Ch. 53 Patients with Liver Problems Flashcards
Hepatitis
A widespread inflammation and infection of the liver cells
Health promotion - Hep vaccines for A&B; no vaccine for hep C or E
5 types of hepatitis
Viral Hepatitis
Cause: environmental (chemicals, drugs, herbs)
Liver toxicity from drug therapy
Infection causes - Epstein Barr, Herpes simplex, varicella, CMV
Hepatitis Risk Factors
Advanced age
High risk exposures, travel, crowds
Blood transfusions (<1992)
Hepatitis A
Mild course
Flu-like symptoms, N/V/D
Fecal-oral route or food/water contamination
Cause: shellfish, direct contact or food exposure
Treatment: symptom control
Hepatitis B
Blood route: sharing needles, needle sticks, blood transfusions, hemodialysis, birth canal, unprotected sex
Diagnosed by blood test (up to 6 months from exposure to +blood test)
Treatment: acute = none; chronic = antivirals
Hepatitis C
Transmission: blood exposure, IV drug needle sharing, blood products, transplants, hemodialysis
Asymptomatic until routine lab tests
Treatment: antivirals
Which hepatitis is the leading cause of end stage liver disease-cirrhosis or liver cancer?
Hep C
Hepatitis Lab & Diagnostic
Hep A,B,C (lab test)
Hep C,D,E (antibody titers)
Elevated liver tests (AST, ALT, ALK phos, Bilirubin)
Liver biopsy
CT scan
Viral Hepatitis Clinical Manifestations
Upper abdominal pain
Yellow sclera (icterus)
Joint pain or muscle pain
Diarrhea or constipation
Light colored stools
Dark or yellow urine
Jaundice, Fever, Fatigue
N/V, Itchy and dry skin
Hepatitis Interventions
Promoting nutrition (HepA give carbs and calories)
Hydration
Prevention of spread of infection (universal precautions, hand washing, pt education)
Drug therapy
Managing fatigue w/ all hepatitis
Cirrhosis
Extensive, irreversible scarring of the liver, usually caused by chronic hepatic inflammation and necrotic injury
Scarring impairs cellular regulation = end stage liver disease
Cirrhosis Pathophysiology
Inflammation caused by toxins or disease with extensive degeneration/destruction of liver cells (hepatocytes)
Liver nodules blocks bile ducts and blood flow = decrease liver function over weeks to years
Cirrhosis Causes
Most common is chronic alcoholism
Chronic viral hepatitis & bile duct disease
Hep B&C
Autoimmune hepatitis
Cirrhosis Risk Factors
Age, obesity, DM, steatohepatitis (chronic inflammation from fatty liver disease), genetic
Drug - isoniazid and flutamide can cause post necrotic cirrhosis
Alcohol Withdrawal S/S
Tremors, jitters, delirium, confusion, anxiety, tachycardia, odd behaviors, high BP, sweating
Cirrhosis Physical Assessment (early signs)
Fatigue
GI symptoms - nausea, abd pain
Abdominal assessment (hepatomegaly, splenomegaly)
Daily wt. or changes in weight, girth measurements
Asterixis: coarse tremors w/ flexion
Anxiety, jitters, tremors
Confusion, agitation, altered LOC
Cirrhosis Clinical Manifestations
Jaundice
Encephalopathy
Spider angioma
Lack of body hair
Muscle wasting
Widened blood vessels
Ascites
Red palms
Jaundice
Cause: hepatocellular disease liver cells can’t excrete bilirubin, intrahepatic obstruction, edema, scarring on hepatic bile ducts interferes with excretion
Patients report itching excessively
Icterus
Late Stage Cirrhosis
Jaundice & Icterus
Itchy and dry skin
Rashes
Petechiae or ecchymoses
Red, hot bright palms of hands (palmar erythema)
Spider angiomas on face, nose, chest
Ascites
Peripheral edema
Cirrhosis Lab
Increased AST, ALT, LDH
Increased Alk phos
Increased total bili
Decreased albumin
Increased ammonia level
Decreased serum sodium
Increased creatinine (late)
Decreased WBC
Complications of Cirrhosis
Ascites & Esophageal varices
Hepatic Encephalopathy
Portal HTN
Biliary Obstruction
Nursing Priorities w/ Cirrhosis
Monitor respiratory status, skin integrity, fluid and electrolyte balance, neurologic status, overall nutrition, pain med, GI assessment
Ascites
Collection of free fluid within the peritoneal cavity caused by increased hydrostatic pressure from portal HTN
Fluid shifts from vascular system to third spacing
Complications: hypovolemia and edema
Esophageal Varices
Fragile thin-walled esophageal veins get distended from pressure
Elevated BP in veins carrying blood from intestines to liver
Location: distal esophagus, stomach, or rectum
Life threatening medical emergency causing hypovolemic shock
Hepatic Encephalopathy
Complex cognitive syndrome from liver failure/cirrhosis (late)
Shunts portal venous blood into central circulation so liver is bypassed
Labs: elevated ammonia (>45)
Hepatic Encephalopathy Clinical Manifestations
Confusion, mental status changes, mood changes , insomnia, speech difficulties (early)
Altered LOC, impaired thinking, neuromuscular problems (late)
Lactulose
Indications: hepatic encephalopathy
PO or Rectal
MOA: excretes ammonia to improve levels (poop it out)
Side effects: can cause diarrhea which can lead to hypokalemia, cramps, distention
Metabolic Encephalopathy Interventions
Strict I&O
Monitor VS trends
Assess pain and nutrition
Portal Hypertension
Obstruction/blockage of blood flow in portal vein causing splenomegaly
Dilated veins in esophagus, stomach, intestines, abdomen, and rectum
Complications: ascites and esophageal varices
Splenomegaly
From backup of blood into the spleen > enlarged spleen destroys platelets causing thrombocytopenia
What is the early sign of liver disease?
Low Platelets
Biliary Obstruction
Genetic
Obstruction of the bile duct that leads to biliary cirrhosis
Production of bile is decreased which prevents clotting factors to produce
Biliary Obstruction Causes
Gallbladder (stones) disease or autoimmune disease
Biliary Obstruction Intervention
Prevention of vitamin K absorption
Managing Fluid Volume
Nutrition therapy - low Na diet, malnutrition w/ IV infusion with vitamins (banana bag)
Drug therapy - diuretic (furosemide or spironolactone); PO potassium or IV potassium
Paracentesis
Paracentesis
Invasive procedure to remove abdominal fluid
US guided (at bedside)
HOB 30 degrees w/ oxygen as needed
Excessive fluid can cause respiratory problems w/ intra-abdominal pressure
Excessive fluid removal can cause fluid shifts
Preventing/Managing Hemorrhage
Preventative med - beta blocker
Emergent Bleeding - Vasoactive drugs (beta blockers and vasopressin or octreotide)
Managing Confusion
Fall risk precautions
Lactulose to remove ammonia in the blood
Managing Pruritic
Due to high bilirubin in blood
Drug therapy - corticosteroids or sertraline
