Med Surg Ch. 49 Hepatic Disorders

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).

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

"How did this happen? I've been faithful my entire marriage." The client requires further teaching if he suggests that he acquired the virus through sexual contact. Hepatitis A is transmitted by the oral-fecal route or through ingested food or liquid that's contaminated with the virus. Hepatitis A is rarely transmitted through sexual contact. Clients with hepatitis A need to take every effort to avoid spreading the virus to other members of their family with precautions such as preparing food carefully, washing hands often, and taking medications as ordered.

The nurse is preparing a client for a thyroid test. Which medications should the nurse document on the laboratory slip that the client is taking that may affect the thyroid test?

-Phenytoin -Metoclopramide -Furosemide -Amphetamine If a client has recently taken a drug that contains iodine or has had radiographic contrast studies that used iodine, thyroid test results may be inaccurate. Other drugs also affect the results of thyroid tests. Phenytoin can lower T4 values. Metoclopramide can raise TSH levels. Amphetamine can lower TSH levels. Furosemide can increase T4 level. Be sure to enter on the laboratory request slip all drugs the client is taking or has taken within the past 3 months. The other drugs do not have relevance to the thyroid test.

What intervention does the nurse anticipate providing for the patient with ascites that will help correct the decrease in effective arterial blood volume that leads to sodium retention?

Albumin infusion Albumin infusions help to correct decreases in effective arterial blood volume that lead to sodium retention. The use of this colloid reduces the incidence of postparacentesis circulatory dysfunction with renal dysfunction, hyponatremia, and rapid reaccumulation of ascites associated with decreased effective arterial volume.

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

B. The client's presentation is most similar to hepatitis B. Mode of transmission is from infected blood or plasma, needles, syringes, surgical or dental equipment contaminated with infected blood; also sexually transmitted through vaginal secretions and semen of carriers or those actively infected. Mode of transmission for hepatitis C is similar to HBV, although less severe and without jaundice. Mode of transmission for hepatitis A is the oral route from feces and saliva of infected persons. The mode of transmission for hepatitis E is similar to HAV.

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.

A nurse is caring for a client with cholelithiasis. Which sign indicates obstructive jaundice?

Clay-colored stools Obstructive jaundice develops when a stone obstructs the flow of bile in the common bile duct. When the flow of bile to the duodenum is blocked, the lack of bile pigments results in a clay-colored stool. In obstructive jaundice, urine tends to be dark amber (not straw-colored) as a result of soluble bilirubin in the urine. Hematocrit levels aren't affected by obstructive jaundice. Because obstructive jaundice prevents bilirubin from reaching the intestine (where it's converted to urobilinogen), the urine contains no urobilinogen.

A client with cirrhosis has been referred to hospice care. Assessment data reveal a need to discuss nutrition with the client. What is the nurse's priority intervention?

Discuss meals that include low-fat high-carbohydrate content. In cirrhosis, the liver's metabolic function is compromised, increasing the client's need for carbohydrates and other energy sources for cellular metabolism. The nurse should limit the client's fat intake to prevent satiation and should restrict protein intake because a cirrhotic liver can't metabolize protein effectively. A client with cirrhosis may have increased edema as a result of reduced plasma albumin, so he should restrict fluid intake rather than drink 64 oz of water daily. Increasing fiber intake isn't a priority intervention for a client with cirrhosis. A client with cirrhosis doesn't need to eliminate caffeine from his diet.

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.

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

Hemolytic Hemolytic jaundice occurs because, although the liver is functioning normally, it cannot excrete the bilirubin as quickly as it is formed. This type of jaundice is encountered in clients with hemolytic transfusion reactions and other hemolytic disorders. Obstructive and hepatocellular jaundice are the result of liver disease. Nonobstructive jaundice occurs with hepatitis.

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

Lactulose Lactulose 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 are used to treat ascites. Cholestyramine is a bile acid sequestrant and reduces pruritus. Kanamycin decreases intestinal bacteria and decreases ammonia but does not act as an osmotic agent.

A client with cirrhosis has a massive hemorrhage from esophageal varices. Balloon tamponade is used temporarily to control hemorrhage and stabilize the client. In planning care, the nurse gives the highest priority to which goal?

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 can be 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.

Which assessments are important in a client diagnosed with ascites?

Measurement of abdominal girth Measurement of abdominal girth, weight, and palpation of the abdomen for a fluid shift are all important assessment parameters for the client diagnosed with ascites. Foul-smelling breath would not be considered an important assessment for this client.

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.

A client has undergone a liver biopsy. Which postprocedure position is appropriate?

On the right side In this position, the liver capsule at the site of penetration is compressed against the chest wall, and the escape of blood or bile through the perforation made for the biopsy is impeded. Positioning the client on his left side is not indicated. Positioning the client in the Trendelenburg position may be indicated if the client is in shock, but is not the position designed for the client after liver biopsy. The high Fowler position is not indicated for the client after liver biopsy.

A patient is prescribed Sandostatin for the treatment of esophageal varices. The nurse knows that the purpose of this cyclic octapeptide is to reduce portal pressure by:

Selective vasodilation of the portal system. Sandostatin slows the flow of blood (via vasodilation) from internal organs to the portal system, thus reducing pressure. The other choices are actions of different drugs used for the treatment of esophageal varices. Refer to Table 25-1 in the text.

The nurse is teaching a client who was admitted to the hospital with acute hepatic encephalopathy and ascites about an appropriate diet. The nurse determines that the teaching has been effective when the client chooses which food choice from the menu?

Pancakes with butter and honey, and orange juice Teach clients to select a diet high in carbohydrates with protein intake consistent with liver function. The client should identify foods high in carbohydrates and within protein requirements (moderate to high protein in cirrhosis and hepatitis, low protein in hepatic failure). The client with acute hepatic encephalopathy is placed on a low-protein diet to decrease ammonia concentration. The other choices are all higher in protein. The client's ascites indicates that a low-sodium diet is needed, and the other choices are all high in sodium.

Which is the most common cause of esophageal varices?

Portal hypertension Esophageal varices are almost always caused by portal hypertension, which results from obstruction of the portal circulation within the damaged liver. Jaundice occurs when the bilirubin concentration in the blood is abnormally elevated. Ascites results from circulatory changes within the diseased liver. Asterixis is an involuntary flapping movement of the hands associated with metabolic liver dysfunction.

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.

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

Reduce fluid accumulation and venous pressure. Methods of treating portal hypertension aim to reduce fluid accumulation and venous pressure. There is no cure for cirrhosis; treating the esophageal varices is only a small portion of the overall objective. Promoting optimal neurologic function will not reduce portal hypertension.

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 patient is scheduled for a diagnostic paracentesis, but when coagulation studies were reviewed, the nurse observed they were abnormal. How does the nurse anticipate the physician will proceed with the paracentesis?

The physician will use an ultrasound guided 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 (Gordon, 2012). Ultrasound guidance may be indicated in some patients who are at high risk for bleeding because of an abnormal coagulation profile and in those who have had previous abdominal surgery and may have adhesions.

Alcohol, which is toxic to the liver, is a common cause of hepatic disorders. As part of health teaching, the nurse advises a group of women that the amount of daily alcohol use should be limited to the equivalent of:

Two 6 oz glasses of wine. Intake of 60 g/day for men and 30 g/d for women (10 g of alcohol is equivalent to 1 oz of bourbon, 12 ounces of beer, or 4 ounces of red wine) is sufficient to cause liver injury.

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.

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

Vasopressin Vasopressin may be the initial therapy for esophageal varices because it constricts the splanchnic arterial bed and decreases portal hypertension. Nitroglycerin has been used to prevent the side effects of vasopressin. Spironolactone and cimetidine do not decrease portal hypertension.

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.

Which condition indicates an overdose of lactulose?

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

A client has just been diagnosed with hepatitis A. On assessment, the nurse expects to note:

anorexia, nausea, and vomiting. Early hallmark signs and symptoms of hepatitis A include anorexia, nausea, vomiting, fatigue, and weakness. Abdominal pain may occur but doesn't radiate to the shoulder. Eructation and constipation are common in gallbladder disease, not hepatitis A. Abdominal ascites is a sign of advanced hepatic disease, not an early sign of hepatitis A.

A physician orders lactulose (Cephulac), 30 ml three times daily, when a client with cirrhosis develops an increased serum ammonia level. To evaluate the effectiveness of lactulose, the nurse should monitor:

level of consciousness (LOC). In cirrhosis, the liver fails to convert ammonia to urea. Ammonia then builds up in the blood and is carried to the brain, causing cerebral dysfunction. When this occurs, lactulose is administered to promote ammonia excretion in the stool and thus improve cerebral function. Because LOC is an accurate indicator of cerebral function, the nurse can evaluate the effectiveness of lactulose by monitoring the client's LOC. Monitoring urine output, abdominal girth, and stool frequency helps evaluate the progress of cirrhosis, not the effectiveness of lactulose.

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

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