Cirrhosis Flashcards
Function of liver
- 🩸 glucose regulation
- bile drainage
- synthesis/storage of amino acids, protein, vitamins and fats
- detoxification
- 🩸 circulation and filtration
What is cirrhosis
- End-stage liver disease
- Extensive degeneration and destruction of liver cells
- Results in replacement of liver tissue by fibrous and regenerative nodules
- Usually happens after decades of chronic liver disease
Typically see nutritional deficiencies with reduced protein intake
- contributes to liver destruction
Who is at risk
•Affects men more
- 40-60 years of age
What causes cirrhosis
- Excessive alcohol is the major factor
- or hepatitis C
What happens to the liver in cirrhosis
- Liver inflammation progresses to necrosis and finally fibrotic scarring.
- Liver cells try and regenerate however the process is disorganized.
- Results in abnormal blood vessel and bile duct architecture.
- The overgrowth of new and fibrous connective tissue distorts the liver’s normal lobular structure, resulting in an irregular shape and impeded blood flow.
- Eventually this disorganized and irregular liver generation, poor cellular nutrition, and hypoxia results in decreased liver function.
Cirrhosis early signs
Fatigue and enlarged liver
Cirrhosis late signs
(start of decompensation)
3 main signs and others ?
1) jaundice
2) peripheral edema
3) ascites
Other
•Skin lesions, hematologic problems , endocrine problems , and peripheral neuropathies
•Liver becomes smaller, nodular
Jaundice in cirrhosis results from
•Overgrowth of connective tissue in liver compresses bile ducts
- Leads to obstruction
- Increase in bilirubin in vascular system
- May be minimal or severe
2 Skin conditions in cirrhosis
What causes them?
1) Spider angiomas (telangiectasia): abnormal collection of blood vessels near the surface of the skin
2) Palmar erythema: redness of palms
Due to increase in circulating estrogen due to inability of liver to metabolize steroid hormones
Endocrine disorders (late sign of cirrhosis)
1) In men—gynecomastia, loss of axillary and pubic hair, testicular atrophy, impotence and loss of libido
2) in women—amenorrhea or vaginal bleeding
3) Hyperaldosteronism in both sexes
Peripheral neuropathy (late sign of cirrhosis)
•Common finding in alcoholic cirrhosis 🍺
- From dietary deficiencies of thiamine, folic acid, and cobalamin
•Sensory symptoms may predominate
Portal hypertension
A complication- what does it cause?
•Increased venous pressure in portal circulation
It causes: •Splenomegaly •Large collateral veins •Ascites •Gastric and esophageal varices
Varicosities
Complication of cirrhosis
1) Esophageal varices: complex of tortuous enlarged veins at lower end of esophagus
2) Gastric varices: dilated veins by upper part of stomach
•Both are very fragile, bleed easily;
Most life-threatening complication
Peripheral edema
Complication of cirrhosis
-caused by increase pressure from portal vein HTN
Occur in lower extremity 🦶🏻
Ascites
Complication of cirrhosis
- accumulation of serous fluid in peritoneal or abdominal cavity
Painful
Don’t eat well- small frequent meals
Hyperaldosteronism
Hepatic encephalopathy (HE)
Complication of cirrhosis
What causes this to happen and 4 signs?
•Liver unable to convert increased ammonia to urea
- Ammonia crosses blood-brain barrier
- Ammonia can be neurotoxic
1) Changes in neurologic and mental responsiveness
2) Inappropriate behavior
3) Sleep disturbances, trouble concentrating
4) Impaired LOC—hepatic coma
Complications causes by Hepatic encephalopathy
•Asterixis: flapping tremors (arms and hands when extended forward) means trending towards coma
- Impairment in writing
- Apraxia: lost ability to carry out purposeful movement (flip comb and brush hair with wrong side)
- Fetor hepaticus: musty sweet smell of breath
Hepatorenal syndrome
Complication of cirrhosis
What are the signs?
•Development of renal failure in pts with advanced liver disease •S/S: 1) azotemia- Elevated levels of urea 2) oliguria 3) intractable ascites •No structural abnormality of kidneys
Diagnostic Liver enzyme tests
1) aspartate aminotransferase (AST)
2) alanine aminotransferase (ALT)
- (will be increased)
Diagnostic lab values
- bilirubin, ammonia 🔼
- Total protein, albumin 🔽
- Cholesterol 🔽
- Prothrombin time (prolonged)
Diagnostic studies for cirrhosis
- Ultrasound- detects the difference in density of parenchymal cells and scar tissue)
- CT, MRI, radioisotope liver scan- give information about liver size, hepatic blood flow and obstruction.
- Liver biopsy- confirms diagnosis
Care of patient with cirrhosis
1) Rest
2) Administration of B-complex vitamins
- liver not metabolizing them so malnourished
3) Avoidance of alcohol!!
4) Minimization or avoidance of aspirin, acetaminophen, and NSAIDs
- risk of bleed
Goal is to slow the progression and prevent complications.
Acute care of ascites
3 things the nurse can do/ give ?
1) Sodium restriction
- 2g/day (water follow salt)
2) Diuretics
3) Albumin
- helps blood volume (volume expander)
Most important management of Esophageal and gastric varices is to:
Prevent bleeding/hemorrhage
Acute Bleeding Varices care/ treatment
What’s the supportive care ( what can the nurse give that the doctor proscribed)
stabilize patient, manage airway, start IV therapy and blood products
Supportive measures for acute bleed: •Fresh frozen plasma •Packed RBCs •Vitamin K •Zantac*
Long Term Care: Bleeding Varices
Decompensated cirrhosis
Medications ?
Each bleed increases the chances for another
Medications:
•Beta-blockers: Propranolol(Inderal)
Medications for Hepatic Encephalopathy
Reduce ammonia formation:
- Lactulose (Cephulac), which traps ammonia in gut and as a laxative excretes it (pts often will have many BMs/day)
- Rifaximin (Xifaxan) antibiotic given to those unresponsive to Lactulose.
Nutritional Therapy for Cirrhosis
High Calories & Carbs
Low fat
Small, frequent meals
•Protein supplements for malnutrition
- Restrict protein IF hepatic encephalopathy cannot be managed with Lactulose
•Low-sodium and fluid restriction for patients with ascites and edema
•1-2 cups of probiotic yogurt TID reduces intestinal flora imbalance by 🔽 E Coli counts
•Water soluble forms of fat-soluble vitamins A, D, and E
•Folic acid and iron to prevent anemia.
•Enteral or parenteral nutrition if vomiting or eating poorly.
Nursing Management of Pruritis secondary to Jaundice
Measures to relieve pruritus?
- Cholestyramine or Hydroxyzine
- Baking soda or Alpha Keri baths (oil)
- Lotions, soft or old linen
- Temperature control
- Short nails; rub with knuckles to avoid bleeding
Nursing management ascites
What to measure ?
Daily weight
I&O
Abdominal girth measurements (umbilicus)
Monitor for edema
Monitor for oliguria
Paracentesis nurses responsibility
How to have them sit?
What to monitor ?
- High Fowler’s position or sitting on side of bed
- Monitor for
- hypovolemia / electrolyte imbalances
- BP and heart rate
- dressing for bleeding/leakage
Risk of Bleeding secondary to Varices
What to look for ?
•Hematochezia: blood in stool
•Hematemesis: blood in vomit 🤮
- throwing up! Not coughing which would be from 🫁
Management of altered LOC secondary to hepatic encephalopathy
What to assess for ?
1) Maintain safe environment
- Prevent falls and injuries
2) Assess carefully (LOC)
- Sensory and motor abnormalities
- Fluid/electrolyte imbalances
- Acid-base imbalances
- Response to treatment measures like meds
- Assess neurologic status every 2 hour
3) Minimize constipation
4) Encourage fluids
DC Planning
What do they need to know?
- Proper diet
- Rest
- Avoiding potentially hepatotoxic OTC drugs like Tylenol
- Abstinence from alcohol
Decompensated cirrhosis *
6 major complications
- portal hypertension
- esophageal and gastric varices**
- peripheral edema
- abdominal ascites
- hepatic encephalopathy
- hepatorenal syndrome
Nursing care for Dyspnea
Semi or high fowlers
C&DB
Rest
Skin care
Special mattress to relive pressure
Turn q2h
ROM
Elevate lower extremity
Drug therapy for varices bleeding
•Octreotide
(used more often due to fewer side effects).
•Vasopressin
produces vasoconstriction, decreases portal blood flow, and decreases portal HTN
Acute surgery for bleeding varices
Endoscopic therapy
- *Endoscopic variceal ligation(EVL)
- a rubber band around vein to cut off blood supply
- Sclerotherapy-solution is injected directly into a vein, causing the lining of the blood vessel to swell and stick together
- Balloon tamponade
Long term care of bleeding varices
Surgery?
Non surgical?
Surgery:
•Repeated EVL (Endoscopic variceal ligation)
•Portosystemic shunts–goal is to decrease portal HTN (after 2nd bleed)
•portacaval and distal splenorenal shunt*
Nonsurgical:
•trans-jugular intrahepatic portosystemic shunt (TIPS)
