsequent loss of function are irreversible, although strict avoidance of alcohol and appropriate therapy may stabilize the disease process and maintain existing liver functions.

You and the HCP talk with Bell and examine her, checking for clinical signs of cirrhosis. What are the clinical signs of cirrhosis? A nausea B jaundice C weight change D ecchymosis E epigastric burning F peripheral edema

A nausea: With cirrhosis, fibrous scar tissue restricts blood from the portal veins (which drain the GI tract, pancreas, and spleen) from entering the liver. The liver may become enlarged (hepatomegaly), and the spleen often becomes enlarged (splenomegaly). Because of poor venous drainage from the GI tract and organs, digestive complaints are common with cirrhosis. These include anorexia, nausea, and vomiting. B jaundice: In clients with cirrhosis, scar tissue replaces normal liver tissue. Liver dysfunction results in impaired uptake, conjugation, and transport of bilirubin. This results in hyperbilirubinemia with jaundice. Jaundice typically becomes evident when total serum bilirubin level exceeds 2 mg/dL. Bell is jaundiced. Her sclera and skin are yellow, and her urine is dark. C weight change:Because of nausea, anorexia, and the liver's inability to metabolize nutrients, many clients with cirrhosis of the liver initially lose weight. As cirrhosis progresses, water weight gain occurs as fluid is retained. Changes in weight with cirrhosis are variable but significant. D ecchymosis: With cirrhosis, prothrombin time (PT) is often prolonged, and bleeding tendency is increased. Bile, secreted by the normal liver, is necessary for absorption of vitamin K from the GI tract. Vitamin K is required for prothrombin production in the liver (the liver produces prothrombin but vitamin K must be present). Fibrinogen, the precursor to fibrin, is also formed in the liver. With severe liver disease, coagulation factors fibrinogen and prothrombin are not produced in adequate amounts, so bleeding tendencies are a result. F peripheral edema: Peripheral edema may occur with cirrhosis, and is caused by the same mechanisms that produce ascites (hypoproteinemia and water retention). Ascites may occur without peripheral edema.

You remind the HCP that she needs to prescribe a diet for Bell. Which diet is she likely to prescribe? A High-protein, low-salt B High-carbohydrate, low-salt C Low-fat, high-protein D Low-carbohydrate, high-fat

B High-carbohydrate, low-salt Bell is malnourished and emaciated, and has been retaining fluids. Sodium restriction is indicated, to decrease water retention. Bell is malnourished and emaciated. A high-carbohydrate diet will provide the extra calories and energy needed for tissue building and weight gain. A low-fat diet may be necessary in some persons with cirrhosis. With liver dysfunction, there is decreased bile production, and digestion of fats may not be normal. However, a high-protein diet is not usually prescribed, because the liver plays a role in protein metabolism. The normal liver metabolizes protein to ammonia, and also detoxifies the ammonia. With severe liver dysfunction, high-protein diets are usually not prescribed, to avoid increases in ammonia level.

You work on Bell's plan of care. Which nursing diagnoses should be included in her care plan? A Ineffective Thermoregulation B Impaired Physical Mobility C Ineffective Airway Clearance D Risk for Infection E Imbalanced Nutrition: Less than Body Requirements F Risk for Injury G Risk for Impaired Skin Integrity

B Impaired Physical Mobility D Risk for Infection E Imbalanced Nutrition: Less than Body Requirements F Risk for Injury G Risk for Impaired Skin Integrity

After Bell is bathed, she uses a bedpan. Which of the following, if observed, should be reported? A Clay-colored stool B Melena C Tea-colored urine

B Melena Clay-colored stools are expected with jaundice. Normal elimination of bilirubin in stool causes brown pigmentation. With liver disease, bilirubin remains unconjugated in the serum and is not eliminated in the stool. Stools become clay-colored (acholic). Since this is expected with jaundice, it is not an unexpected finding and need not be reported. Tea-colored urine is expected with jaundice. Accumulation of bilirubin in the serum, due to inefficient conjugation of bilirubin by a failing liver, causes bilirubin to be eliminated in the urine, resulting in tea-colored urine.

After the HCP completes the paracentesis procedure, which nursing actions are indicated for Bell's care? A Insure that Bell maintains bed rest for a few hours B Monitor Bell's pulse and blood pressure frequently C Assess the procedure site and dressing

B Monitor Bell's pulse and blood pressure frequently Bell does need frequent vital signs assessment after the paracentesis procedure. Paracentesis can cause peritoneal bleeding. With significant bleeding, intravascular fluid volume depletion would be reflected in hypotension and tachycardia. Paracentesis with removal of fluid from the peritoneal cavity can also result in significant fluid shift from the intravascular compartment into the peritoneal cavity. This also would cause volume depletion. BP and pulse are commonly monitored every 15 minutes for the first hour after the paracentesis procedure and per hospital protocol for the next four hours. C Assess the procedure site and dressing The paracentesis site should be monitored for bleeding and fluid leakage. Clients with cirrhosis are at high risk for bleeding. Bell does not need to be on bed rest after the paracentesis procedure. However, because of fluid shifts that might occur as a result of removal of fluid from the abdominal cavity, Bell may become hypotensive and dizzy with rising and movement. Assistance is indicated.

Characteristic of advanced cirrhosis, Bell's abdomen is enlarged due to accumulation of fluid in the peritoneal cavity. This is called: A dependent edema B ascites C hepatomegaly D peritonitis

B ascites Accumulation of fluid in the peritoneal cavity, as seen with cirrhosis, causes a protuberant abdomen. This accumulation of fluid is called ascites. -Dependent edema involves fluid accumulation in the subcutaneous tissues of the lower extremities and possibly the sacrum. -Hepatomegaly is enlargement of the liver. Hepatomegaly may occur with cirrhosis. -Peritonitis is inflammation of the lining of the abdominal cavity. It may cause abdominal distention.

How does the HCP confirm that Bell has abdominal ascites? A palpation of abdominal rigidity in the right upper quadrant (RUQ) B percussion of dullness in dependent areas of the abdomen C absence of bowel sounds with auscultation D rebound tenderness with palpation in the left upper quadrant (LUQ)

B percussion of dullness in dependent areas of the abdomen Ascites is accumulation of fluid in the peritoneal cavity. The presence of ascites can be determined with observation of a protuberant abdomen, and further assessment in which dullness (due to fluid) is noted with percussion in the dependent areas of the abdomen, and tympany (due to air) is noted in upper areas. Ascites can also be detected by palpating for a fluid wave.

Albumin is expected to alleviate ascites by which mechanism? A Albumin will make the vascular compartment hypotonic, causing a fluid shift from the peritoneal cavity into the bloodstream B Albumin will increase the kidney's ability to excrete sodium and water C Albumin will decrease the bacterial count of ascitic fluid, facilitating its excretion D Albumin will make the vascular compartment hypertonic, causing a fluid shift from the peritoneal cavity into the bloodstream

D Albumin will make the vascular compartment hypertonic, causing a fluid shift from the peritoneal cavity into the bloodstream Albumin acts as a plasma expander, creating a hypertonic vascular compartment, causing fluid to shift from areas such as the peritoneal cavity into the bloodstream.

The HCP's prescriptions reflect the need to carefully monitor Bell's fluid balance. Which of the following provides the most useful data for monitoring fluid loss or gain?

Daily Weights Fluid retention adds measurable weight and fluid loss results in measurable weight loss. One liter of fluid is equivalent to 1 kg (2.2 pounds). Weight should be measured at the same time each morning, before breakfast. The same scale should be used when comparing weights from day to day. Intake and output records are important and should be kept and evaluated, but these are not a sensitive indicator of fluid retention or fluid loss. Abdominal girth measurements also are not sensitive indicators of fluid loss or gain, but are frequently used to monitor the degree of ascites. Abdominal girth is measured with a client lying supine, using a tape measure to determine the circumference of the abdomen at the umbilicus.

Until Bell's ascites is resolved, which position do you encourage her to take while she is in bed?

Fowlers The upright Fowler's position (at an angle most comfortable for Bell) will reduce pressure on the diaphragm and will probably be the most comfortable position. Breathing should be easiest in this position. However, Bell's position should be changed at least every two hours to reduce the risk of a pressure ulcer at the coccyx. With the head of the bed slightly lowered, she can be turned from side to side. Shift of position is important in preventing pressure ulcers.

hepatic encephalopathy

Hepatic encephalopathy occurs when toxic substances (ammonia and other substances) are not detoxified by the liver. Neurologic signs may also occur with cirrhosis, usually when the disease process is advanced. Neurologic changes are often a result of hepatic encephalopathy. Hepatic encephalopathy causes disturbances in mentation, progressing from forgetfulness and confusion to stupor and coma. The sleep-wake cycle is often reversed. Handwriting and self-care abilities deteriorate. Hepatic encephalopathy also often includes inability to maintain voluntary muscle contraction and position. Asterixis (flapping tremor) may be observed. With asterixis, a stretched out hand and arm cannot be maintained.

Factors that may cause cirrhosis:

Hepatitis, right-sided heart failure, biliary tract obstruction. cirrhosis is more often a result of chronic alcoholism

Why does cirrhosis predispose clients to esophageal bleeding?

In clients with cirrhosis, scar tissue replaces normal liver tissue. Fibrous scar tissue restricts blood from the portal veins (which drain the GI tract, pancreas, and spleen) from entering the liver. Portal hypertension develops and blood backs up in the portal system, especially esophageal blood vessels, which dilate and become tortuous. These dilated, torturous blood vessels are called esophageal varices. Hot liquids can cause fragile esophageal varices to dilate and subsequently rupture, leading to bleeding.

Medications to prescribe

Thiamine, folic acid, and multivitamins are also prescribed for Bell. Bell is also started on spironolactone, a diuretic. In addition, albumin 25% is ordered IV, to alleviate ascites. lorazepam is prescribed IV on a PRN basis if tremors, anxiety/agitation, or diaphoresis occur.

________ is elevated with severe cirrhosis, secondary to the impaired metabolism and/or excretion of bilirubin by the liver.

Total bilirubin

When evaluating the effectiveness of interventions in Bell's care, which criterion is most useful and realistic with regard to goals for Bell's care? A Normal liver enzymes B Weight loss with decrease in ascites and edema C Absence of abdominal pain

Weight loss with decrease in ascites and edema

How many drinks per day put a patient at risk for alcoholic liver disease?

Women are at risk for alcoholic liver disease when they drink more than 1-2 drinks per day. Men are at increased risk when they drink 5 or more drinks per day.

Wernicke's disease

characterized by confusion, unsteady gait (ataxia), and ophthalmoplegia (paralysis of ocular muscles, often presenting as nystagmus). Most persons with Wernicke's disease also develop Korsakoff's psychosis. Thiamine deficiency is common in alcoholics who are undernourished, and can lead to Wernicke's disease. Thiamine supplementation can correct thiamine deficiency and prevent Wernicke's disease

Korsakoff's psychosis

characterized by impaired memory and learning, and confabulation (substituting events for those that cannot be remembered so a story makes sense).

Alcoholics undergoing withdrawal are treated with:

sedatives. The benzodiazepine lorazepam, by mouth or IV, is widely used, because it has less effect on the liver than other sedatives. The typical antipsychotic drug haloperidol, by mouth or IM, may be needed for treatment of agitation and hallucinations associated with delirium tremens (DTs).