Cirrhosis Flashcards by Brina Quintanilla Reyes

the following flashcards is going to be on the in class recording for cirrhosis

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what is the function of the liver?
(7 things she mentions in class)

metabolizes drugs
( lack of the medication in the body to aid )

produces clotting factors
( bleeding tendencies )

purifies your blood
( focuses on ammonia )

jaundice
( we are not breaking down bilirubin )

amber colored urine

pale colored stool

pruritus - leak out through the skin - bile/salt
- aid with the itching, trim their nails, antihistimaintes for the medication
- oatmeal warm baths

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when you have too much ammonia, what happens to our body ?

confusion -> encephalopy

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what is cirrhosis ?

end stage liver disease

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what are is the patho behind cirrhosis ?

inflammation and necrosis of cells leads to fibrosis
resulting in extensive degeneration and destruction of the liver cells

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what are some main/common causes for why patients end up developing cirrhosis ?

hepatitis C
NASH
alcohol

other causes include
- extreme dieting
- malabsorption
- obesity
- environmental factors
- genetic predisposition

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what is NASH?
nonalcoholic steatohepatitis?

a really aggravated fatty liver that can result in patients developing cirrhosis

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what is biliary cirrhosis ?

associated with blockage of bile ducts or inflammation and obstruction of bile

( gallstones )^

can be associated with colitis or crohns disease

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what is cardiac cirrhosis?

results from long-standing severe right-sided heart failure

fluid goes to the peripheral, so the organs will enlarge

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how are we going to treat cardiac cirrhosis ?

so as she’s talking in the recording, she’s mentioning that we always want to treat the underlying causes, weather the disease is the same for everything.

for cardiac cirrhosis, its our heart that is causing problems to our liver, so we are going to try to treat the right sided heart failure first then treat the resulting pain in the liver after

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what are the clinical manifestations you will see in a patient with early stage liver disease?

very few to none

but you will see fatigue and an enlarged liver

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what are some later clinical manifestation related to liver failure and portal hypertension?

jaundice
peripheral edema
ascites
skin lesions
hematologic,endocrine, neurologic disorders

liver becomes smaller and nodular

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why do patients with cirrhosis end up having jaundice ?

results from decreased ability to conjugate and excrete bilirubin

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not only do patients end up with jaundice from the fact that they can’t excrete it, but also from what?

the overgrowth of connective tissue in liver compresses bile ducts
- leading to obstruction and increase in bilirubin in vascular system

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why do patients develop skin lesions when they have cirrhosis ?

due to increase in circulating estrogen due to inability of liver to metabolize steroid hormones

this is very itchy

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what are the 2 skin lesions patients with cirrhosis have?

spider angioma
palmar erythema

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why are we concerned for patients with cirrhosis when it comes to developing hematologic disorders ?

bone marrow suppression, anemia, and coagulation disorders because the liver can not make clotting factors

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why are we concerned for patients with cirrhosis when it comes to developing endocrine disorders ?

describe what happens to men
describe what happens to women

gynecomastia - breast
- loss of axillary and pubic hair, testicular atrophy, impotence and loss of libido

women
- amenorrhea or vaginal bleeding

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endocrine disorders can lead to something called hyperaldosteronism in both sexes, meaning what two things?

sodium and water retention
potassium loss

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so we understand that cirrhosis is going to cause the patient to experience a lot of clinical manifestation, but as mentioned in the last flashcard, we are going to have a lot of aldosterone in our body. But due to this high aldosterone, it is going to cause us to have potassium loss.

we know that a patient with cirrhosis is at a very high risk for developing acsitits, so normally we are going to want to use a diuretic to treat it, but we know diuretic are potassium wasting. but what is the name of the diuretic we are going to use to help aid this patient ? and its for two reason too.

spirolantone
- potassium sparing
- aids with that aldosterone

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why does peripheral neuropathy occur in patients with cirrhosis ?

usually due to the dietary deficiencies of thiamine, folic acid, and cobalamin
(vitamin b12)

remember in tb, how to treat peripheral neuropathy, give them b6 ( pyradixe )

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what were the clinical manifestation for these patients that we just talked about ? (5)

jaundice
skin lesions
hematologic disorders
endocrine disorders
peripheral neuropathy

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in compensated cirrhosis, so meaning your body and medication is helping you, what complications can you get?

nothing

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in decompenstated cirrhosis what are the complications we are going to talk about ? (6)

portal hypertesnion
esophageal & gastric varices
peripheral edema
abdominal ascites
hepatic encephalopathy
hepatorenal syndrome

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what is portal hypertension?

obstruction of normal blood flow in and out of the liver

what does an increase portal hypertension mean?

increased venous pressure in portal circulation splenomegaly - fluid backs up large collateral veins ascites gastric and esophageal varices

what is esophageal varices ?

complex of tortuous, enlarged veins at Lower end of esophagus and bleed easily

esophageal varies is a life threatening complication, why do you think that is ? think of the example she was using the recording

lets say you have an esophageal varies, we understand that this is an outpouching of a large vein at the end of your esophagus. lets say you get food poisoning, and you start vomiting it out, with that vomit, you can pop the vein and cause life threatening bleeding. remember you also have cirrhosis, so you dont have the clotting factors that you need to stop it, and not to mention, its hard to stop bleeding, deep inside your mouth.

how do you get peripheral edema?

decreased vascular pressure due to decreased albumin production by the liver

how do you get ascites?

accumulation of serous fluid in peritoneal or abdominal cavity

what are the 3 main causes or several mechanism on how patients with cirrhosis end up getting ascites?

portal hypertension causes proteins to leak into lymph system. the lymph system becomes overwhelmed and leak out. hypoalbuminemia hyperaldosteronism

patients with severe ascites are at risk for developing what? and what is it?

pleural effusion - accumulation of fluid in the pleural space up near the lungs - risking patient with aspiration and cardiac tamponade - causing short of breathe, pnuemonia risk

why do we assess a patients respiratory function when they have ascites?

remember think of how the fluid will move in the body. the lower gi is not that far from your diaphragm and lungs. so fluid can shift upwards and cause discomfort in your lower respiratory tract, causing your ability to breathe to be alerted and potentially stopped.

what are you going to hear when you are percussing on a patients abdomen? what are you going to see if you push on a patients ascites belly?

dullness, its just pure fluid wave like motion, remember its just free sitting fluid

how do patients with cirrhosis end up having hepatic encephalopathy?

liver unable to convert increased ammonia to urea

why is having an increased ammonia level bad in general? and describe how patients will behave

its neurotoxic because it crosses the blood brain barrier and results in patients being confused, change in personality, sleep disturbances, and end up imparing their consciousness

what are the 3 main hepatic encephalopathy clinical manifestations?

asterixis apraxia fetor hepaticus

what does asterixis mean ? what does apraxia mean? what does fetor hepaticus mean?

flapping tremors impairment in writing ( difficulty in moving pen left to right ) musty, sweet odor of patients breath - from accumulation of digestive by products

how do patients with cirrhosis end up developing hepatorenal syndrome ?

renal failure with azotemia ( increase nitrogen waste ), oliguria and intractable ascites acute kidney injury from the fact that your liver in damaged

how do you treat hepatoreneal syndrome ?

liver transplant remember its not that your kidneys are messed up, its because your liver is messed up and causing kidney problems so if we fix your liver, your kidneys will be fixed too

what are some diagnostic studies for patients with cirrhosis ? what is the goal standard?

gold standard is a liver biopsy liver enzyme tests total protein, albumin levels serum bilirubin, globulin levels

when doing a liver biopsy on a patient who has cirrhosis, what is our main concern after the procedure and why ?

bleeding remember they dont have the clotting factors to stop the bleeding

we always want to tell patients that have cirrhosis to rest, however we also want to tell them to avoid ____and what medications (3)?

alcohol medications 1. aspirin 2. acetaminophen 3. nsaids

remember patients with cirrhosis are going to have a lot of vitamin deficency, but remember they have peripheral neuropathy, what is that one specific vitmain we are going to encourage these patients to have more of?

vitamin b complex

what is the scale that we are going to use for patients who drink? - we also need to manage their withdrawals symptoms as well

CIWA scale

patients with cirrhosis are at risk for developing ascites so we are going to tell them to avoid what? (how much as well) and what are we going to use to treat their ascites ?

avoid sodium for the fluid retention ( 2 grams or less per day) diuretics - spironolactone ( aldosterone agonist and potassium sparing )

why are we going to tell patients with cirrhosis that should consume things with more albumin in it? or receive an albumin infusion?

remember, low albumin levels indicate poor nutritional values typically patients with alcohol or beer consumption, get full off those drugs, so they won't eat, meaning they will loss weight and put on that beer belly. we need to make sure they are getting the proper nutritents they need, so we recommend them getting albumin infusion

what is the procedure that we can do to help aid patients with ascites?

paracentesis

if a patient has a high portal hypertension and a lot of ascites, we can do something called ? and what does it do?

TIPS - transjugular intrahepatic portosystemic shunt help reduce the portal pressure

for esophageal and gastric varies, its is the most lethal complication with patient with cirrhosis. we must prevent bleeding/hemorrhaging for these patients. so we tell them to avoid what? how do we know they have this? so like what's the diagnostic study? how do we aid these patients to decreases the chances of it bleeding? what medication ?

alcohol, aspirin and nsaids. endoscopy screening nonselective beta blockers will decrease high portal pressure and decrease bleeding

test question patient with esophageal varies has started on a beta blocker, how do you know the mediation is working?

their varies have gotten smaller or they are not bleeding from their varices

this is just additional information that I can't find on the powerpoint but dr.brooks is mentioning it. esophageal varies is a medical emergency, remember these patients dont have any clotting factors, so the risk of bleeding becomes extremely high. we need to tell patients to be careful with what they eat, drink and even do because one pop, and they are bleeding to death. we as a nurse need to recognize that they have this to avoid this. what doctors can do is put bands behind these varices and make it lose blood supply and then cut it off at the end.

if bleeding occurs from a esophageal varices, what do we do?

stablize patient manage airway start iv therapy and blood products give them beta blockers

what are the two therapies we can do to help aid esophageal varices ? (3)

endoscopic variceal ligation ( banding ) scleortherpay - scar the vessels, and close it off - so blood will be redirect to deeper vessels balloon tamponade - mechanical compression of varies

what are supportive measures for acute bleed with esophageal varices? dont over think it

fresh frozen plasma packed RBCS vitamin K proton pump inhibitors antibiotics

what are the two medications we are going to give these patients with an acute bleed from esopheageal varices?

lactulose ( cephulac ) rifaximin ( xifaxan )

what does lactulose (cephulac ) do? biggest side effect?

decrease intestinal production and absorption of ammonia diarrhea

breakdown of blood in the gut causes increase ___ so we must take measures to prevent ____ which is result from having this too much

ammonia constipation

what is our main concern/goal with patients with hepatic encephalopathy ?

reducing the ammonia formation

what medication are we going to use to help reduce the ammonia formation in hepatic encephalopathy ?

lactulose ( cephulac ) - which traps ammonia in gut

what is the diet for patients with cirrhosis ? (4)

high calories (3000/day) high carbohydrate protein restriction moderate to low fat

nursing assessment notes Subjective data Past health history - Hepatitis - NASH - Chronic biliary obstruction and infection - Severe right-sided heart failure Medications - Adverse reactions - Anticoagulants, aspirin, NSAIDs, acetaminophen

nursing assessment Subjective data: Chronic alcohol use Weakness, fatigue Anorexia, weight loss Dyspepsia Nausea and vomiting Gingival bleeding Dark urine Decreased output Light-colored or black stools Flatulence Change in bowel habits Dry, yellow skin Bruising RUQ or epigastric pain Numbness, tingling Pruritus Impotence Amenorrhea

nursing assessment objective Fever, cachexia, wasting of extremities Icteric sclera, jaundice Petechiae, ecchymoses Spider angiomas, palmar erythema Alopecia, loss of axillary and pubic hair Shallow, rapid respirations Peripheral edema Epistaxis Abdominal distention, ascites Distended abdominal wall veins Palpable liver and spleen Foul breath Hematemesis; black, tarry stools Hemorrhoids Altered mentation Asterixis Gynecomastia Testicular atrophy Impotence Loss of libido Amenorrhea, vaginal bleeding Anemia, thrombocytopenia, leukopenia Decreased serum albumin and potassium levels Abnormal liver function studies Increased INR Increased ammonia and bilirubin levels Abnormal findings on abdominal ultrasonography or MRI

nursing management clinical problems Nutritionally compromised Ineffective tissue perfusion Activity intolerance Fluid imbalance planning Overall goals Relief of discomfort Minimal to no complications Return to as normal a lifestyle as possible

nursing management Health promotion Reduce or eliminate risk factors Treat alcoholism Maintain adequate nutrition Identify and treat acute hepatitis Bariatric surgery for morbidly obese

nursing management nutrition Acute care Rest needs Prevent complications Modify schedule Nutritional needs Oral hygiene Between-meal snacks Offer preferred foods Explanation of dietary restrictions

what is the medication we are going to use help patients with pruritus ?

cholestyramine - watch our for binding affects

nursing implementation Acute care Monitor color of urine and stools Accurate I/O recording Daily weights Extremities measurement Abdominal girth measurement

before a patient gets a paracentesis for their ascites, what do we tell them to do ? and why ? what position are they going to be in? what are we monitoring ?

void immediately to avoid puncture into the bladder high fowlers or sitting on the side of the bed hypovolemia and electrolyte imbalance cause of all the fluid we are laking out

nursing implementation Acute care Relief of dyspnea Semi- or high Fowler’s position Skin care Special mattress Turning schedule, at least every 2 hours ROM exercises Coughing/deep breathing exercises Elevate lower extremities/scrotum Acute care Monitor for fluid and electrolyte imbalances Hypokalemia Water excess (hyponatremia) Observe for bleeding tendencies Assess patient’s response to altered body image Supportive listening

nursing management bleeding varices Close observation for signs of bleeding Balloon tamponade care Explanation of procedure Check for patency Position of balloon verified by x-ray Monitor for complications (i.e., aspiration pneumonia) Scissors at bedside Semi-Fowler’s position Oral/nasal care

nursing management hepatic encephalopathy notes assess neuro status Q 2 hours Include exact description of behavior Level of responsiveness Sensory and motor abnormalities Fluid/electrolyte imbalances Acid-base imbalances Maintain safe environment and minimize injuries Encourage fluids Response to treatment measures

Ambulatory care Supportive measures Proper diet Rest Avoiding potentially hepatotoxic OTC drugs Abstinence from alcohol Caring attitude always Community support programs Symptoms of complications When to seek medical attention Written instructions with adequate explanations for patient/family Referral to community or home health nurse

nursing management evaluation Maintenance of food/fluid intake to meet nutritional needs Maintenance of skin integrity Normalization of fluid and electrolyte balance Treatment for substance use