[Exam 1/Final] Chapter 49: Hepatic Disorders Flashcards
Liver: Where is this located?
RUQ
Liver: How does it receive blood?
Portal vein and from the hepatic artery
Liver: Lobes in here?
Two lobes
Liver: What are lobules?
The small functional units of the liver.
Liver: What are kuppfer cells?
They engulf bacteria
Liver - Metabolic Functions: Functions of the liver?
Glucose Metabolism Ammonia Conversion Protein Metabolism Fat Metabolism Vitamin/Iron Storage Bile Formation Bili Excretion Drug Metabolism
Liver - Metabolic Functions: What is Ammonia?
Waste product of protein, that is converted to urea to be excreted.
Liver - Metabolic Functions: What vitamins stored?
A,B,D
Liver - Metabolic Functions: Purpose of bile?
Aids in digestion.
Liver - Assessment: What should we ask abotu liver?
Drug/Alcohol Usage
IV Drug User
Exposure At Work
Travel For Work?
Liver - Assessment: Whats included in physical assessment?
Skin Color (Jaundice, Pallor, Edematous)
Liver Function Studies: What to be aware of AST/ALT?
More than 70% of liver may be damaged before these are elevated
Liver Function Studies: Protombin increased in liver disease why?
They no longer make proteins as well and cannot control bleeding
Liver Function Studies: Serum Alkaline Phosphate elevated when
IF there is a blockage
Liver Function Studies: Why can serum ammonia be elevated?
Because protein cannot be converted into urea.
Liver Diagnostic Studies: GOld standard to test this?
Liver Biopsy to determine whats going on in liver. Look at labs to make sure not at big risk for bleeding.
Liver Diagnostic Studies: How will patient be positioned after?
Liver is on right side, so you want to place the right side down to help provide pressure.
Hepatic Dysfunction: What can go wrong with liver?
Jaundice, Portal Hypertension, AScites, Acute/Chronic, Cirrhosis of Liver
Hepatic Cirrhosis: What are teh types?
Alcholic (Scar tissue around portal tissue)
Post Nectrotic (Broad bands of portal tissue , caused by hepatitis)
Biliary (Scarring around bile ductS)
Hepatic Cirrhosis: What is cirrhosis?
Liver disease where the liver cells become so severely damaged that they get replaced with fibrious tissues so its scarring.
Hepatic Cirrhosis: Why does this happen?
Some are more susceptible. Excessive alcohol intake may cause this?
Can be a viral infection as well.
Increased fat in the liver. so obesity and diabetes
Blockage of bile duct
Hepatic Cirrhosis: CMs?
Liver enlargement, portal obstruction and ascites, GI varices, edema, vitamin deficiency, anemia, mental detoriation
Hepatic Cirrhosis: Late CMs of this?
Jaundice Enlarged Spleen Hemorrhoids AMS (Bc increased ammonia) Spider Angiomas on face, neck, shoulder)
Hepatic Cirrhosis: Assessment will include what?
Health Hx, and focus assessment on skin, mental status, and GI. Good head-to-toe assessement
Hepatic Cirrhosis: Diagnosis of this?
FVE Confusion Ineffective Breathing Pattern Fatigue RF Infection
Hepatic Cirrhosis: What interventions can be performed?
Promote rest and improve nutritional status.
Reduce risk of injury and bleeding.
Hepatic Cirrhosis: Manifestations of this?
Jaundice
Portal Hypertension, Ascites, Varices
Hepatic Encephalopathy/Coma
Nutritonal Deficiencies
Jaundice: What is this?
Yellow or green tinged body tissues, sclera, skin due to increased serum bilirubin levels
Jaundice: What are some types
Hemolytic (Can’t be broken down)
Hepatocellular (Can’t clear bili from blood)
Obstructive (Bile duct blocked)
Herediatary (Naturally elevated)
Jaundice: How will patient with hepaocellular appear?
Mildly or severely ill. Lack of appetite, nausea, weight loss.
Fatigue and Weakness
Headache and Chills and fever if infectious of origin.
Jaundice: How will those with obsturctive appear?
Dark orange - brown urine and light colored stools
Dyspepsia and intolerance of fats, impaired digestion
Pruritus (itching because bile acids are coming through the skin)
Portal Hypertension: What is this?
Obstructed blood flow through the liver resulting in increased pressure throughout the portal venous system
Portal Hypertension: What does this result in?
Ascites, Esophageal Varices,
Ascites: What is this?
Accumulation of plasma and albumin rich fluid and the abdominal cavity. Portal hypertension is often the cause of this due to vasodilation of the system.
Ascites: Change in ability to do what?
Metabolize aldosterone, increasing fluid retention
Ascites: Decreased synthesis of what?
Albumin, decreasing serum osmotic pressure.
Ascites: How will you assess this?
Record abdominal girth and weight daily.
Ascites: how will they appear?
May have striae, distended veins, and umbilical hernia.
Ascites: How would fluid in abdominal cavity be assessed?
By percussion for shifting dullness or by fluid wave
Ascites: Monitor for what imbalance?
Fluid and electrolyte imbalance
Ascites: How do you treat this?
Low Sodium diet so they don’t retain water
Diuretics
Bed Rest (Walking activates RAAS)
Paracentesis
Give Salt-Poor Albumin
Transjugular Intrahepatic Portosynemic Shunt (TIPS)
Ascites: What does a low sodium diet incldue?
2 g sodium diet with no salt substitues so ammonia levels do not go any higher
Ascites: What is done to remove fluid?
Paracentesis. Patient sitting in chair and will be ultrasound guided.
Ascites: What is done to fluid from paracentesis?
Fluid is sent to lab to analyze it.
Ascites: What should be done pre-procedure?
Make sure there has been consent. Radiologist will help drain this. Make sure aseptic technique is maintained while monitoring vitals.
Ascites: What should you assess for after procedure?
Hypovolemia, making sure that you did not take too much fluid off
Ascites - TIPS: What is this?
Catheter put into hepatic vein to help open it up to relieve pressure and to help relieve the asictes.
Bleeding of Esophageal Varices: How common is this?
33% of patients have this
Bleeding of Esophageal Varices: What is this?
Varices (outpouching) within esophagus from pressure from liver that lead to bleeding.
Bleeding of Esophageal Varices: Manigestions of this?
Hematemesis , Melena (Digesting blood) , general detoriation, and shock.
Bleeding of Esophageal Varices: How often should they be screened for this?
Every 2 years using a endoscope
Bleeding of Esophageal Varices: Nursing Mx for this?
Monitor patients condition frequently.
Bleeding of Esophageal Varices: What complications can occur?
Hepatic encephalopathy from blodo breakdown in GI tract and delirium related to alcohol withdrawal.
Bleeding of Esophageal Varices: If they are bleeding out, you have to treat what
Shock
Bleeding of Esophageal Varices Tx: What should you give them initially?
Oxygen, IV Fluids, Electrolytes, and Volume Expanders.
Then give blood to replace what has been lost
Bleeding of Esophageal Varices Tx: What meds can be given?
Vasopressin, Somatostatin to decrease bleeding
Nitro to reduce coronary vasoconstriction
Propranolol and nadolol to decrease portal pressure.
Bleeding of Esophageal Varices Tx: When would you not want to give vasopressin?
When they have CAD. Will lead to a MI
Bleeding of Esophageal Varices Tx: What is a BalloonTamponade?
This is used to treat life-threatening bleeding in event that we cannot get it under control. Will need to intubate the patient.
Bleeding of Esophageal Varices Tx: What is endoscopic sclerotherapy?
Done before they rupture. You can inject sclerating agent to promote thrombus to help clot it off and causing sclerosis.
Want to give PPI as well to prevent eroding of esophagus
Bleeding of Esophageal Varices Tx: What is a varicie?
Weaking, outpouch point in the vessel
Bleeding of Esophageal Varices Tx: What is Esophageal Banding?
Scope goes in. Find varicie and put a band around it. It is suctioned into the tip and clips it off and decreases the rate of bleeding. Will cut it off and die off.
Bleeding of Esophageal Varices Tx: What are Portal Systemic Shunts?
Similar to TIPS. Created to decrease portal hypertension.
Hepatic Encephalopathy and Coma: What is this?
Life-threatening complication of liver disease. May result from accumulation of ammonia and other toxic metabolities in the blood
Hepatic Encephalopathy and Coma: Stages of this?
4
Normal
Drowsy
Stuporness
Coma
Hepatic Encephalopathy and Coma: Early symptoms?
See small mental changes and start to stay up at night. Mood disturbances and become more agitated and confused.
Hepatic Encephalopathy and Coma: What diagnostics can be performed?
EEG.
Hepatic Encephalopathy and Coma: What assessments can you perform?
EEG
Hepaticus (Breath of the Dead of Ammonia Buildup)
Ammonia Levels
Changes in LOC
Hepatic Encephalopathy and Coma: They develop asterixis, whcih is what?
Liver flap. They have a flapping of the hand.
Hepatic Encephalopathy and Coma: These problems can be increased by what?
Constipation, Infection, Hypovolemia, Hypokalemia, GI Bleed, Opioid Meds
Hepatic Encephalopathy and Coma: How do you treat this?
Lactulose (Helps them go to bathroom and get rid of bathroom)
Vancomycin to treat
Promote diet high in carbs to help prevent ammonia growing in duct
Hepatic Encephalopathy and Coma: What is constructional apraxia?
Unable to reproduce a star if it is drawn
Hepatic Encephalopathy and Coma: How to manage this?
Eliminate precipitating cause.
Lactulose to reduce serum ammonia levels
IV Glucose to minimize protein catabolism
Protein restriction
Reducing ammonia in GI tract by gastric suction, enemas, oral antibiotics.
Discontinue sedatives and treat infections
Hepatic Encephalopathy and Coma: What medication is given most often?
Neomyosin and Flagelle to decrease levels of ammonia forming in colon
Hepatic Encephalopathy and Coma: How can Lactulose be given?
Orally or rectally. May see if they get too much lactulose, they end up wit diarrhea causing electrolyte imbalance.
Hepatitis: What is this?
Systemic viral infection that causes necrosis and inflammation of liver cells with characteristic symptoms and cellular and biochemical changes
Hepatitis: What are the types?
A,B,C,D,E,G
Hepatitis: Nonviral hepatitis caused by what
Toxin or drug induced
Hepatitis: How to remember Hep A/E?
Hepatitis with a vowel comes from the bowel
Transmission from fecal, oral
Vaccine only for A
Hepatitis: How to remember Hep B?
B = Body Fluids.
Transmissted through blood, semen, salvia.
Vaccine available
Hepatitis: How to rememeber Hep C?
C = Circulation. Through blood and semen
No Vaccine
Hepatitis: How to remember Hep D?
Co-Infection with HBV. Through blood and no vaccine.
Hepatitis A: Transmitted how?
FEcal-Oral. Spread through poor hygieen, hand-to-mouth contact, close contact.
Hepatitis A: Illness lasts how long
4-8 weeks . Incubation of 15-50 days
Hepatitis A: Signs of this?
Mild flu-like symtpoms, low grade-fever, anorexia, later jaundice and dark urine, indigestiona nd epigastric distress, enlargement of liver and spleen
Hepatitis A: What is done after this appears?
Anti-HAV antibody in serum to help boost immune system
Hep A: How to prevent?
Good handwashing, safe water, proper sewage disposal.
Get a vaccine
Hep A: What should be done during acute stage?
Best rest along with nutritional support
Hep B: Transmitted how?
Blod, salvia, semen, vaginal secretions, transmitted to infant at birth
Hep B: This can cause what disease?
Cirrhosis and liver cancer. More at risk for cancer.
Hep B: Incubation period?
1-6 months
Hep B: Manifestations?
Variable, similar to Hep A. Weakness, Jaundice, enlarged spleen/liver.
Hep B: How to prevent this?
Vaccine for those high risk.
Passive immunization for those exposed
Standard precautions/infection control measures
Screening of blood products
Hep B: What should be done if you have this?
Bed Rest / Nutritional Support
Hep B: Medications for this?
Alpha Interferon and Antiviral Agents : Lamivudine (EPivir) and Adefovir (Hepsera)
Hep B: Antiviral agents improve what?
Liver function, decrease load of virus. May take 2-4 months to recover
Hep C: TRansmitted how
blood, sexual contact including needle sticks
Hep C: Most common what?
Of the bloodborne infections
Hep C: 1/3 cause of what?
Liver cancer and the most common reason for liver transplant
Hep C: Symptoms are usually what
mild
Hep C: Best thing to do for this?
Prevention and education on safe sex and no sharing of needle.
Hep C: What does alcohol do for this?
Encourages the progression of the disease. So alcohol and medications that affect liver should be avoided.
Hep C: What antiviral agents can be given?
Interferon and ribavirin (Rebetol)
Hep D: Who is at risk for this?
Only those with Hep B
Hep D: Transmitteed how?
Transmission through blood and sexual contact
Hep D: Patient is likely to develop what?
fulminant liver failure and chronic active hepatitis and cirrhosis
Hep E: Transmitted how?
Fecal-oral route
Hep E: Incubation period?
15-65 days
Hep E: Resembles what?
Hep A. Self-limited with abrupt onset. No chronic form
Nonviral HepatitisL: This incldues what?
Toxic hepatitis and drug-inducted hepatitis
Nonviral HepatitisL: What is toxic hepatitis?
Chemicals harm liver causing necrosis and will need a liver transplant.
Nonviral HepatitisL: What is drug-induced hepatitis?
Tylenolol. Damaging to liver, only 4000mg max per day. Taking away tylenol may reduce symptoms.
Fulminant Hepatic Failure: What is this?
Rapid onset of liver failure and they will need liver transplant
Cancer of the Liver: Usually associated with what?
Hep B, C, and Cirrhosis
Cancer of the Liver: What is a primary liver tumor example?
Hepatocullar Carcinoma (HCC). May be caused by smoking
Cancer of the Liver: Liver is a frequent site of metastatic cancer why?
Because there is a hepatic portal right there that goes to the whole body.
Cancer of the Liver: Manifestations of this?
Pain , dull continuous ache in RUP, epigastrium or back
Weight lsos, loss of strengh
Jaundice if bile ducts occluded, asictes if obstructed
Cancer of the Liver: What diagnosis can be done?
ALT/AST
CT / Ultrasound / Biopsy
Draw specific tumor markers
Cancer of the Liver: How is this treated if underlying cirrhosis??
Surgery risk will be increased because they are more at risk for bleeding. Will need surgery
Cancer of the Liver: What types of treatment will be performed?
Radiation Therapy
Chemotherapy
Percutaneous Biliary Drainage (To bypass any obstructed ducts)
Other Nonsurgical Treatments like Immunotherapy and Arterial Embolization (Embolize the blood flow to tumor on liver)
Surgical Mx of Liver Cancer: Treatmetn of choice for HCC?
Surgery if confined to one lobe
Surgical Mx of Liver Cancer: Types of surgery?
Lobectomy
Cryosurgery (Liquid nitrogen)
Liver Transplant
Liver Transplant: If living donor, what side is taken?
The right side and the rest will regenerate.
Liver Transplant: How do they decide about liver transplant?
Meld Score . Way to determine who is the most urgent to get liver. Looks at Bili, INR, Creatinine. Gives them score.
Liver Transplant Nursing Care: PreOp Intervention?
Education, especially psychosocial. Since someone has to die for you to live.
Also managing patients current symptoms if they have ascites, fluid and electrolyte imbalancne.
Education on surgery
Liver Transplant Nursing Care: Postop Interventions?
Hemodynamic monitoring.
Monitoring Drains
Teach about liver labs and that labs will be drawn frequently
Signs of infection and rejection.
Liver Transplant Nursing Care: Complications from this?
Bleeding, Infection, May Reject
Liver Transplant Nursing Care: What is Live Donor Liver Transplant?
Living donor will donate right lobe. Will have to be counseled on potential scenarios that may occur.
Liver Transplant Nursing Care: Liver transplant patient cannot take what
NSAIDS like ibuprofen because it can mess with it. Can have tylenol because they have a healthy liver.
