Nursing 265 Hesi Case Study

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. You work on Bell's plan of care. At this time, what is the major goal of nursing care for Bell?

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. Bell is weak and emaciated and probably has a variety of nutritional deficiencies. The goal of improving Bell's nutritional status takes high priority at this time.

Aspirin and other non-steroid antiinflammatory drugs (NSAIDS) are contraindicated in clients with severe liver disease because they inhibit platelet synthesis and interfere with blood clotting.Acetaminophen in small amounts usually can be used by persons with cirrhosis, provided they are not currently drinking. Alcohol and acetaminophen in combination can be damaging to the liver.All drugs are used cautiously in clients with cirrhosis, especially those that are metabolized in some form by the liver. Propranolol is prescribed. 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.Because Bell is not currently exhibiting any signs of alcohol withdrawal, lorazepam is prescribed IV on a PRN basis if tremors, anxiety/agitation, or diaphoresis occur. Albumin is expected to alleviate Bell's ascites by which mechanism?

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.

Which situation about Bell's history increased her risk for cirrhosis of the liver?

Although other factors may cause cirrhosis (hepatitis, right-sided heart failure, biliary tract obstruction), cirrhosis is more often a result of chronic alcoholism. Consumption of alcohol in large quantities is toxic to liver cells. Symptoms of cirrhosis generally appear after many years of excessive alcohol abuse. Continued drinking advances the disease, resulting in more severe liver dysfunction and complications. Bell has alcoholic cirrhosis. She has been drinking heavily for many years. Despite repeated admissions and attempts to get Bell to stop drinking, she has continued to drink.

Bell's skin and hair are dirty, and her skin is itchy from jaundice. Which action should the nurse take when bathing Bell and caring for her skin?

Apply lotion to dry skin areas Bell has pruritus. Lotion, applied to skin within a few minutes of bathing, will moisten Bell's skin, decrease itching, and reduce risk for skin breakdown. Soap should be used sparingly, since it can dry the skin and increase itching. Bath water should be warm enough but not too hot, since heat increases itching.

Bell is anorexic. Which approach is best to help improve Bell's desire to eat?

Arrange for Bell to have small frequent meals Small frequent meals are often more appetizing and more easily tolerated by clients with anorexia. Ascites creates pressure on the stomach, limiting the volume of food that can be comfortably eaten at one time.

Bell's HCP prescribes a low-sodium, high-carbohydrate diet for Bell.You try to determine from Bell foods that are appealing to her, in the hope of improving her appetite. When determining the extent of Bell's liver dysfunction, which blood tests are monitored?

Aspartate aminotransferase (AST) Aspartate aminotransferase (AST) is an important liver function test. The enzyme AST is found in high concentrations in heart, liver, and skeletal muscle cells. Hepatocellular damage generally causes elevations of the AST as the enzyme is released from damaged liver cells into the serum. Bell's AST level has been high for some time. Alanine aminotransferase (ALT) Alanine aminotransferase (ALT) is an important liver function test. The enzyme ALT is found primarily in the liver. Hepatocellular damage generally causes elevations of the ALT as the enzyme is released from damaged liver cells into the serum. Bell's ALT level has been high for some time. Creatinine Hepatorenal syndrome, renal failure in the absence of renal disease, is a potential complication of advanced liver disease. Serum creatinine and blood urea nitrogen (BUN) are renal function studies that are followed to determine if Bell has any renal disease due to her advanced cirrhosis. Albumin The normal liver synthesizes serum proteins, including albumin. Serum albumin level is often decreased with severe liver disease and malnutrition. Bell's albumin level is low. Ammonia The normal liver plays a major role in degrading the products of protein metabolism, including ammonia. Accumulation of ammonia in the serum can cause hepatic encephalopathy. Ammonia level is frequently elevated with advanced cirrhosis. Bell's ammonia level is elevated. Prothrombin time (PT) The normal liver synthesizes fibrinogen and prothrombin, both of which are needed for normal clotting. With degenerative liver disease, a prolonged PT increases risk for bleeding. Bell's PT is prolonged.

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?

Assess vital signs Bleeding from varices is usually painless but massive. It would be critical to check vital signs. With significant blood loss and a decreasing circulating fluid volume, blood pressure would decrease and pulse rate would increase as compensatory measures to maintain tissue perfusion. Blood pressure and pulse pressure would decrease with progression to hypovolemic shock. Turn the client on her side When a client is vomiting, turning the client on her side reduces risk for aspiration. The client can also be on her back with the head of the bed elevated, with the head turned to the side. Prepare to administer oxygen Red blood cells, which carry oxygen, are lost with hemorrhage. Oxygen administration would be indicated to maximize tissue oxygenation. Prepare suctioning equipment Airway suctioning would be needed if the person could not effectively clear her airway. Suctioning equipment should be readily available. Insure an IV access With bleeding varices, fluids (normal saline or Lactated Ringer's) would be indicated to replace fluid volume and sustain blood pressure until blood is available. A large bore needle would be wide enough for blood transfusion as needed. Bell has an IV access in case it is needed. Prepare for insertion of a nasogastric tube A nasogastric (NG) tube would be inserted for gastric lavage and removal of blood.

Bell's lunch arrives. You sit with her, helping her eat. Although she complains about the lack of salt, she finishes her meal.You use this time to discuss Bell's care with her.Although confused at times, Bell seems to understand your explanations. She is rather passive, telling you to do "whatever you need to do." "Just get my belly down." You explain to Bell that her low-salt diet and fluid restriction should help. Bell is comfortable when you leave work for the day.You remind her that she will not be able to eat or drink anything during the night or in the early morning. Endoscopy is scheduled for the morning. Recent lab reports reveal elevated liver enzymes and ammonia level. Prothrombin time (PT) is prolonged. Bell is borderline anemic. Her creatinine is normal. Electrolytes are also normal, except for magnesium, which is low (1 mEq/L). This deficiency is common with chronic alcohol ingestion.Hypomagnesemia depresses cardiovascular and nervous system functions, and is frequently overlooked. Cardiac dysrhythmias, ataxia, double vision, and seizures can occur with low magnesium levels. Magnesium sulfate per IV is prescribed for infusion over four hours. Which of the following are important with this drug administration?

Calcium gluconate IV should be available Hypermagnesemia may occur with magnesium replacement. If this 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. Urine output should be adequate Hypermagnesemia may occur with magnesium replacement. 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. Vital signs should be checked frequently Hypermagnesemia may occur with magnesium replacement. 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. The patellar reflex should be checked Hypermagnesemia may occur with magnesium replacement. 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. Observe for nausea and vomiting Hypermagnesemia may occur with magnesium replacement. Nausea and vomiting may occur with the presence of excess magnesium. Weakness, drowsiness, and flushing may also occur.

You are a nurse on a busy medical-surgical floor. Mrs. Bella, admitted with a medical diagnosis of cirrhosis of the liver, has been a client on your unit before. The staff members on your unit call her Bell. Bell was admitted through the Emergency Department (ED) in a confused state. She is weak and emaciated, with a large protuberant abdomen. She says that her "stomach is too big" and that "it's hard to walk and breathe." Her speech is slurred. You perform a brief assessment and gather data from Bell's previous records. As you continue your assessment of Bell, you recall the pathophysiology of cirrhosis of the liver. Which statement best describes cirrhosis?

Cirrhosis is an irreversible loss of liver cells with scarring

As you continue your assessment of Bell, you recall the pathophysiology of cirrhosis of the liver. Which statement best describes cirrhosis?

Cirrhosis is an irreversible loss of liver cells with scarring Cirrhosis is characterized by mostly irreversible chronic injury to liver cells, with extensive fibrosis (scarring) and formation of nodules. In clients with cirrhosis, scar tissue replaces normal liver tissue. Liver dysfunction occurs as a result.

You carefully review the HCP's prescriptions for Bell, written after the paracentesis. 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?

Fowler's 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.

You remind the HCP that she needs to prescribe a diet for Bell. Which diet is she likely to prescribe?

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.

You work on Bell's plan of care. Which nursing diagnoses should be included in her care plan?

Impaired Physical Mobility Due to her protuberant abdomen that alters her balance and impaired nutrition that has reduced her muscle mass, Bell has trouble walking and is weak. Impaired Physical Mobility applies as a problem for Bell at this time. Bell needs assistance with moving and turning. Risk for Infection Chronic liver failure affects function of Kupffer cells in the liver. These Kupffer cells normally act as phagocytes, digesting potentially infective bacteria and viruses. Risk for Infection is a problem for Bell. Guidelines for infection control are critical, especially hand hygiene. Imbalanced Nutrition: Less than Body Requirements Bell is weak and emaciated. Protein-calorie malnutrition with muscle wasting, and other nutrient deficiencies, are common with cirrhosis. Imbalanced Nutrition: Less than Body Requirements is a problem that applies to Bell. Risk for Injury Bell is confused. This confused state, along with her weakened condition, increases her risk of falling and injuring herself. Risk for Injury is a problem for Bell. Measures to avoid injury are indicated. These include frequent observation, and keeping the bed in the low position. Risk for Impaired Skin Integrity Bell is weak. Her limited mobility, and dry, itchy skin increase risk for skin breakdown. Risk for Impaired Skin Integrity is a problem for Bell. Measures to avoid pressure ulcers are indicated.

After Bell is bathed, she uses a bedpan. Which of the following, if observed, should be reported?

Melena Melena (black, tarry stool) is the result of intestinal bacteria acting on blood passing through the GI tract. It suggests upper GI bleeding, a potential complication of cirrhosis, and should be reported. Bell does have a bowel movement, which is dark, but not black. Because Bell is at risk for bleeding, you check all her bowel movements for blood. Her stool checks positive for blood.

Bell's HCP estimates that she has about 4000 mL of ascitic fluid in her abdomen. Her abdomen is tight and her umbilicus is protruding.To prevent dramatic changes in fluid volume, just enough fluid (2000 mL) is removed during the paracentesis to make Bell's breathing easier. Hopefully, remaining ascitic fluid will be reduced using diet and fluid restriction. Bell still has significant ascites. After the HCP completes the paracentesis procedure, which nursing actions are indicated for Bell's care?

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. 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.

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. Preventative treatment for alcohol withdrawal will be started for Bell, following your hospital's alcohol withdrawal protocol.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). It is apparent that Bell's condition has deteriorated since her last admission. Exacerbation of ascites is common when a client is noncompliant with recommended fluid and sodium restrictions or when those restrictions have not been effective.To alleviate Bell's abdominal discomfort, her HCP plans to drain some fluid from her abdominal cavity. The medical procedure that removes excess fluid from the peritoneal cavity is called:

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

In cirrhosis, which factors contribute to ascites?

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. 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. 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. Hypersecretion of aldosterone Secretion of aldosterone is not increased in clients with cirrhosis.

Bell is predisposed to esophageal bleeding because of her advanced cirrhosis. 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.Bell is scheduled for endoscopy to determine if she has esophageal varices and is at risk for GI bleeding. Stool with blood could be a result of upper GI bleeding from esophageal varices. Hot liquids can cause fragile esophageal varices to dilate and subsequently rupture, leading to bleeding.Because Bell could have esophageal varices, only lukewarm or cool liquids are offered to her. 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?

Reduction of serum ammonia level A trigger, like GI bleeding, often (but not always) initiates hepatic encephalopathy. With GI bleeding, there is accumulation of blood (red cell protein) in the GI tract. Bacteria in the GI tract act on the protein and make ammonia. If a diseased liver is unable to degrade the increasing ammonia (because of the liver dysfunction and/or disrupted blood flow from the GI tract to the liver), ammonia is absorbed from the GI tract and a high blood ammonia level results. 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. Onset of soft stools A trigger, like GI bleeding, often (but not always) initiates hepatic encephalopathy. With an accumulation of blood (red cell protein) in the GI tract, intestinal bacteria produce ammonia. If a diseased liver is unable to degrade the increasing ammonia (because of the liver dysfunction and/or disrupted blood flow from the GI tract to the liver), it is absorbed from the GI tract and a high blood ammonia level results. 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.

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?

Weight loss with decrease in ascites and edema Weight loss in conjunction with decrease in edema and ascites is a relevant and realistic goal of therapy.

Bell is also confused. 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. Hepatic encephalopathy occurs when toxic substances (ammonia and other substances) are not detoxified by the liver.The normal liver metabolizes protein to ammonia, and also detoxifies the ammonia. With severe liver dysfunction, serum ammonia level increases. Ammonia is toxic to brain cells, and causes signs and symptoms of hepatic encephalopathy. A trigger, like gastrointestinal (GI) bleeding, often (but not always) initiates hepatic encephalopathy. With GI bleeding, there is accumulation of blood (red cell protein) in the GI tract. Bacteria in the GI tract act on the protein and make ammonia. If a diseased liver is unable to degrade the increasing ammonia (because of the liver dysfunction and/or disrupted blood flow from the GI tract to the liver), ammonia is absorbed from the GI tract and a high blood ammonia level results. GI bleeding is the most common cause of hepatic encephalopathy and is usually associated with rupture of esophageal varices which resulted from portal hypertension.Other triggers of hepatic encephalopathy include dehydration, hypokalemia and azotemia (a build up of nitrogenous waste products.) In persons with cirrhosis, neurological changes may also be related to nutritional problems. Individuals who abuse alcohol often are seriously malnourished as a result of poor nutritional intake.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. Wernicke's disease is 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.Korsakoff's psychosis is characterized by impaired memory and learning, and confabulation (substituting events for those that cannot be remembered so a story makes sense). 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?

anxiety Anxiety characterizes early alcohol withdrawal, which begins within 6-8 hours after the cessation of drinking. 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. 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. irritability 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. diaphoresis Early signs of alcohol withdrawal begin within 6-8 hours after the cessation of drinking. Sweating is common during this period.

The attending healthcare provider (HCP) arrives to examine Bell and writes prescriptions for her care.Bell is cooperative and, although confused, she easily follows her HCP's requests as she is examined. You remain with the HCP as she examines Bell, collecting data to determine nursing care. Characteristic of advanced cirrhosis, Bell's abdomen is enlarged due to accumulation of fluid in the peritoneal cavity. This is called:

ascites Accumulation of fluid in the peritoneal cavity, as seen with cirrhosis, causes a protuberant abdomen. This accumulation of fluid is called ascites.

How should you prepare Bell for the paracentesis?

ask her to void During paracentesis, a needle is inserted through the abdomen into the peritoneal cavity. Bell should pass her urine before paracentesis is done to reduce risk of perforation of a distended bladder when the needle is inserted. After voiding, Bell should assume a sitting position to prepare for the procedure.

You and the HCP talk with Bell and examine her, checking for clinical signs of cirrhosis. What are the clinical signs of cirrhosis?

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. Bell says she "never feels hungry." 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. 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. Except for her abdomen, Bell appears thinner and more emaciated than during her last admission three months ago, but her current weight of 45.5 kg (100 pounds) is 2.3 kg (5 pounds) more than her weight at that time. 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. Bell has dependent edema of her lower legs. 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. Bell has bruises on her arms.

How does the HCP confirm that Bell has abdominal ascites?

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.

Other blood tests monitored when liver disease is present include the alkaline phosphatase, gamma-glutamyl transferase (GGT), and bilirubin. Alkaline phosphatase is an enzyme that is non-specific for liver disease, but often elevates with liver dysfunction, especially when liver dysfunction is due to obstruction of the biliary tract. GGT is also a non-specific enzyme. It often correlates with the alkaline phosphatase, and is very sensitive for biliary tract disease. Total bilirubin is elevated with severe cirrhosis, secondary to the impaired metabolism and/or excretion of bilirubin by the liver. Many persons who drink alcohol may not realize their risk for alcoholic liver disease. Alcohol abuse is suspected when the gamma-glutamyl transferase (GGT) is elevated and the person has elevated aspartate aminotransferase (AST) and alanine aminotransferase (ALT) levels at a ratio of 2:1.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. 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?

propranolol or nadolol The client starts on a low dose that is increased every 3 to 5 days until the heart rate is about 55 beats per minute. By decreasing heart rate and the hepatic venous pressure gradient, the chance of bleeding may be reduced.