Med Surg: Hepatic Disorders

Hepatitis C

-transmission: percutaneous or mucosal; blood, body fluids, needles, sharp instruments -source: blood, body fluids -chronic -incubation period: 2-25 weeks -no vaccine available -treatment: interferon & antivirals

Clinical manifestations of liver problems

-fever -N/V, malaise -abdominal pain -dyspepsia -pruritis (accumulation of bile salts) -jaundice-liver unable to metabolize bilirubin -abnormal AST, ALT, bilirubin, ammonia, decreased albumin -clay colored stools -amber urine (excretion of bilirubin through urinary tract) -ascites (due to decreased albumin and leakage of fluid into the peritoneal cavity) may require paracentesis -hepatomegaly and splenomegaly (firm nodular liver) -bleeding problems (thrombocytopenia and prolonged PT): anemia, bruise easily, varices and esophageal bleeding

Hepatitis ___ and __ cause 80% of all liver cancers and can lead to progressive damage

B and C

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.

post-icteric phase

fatigue, relapses, jaundice

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.

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.

A client with acute pancreatitis has jaundice with diminished bowel sounds and a tender distended abdomen. Additionally, lab results indicate hypovolemia. What will the physician order to treat the large amount of protein-rich fluid that has been released into the client's tissues and peritoneal cavity? Select all that apply.

diuretics albumin Diuretics are given if circulating fluid is excessive. IV albumin may be given to pull fluid trapped in the peritoneum back into the circulation. Sodium would not be used to treat excessive fluid accumulation. Blood glucose levels can be elevated in clients with acute pancreatitis; therefore, glucose solutions would not be administered nor would they be used to treat excessive fluid accumulation.

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.

A student accepted into a nursing program must begin receiving the hepatitis B series of injections. The student asks when the next two injections should be administered. What is the best response by the instructor?

"You must have the second one in 1 month and the third in 6 months." Both forms of the hepatitis B vaccine are administered intramuscularly in three doses; the second and third doses are given 1 and 6 months, respectively, after the first dose.

4 major functions of liver

-detoxifying body -helps blood to clot- #1 concern is bleeding -metabolizes carbohydrates, fats, and protein; synthesizes albumin and is the storage area for vitamins A, D, E, and K, and iron -helps to break down drugs

Hepatitis A

-transmission: fecal-oral, contaminated water or food -source of virus: feces, contaminated water or food -acute -incubation period: 15-50 days -vaccine available -symptomatic treatment

The single modality of pharmacologic therapy for chronic type B viral hepatitis is:

Alpha-interferon Alpha-interferon is a biologic response modifier that is highly effective for treatment of hepatitis B. The other antiviral agents are effective but not the preferred single-agent therapy.

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).

Which of the following would the nurse expect to assess in a client with hepatic encephalopathy?

Asterixis Hepatic encephalopathy is manifested by numerous central nervous system effects including: disorientation, confusion, personality changes, memory loss, a flapping tremor called asterixis, a positive Babinski reflex, sulfurous breath odor (referred to as fetor hepaticus), and lethargy to deep coma.

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 is seeing the physician for a suspected tumor of the liver. What laboratory study results would indicate that the client may have a primary malignant liver tumor?

Elevated alpha-fetoprotein Alpha-fetoprotein, a serum protein normally produced during fetal development, is a marker that, if elevated, can induce a primary malignant liver tumor. Total bilirubin and serum enzyme levels may be elevated. White blood cell count elevation would indicate an inflammatory response.

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.

While conducting a physical examination of a client, which of the following skin findings would alert the nurse to the possibility of liver problems? Select all that apply.

Jaundice Petechiae Ecchymoses The skin, mucosa, and sclerae are inspected for jaundice. The nurse observes the skin for petechiae or ecchymotic areas (bruises), spider angiomas, and palmar erythema. Cyanosis of the lips is indicative of a problem with respiratory or cardiovascular dysfunction. Aphthous stomatitis is a term for mouth ulcers and is a gastrointestinal abnormal finding.

A client has a blockage of the passage of bile from a stone in the common bile duct. What type of jaundice does the nurse suspect this client has?

Obstructive jaundice Obstructive jaundice is caused by a block in the passage of bile between the liver and intestinal tract. Hemolytic jaundice is caused by excess destruction of red blood cells. Hepatocellular jaundice is caused by liver disease. Cirrhosis of the liver would be an example of hepatocellular jaundice.

What initial measure can the nurse implement to reduce risk of injury for a client with liver disease?

Pad the side rails on the bed Padding the side rails can reduce injury if the client becomes agitated or restless. Restraints would not be an initial measure to implement. Four side rails are considered a restraint, and this would not be an initial measure to implement. Family and friends generally assist in calming a client.

The nurse is preparing a care plan for a client with hepatic cirrhosis. Which nursing diagnoses are appropriate? Select all that apply.

Risk for injury related to altered clotting mechanisms Activity intolerance related to fatigue, general debility, muscle wasting, and discomfort Disturbed body image related to changes in appearance, sexual dysfunction, and role function Risks for injury, activity intolerance, and disturbed body image are priority nursing diagnoses. The appropriate nursing diagnosis related to nutrition would be altered nutrition, less than body requirements, related to chronic gastritis, decreased gastrointestinal motility, and anorexia. Urinary incontinence is not generally a concern with hepatic cirrhosis.

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.

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.

Which of the following diagnostic studies definitely confirms the presence of ascites?

Ultrasound of liver and abdomen Ultrasonography of the liver and abdomen will definitively confirm the presence of ascites. An abdominal x-ray, colonoscopy, and computed tomography of the abdomen would not confirm the presence of ascites.

Which position should be used for a client undergoing a paracentesis?

Upright at the edge of the bed The client should be placed in an upright position on the edge of the bed or in a chair with the feet supported on a stool. The Fowler position should be used for the client confined to bed.

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 produces constriction of 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.

The nurse is administering Cephulac (lactulose) to decrease the ammonia level in a patient who has hepatic encephalopathy. What should the nurse carefully monitor for that may indicate a medication overdose?

Watery diarrhea The patient receiving lactulose is monitored closely for the development of watery diarrhea stools, because they indicate a medication overdose. Serum ammonia levels are closely monitored as well.

icteric phase

altered bilirubin excretion

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.

A nurse educator is providing an in-service to a group of nurses working on a medical floor that specializes in liver disorders. What is an important education topic regarding ingestion of medications?

metabolism of medications Careful evaluation of the client's response to drug therapy is important because the malfunctioning liver cannot metabolize many substances.

pre-icteric phase

non-specific symptoms

cirrhosis

-irreversible chronic disease that causes cell destruction, fibrosis or scarring of hepatic tissues -because of this damage there is alteration of circulation within the liver which causes increased BP (portal hypertension) -can be caused by a virus such as hepatitis (frequently hep C) and the other most common cause is alcohol (Lannec's cirrhosis) -can also be caused by autoimmune diseases and fatty liver or binary disease, exposure to certain medications, industrial chemicals, poisonous mushrooms

Liver receives ____ of the cardiac output through the hepatic portal vein and hepatic artery

25%

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.

What test should the nurse prepare the client for that will locate stones that have collected in the common bile duct?

Endoscopic retrograde cholangiopancreatography (ERCP) ERCP locates stones that have collected in the common bile duct. A colonoscopy will not locate gallstones but only allows visualization of the large intestine. Abdominal x-ray is not a reliable locator of gallstones. A cholecystectomy is the surgical removal of the gallbladder.

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.

A client has an elevated serum ammonia concentration and is exhibiting changes in mental status. The nurse should suspect which condition?

Hepatic encephalopathy Hepatic encephalopathy is a central nervous system dysfunction resulting from liver disease. It is frequently associated with an elevated ammonia concentration that produces 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 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.

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.

In actively bleeding patients with esophageal varices, the initial drug of therapy is usually:

Pitressin In an actively bleeding patient, medications are administered initially because other therapies take longer to initiate. Vasopressin (Pitressin) may be the initial mode of therapy, because it produces constriction of the splanchnic arterial bed and decreases portal pressure. It may be administered by IV infusion.

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.

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.

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 female client with chronic hepatitis B has been prescribed recombinant interferon alfa-2b in combination with ribavirin. Which of the following instructions should a nurse provide this client?

Use strict birth control methods. A female client who has been prescribed recombinant interferon alpha-2b in combination with ribavirin should be instructed to use strict birth control methods. This is because ribavirin may cause birth defects. It is not essential for the client to avoid calcium-rich foods or hot baths or soaks. The client needs to maintain physical rest during therapy.

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.

Total parental nutrition (TPN) should be used cautiously in clients with pancreatitis because such clients:

cannot tolerate high-glucose concentration. Total parental nutrition (TPN) is used carefully in clients with pancreatitis because some clients cannot tolerate a high-glucose concentration even with insulin coverage. Intake of coffee increases the risk for gallbladder contraction, whereas intake of high protein increases risk for hepatic encephalopathy in clients with cirrhosis. Patients with pancreatitis should not be given high-fat foods because they are difficult to digest.

A client is admitted for suspected GI disease. Assessment data reveal muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendency. The nurse suspects the client has:

cirrhosis. Muscle wasting, a decrease in chest and axillary hair, and increased bleeding tendencies are all symptoms of cirrhosis. The client may also have mild fever, edema, abdominal pain, and an enlarged liver. Clients with peptic ulcer disease complain of a dull, gnawing epigastric pain that's relieved by eating. Appendicitis is characterized by a periumbilical pain that moves to the right lower quadrant and rebound tenderness. Cholelithiasis is characterized by severe abdominal pain that presents several hours after a large meal.

A client who has worked for a company that produces paint and varnishing compounds for 24 years is visiting the clinic reporting chronic fatigue, dyspepsia, diarrhea, and a recently developing yellowing of the skin and sclera. The client reports clay-colored stools and frequent nosebleeds. Which type of cirrhosis is the likely cause of the client's symptoms?

postnecrotic Postnecrotic cirrhosis results from destruction of liver cells secondary to infection (e.g., hepatitis), metabolic liver disease, or exposure to hepatotoxins or industrial chemicals. Alcoholic cirrhosis develops as a consequence of long-term alcohol abuse. Respiratory cirrhosis is not a type of cirrhosis. Biliary cirrhosis is less common than other types and is associated with scarring in the bile ducts.

Which symptoms will a nurse observe most commonly in clients with pancreatitis?

severe, radiating abdominal pain The most common symptom in clients with pancreatitis is severe midabdominal to upper abdominal pain, radiating to both sides and straight to the back.

location of liver

under the diaphragm in the right upper quadrant of abdominal cavity

A client who was recently diagnosed with carcinoma of the pancreas and is having a procedure in which the head of the pancreas is removed. In addition, the surgeon will remove the duodenum and stomach, redirecting the flow of secretions from the stomach, gallbladder, and pancreas into the middle section of the small intestine. What procedure is this client having performed?

radical pancreatoduodenectomy Radical pancreatoduodenectomy 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. Cholecystojejunostomy 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.

Hepatitis B

-transmission: percutaneous or mucosal; blood, body fluids, needles, sharp instruments -source: blood, body fluids -incubation period: 45-60 days -chronic -vaccine available -treatment: interferon and antivirals

Fulminating viral hepatitis

severe, rapidly progressing, life threatening form of acute liver failure

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. 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.