Care of the Hepatic Failure Patient Flashcards
how does the liver function
removes potentially toxic by products of certain medications
-prevents shortages of nutrients by storing vitamins, minerals and sugar
- metaabolizes or breaks down nutrients from food to produce energy, when needed
- produces most proteins needed by the body
helps your body fight infection by removing bacteria from the blood
- produces most of the substances that regulate blood clotting
-produces bile, a compound needed to digest fat and to absorb vitamins A, D, E, K
what could happen if the liver fails
build up of meds
- uable to retain nutrients from food or breakdown ammonia
- bacteria builds up in the blood
- blood clotting goes haywire
- bile cannot be regulated
- no albumin production (protein)
- shortage of vitamins, minerals and sugar
what is liver failure
inability of liver to function normally
starts out as inflammation of the liver cells
- can be acute or chronic
_______ inflammation eventually results in ______ _______ formation in the liver or _______
chronic; scar tissue; cirrhosis
liver cirrhosis is when the liver is made up of mostly
scar tissue
why will liver enzymes be elevated when drinking alcohol
because it gets rid of alcohol through the liver
complete liver failure =
death
if the liver fails, the body will
fail
if a person donates part of liver will it regenerate
yes
how much of the liver can an adult donate to another adult
part of liver
how much of the liver can an adult donate to a child
1/3 and it will grow with the child
how long does it take for the liver to regrow
6 weeks
for a pt who has a liver transplant how long is recovery
6 mos
what must match in order to donate a liver
blood type and body size
rapid deterioration of liver function
-appears in as little as 48hrs
acute liver failure
- seen in previously healthy individual with NO prior S/S
- *medical emergency
what are causes of acute liver failure
- exposure to viruses Hep A, B, and C
- drug use (acetaminophen and tuberculosis meds)
- genetic disease
- ingestion of poisonous substances
- pregnancy
what are S/S of acute liver failure
encephalopathy
coagulation abnormalities
jaundice
*comes in being very vague (talking funny, not feeling great, foggy)
what is encephalopathy
confusion, family says they haven’t been themselves, forgetful
what is coag abnormalities
increased clotting time, abnormal bruising, frank blood, nose bleed, labs
what is an early sign of jaundice
yellow sclera
what are complications of acute liver failure
cerebral edema renal failure hypoglycemia metabolic acidosis sepsis multiorgan failure
what medical management is done to dx and correct the cause of liver failure
- H and P
- lab work (acetaminophen level, drug studies, viral hep serologies)
- CT scan (enlarged liver)
- MRI
- ultrasound (enlarged liver)
- liver biopsy
large bore needle inserted into liver through abd wall to remove sample of tissue for testing
liver biopsy
what should be done pre op of liver biopsy
assess coagulation tests (PT, PTT, platelets)
educate pt and obtain consent
assess vitals
what should be done post op of liver biopsy
assess vitals
monitor for bleeding and peritonitis
bedrest- risk for bleeding (6 or +hrs)
place client on right side with pillow under costal margin
avoid coughing or straining for 24hrs
avoid heavy lifting or exercise for one week
what are signs of bleeding
bruising, nose bleeds, bleeding gums, decreased BP, decreased H and H, blood in urine, pale, increased HR
why do we put the pt who just has a liver biopsy on their right side
this is the side the liver is on and we want to put pressure on and stop bleeding
what can we give pt to avoid straining
fiber, fluids, stool softener
elevated biliruben =
jaundice
AST level should be no more than
40
ALT level should be no more than
60
elevated WBC=
inflammation or infection
what two labs hold hands, are best buds
K and Mg
*low potassium and can’t get potassium up then know what Mg level is, if low then Mg should be given too
normal biliruben level
<1
normal PT level
11-12.5 sec
normal INR level
0.8-1.1
an AST/ALT level above 10,000 most often is
acetaminophen OD
normal glucose level
76-106
how can the glucose be extremely low
impairment in glycogen release, if liver is in failure it does not release glucose but the pancreas cont to secrete insulin, therefore blood glucose levels decreases
normal WBC level
5,000-10,000
WBC _____ in acute liver injury and ______ in splenomegally
elevates; decreases
normal K level
3.5-5.0
normal Mg level
1.3-2.1
normal platelet level
150-400
normal ammonia level
10-80
normal lactic acid level
0.6-2.2
normla creatinine level
0.5-1.21
normal alkaline phosphatase level
30-120
normal Hgb level
12-18
normal Hct level
42-52% males and 37-47% in females
activated charcoal binds to
poisonous substance
antidote for acetaminophen
N-acetylcystine
what medication pulls fluid off the brain
mannitol
*an osmotic diuretic but be careful too much can lead to dehydration of brain
what drug should be given if pt is seizing, if your worried about encephalopathy
pentobarbital, thiopental
*barbiturate agents
what drug is given for anxiety, pt with swelling in brain are at risk for ICP
midazolam
*benzo
if pt is on ventilator they have to have an anesthetic agent which will most likely be
propofol
if a pt is bleeding a LOT what is given
transfusions of fresh frozen plasma and/or whole blood
what types of meds mask near changes the pt has and what should be done to avoid this
barbiturates, benzos, anesthetic agents
give sedation vacation to monitor near status
when the majority of hepatocytes are replaced with scar tissue… scar tissue results in impaired blood flow through the liver… irreversible as of today
cirrhosis
what are causes of cirrhosis
any chronic liver disease chronic alcoholism chronic viral hepatitis cardiac cirrhosis nonalcoholic fatty liver disease (NAFLD) that leads to nonalcoholic steatohepatitis (NASH)
cirrhosis is not a _____ but can cause you to have liver disease as a result
disease
what is the “early” sign of cirrhosis
fatigue
what are later signs of cirrhosis
jaundice with or with our pruritis peripheral edema ascites skin lesions- spider lesions on chest/neck hematologic disorders endocrine disturbances peripheral neuropathies
what causes peripheral edema in cirrhosis
no albumin telling fluid to stay in vascular system
a cirrhosis pt will be _______, will have no muscle but big ______ full of fluid. these pt will sit at 90 degrees to breath, in pain, and uncomfortable
malnourished; bellies (ascites)
what are major complications of cirrhosis
portal hypertension
peripheral edema
hepatic encephalopathy
hepatorenal syndrome (decreased blood flow to kidneys)
portal vein is where the liver receives blood from the heart and these pts will be _______ but have _____ pressure at portal vein
hypotensive; high
portal hypertension causes
ballooning out of vessels called varices
*most common in the stomach and esophagus
once pt gets varicose they are at risk for
bleeding (they may pop)
what are dx studies of cirrhosis
ultrasound- assess severity of cirrhosis
upper endoscopy (EDG)- to find varicies
radioisotope liver scan- show layout of liver, is blood getting through the liver
what lab is for CHRONIC cirrhosis
alkaline phosphatase
in cirrhosis AST and ALT initially will be ______ but in end stage may be normal
elevated
what is the medical management for ascites
albumin infusion and diuretic therapy
fluid removal (paracentesis)
*normally we would just pull off fluid with lassie bit with these pts it will dehydrate them so give albumin and diuretic
*albumin should be given 30 min before lassie in order to work
what is the medical management of varices
- can’t just leave them because they are at risk for rupture so give BB, BB decrease pressure (these pts already have low BP but is is very important they have it ) so keep pressure up with fluids, FFP, more albumin
- banding will keep blood from flowing into varicies
- scleroptherapy is when they freeze them
- balloon tamponade is ONLY done if bleeding can not stop and can’t clot (puts pressure on varices
what is the medical management for nutritional needs of the cirrhosis pt
TPN, Tube feeding
high carb, high cal, moderate fat, don’t restrict protein
*but if pt has craving for whatever it is get it for them they just need something (usually have NO appetite)
the removal of fluid from the abd cavity using a large bore needle
paracentesis
what should be done pre op of paracentesis
educate
have pt void to avoid bladder injury
measure abd girth, wt, and vitals (baseline)
assist with positioning HOB at 30-45 degrees
what should be done post op of paracentesis
vitals monitor for bleeding measure abd girth and wt monitor for hematuria and instruct pt to do the same (injury to bladder) watch for hypovolemia watch for infection and peritonitis
what are S/S of hypovolemia
pale, nausea, decreased BP, increased HR, dizzy, same as hungover, decreased urine output, thirsty
alteration of brain function or structure or both caused by a build up of toxins in the body as a result of liver dysfunction
hepatic encephalopathy
what can cause hepatic encephalopathy
GI bleeding infection hypokalemia and or met alkalosis renal failure hypovolemia hypoxia sedative tranquilizer use hypoglycemia constipation hepatocellular carcinoma and or vascular occlusion (rare)
which posturing is worst
decerebrate is worse
*if pt goes from decorticate to decerebrate it indicates brain stem herniation
what kind of painful stimulus should be done to get a response
core painful stimuli- sternal rub or orbital notch pressure every 2 hrs
what are Symptoms of hepatic encephalopathy
confusion lethargy that may progress to coma inappropriate behavior or personality changes asterixis (flapping tremor when hands or feet are extended) problems with fine motor activities sweet breath or musty odor seizures hyperventilation suppressed gag reflex
what are severe complications of hepatic encephalopathy
brain swelling (increased ICP)
organ failure
brain herniation
why is it important for the hepatic encephalopathy pt to have atlas 2 bowel movements
important to get rid of the ammodium if not it will build up
* DONT hold the lactulose, call doc first
how would you lower ammonia levels
lactulose and rifaximin therapy
*rifaximin is to decrease risk for infection (curb bacteria from the food they eat)
