Exam 2: Hepatic Disorders Flashcards
Manifestations of hepatic dysfunction
Jaundice
Portal hypertension
Ascites
Esophageal varices
Nutritional deficiencies
Hematological problems
Hepatic encephalopathy or coma
Jaundice
Increase bilirubin concentration in the blood, can see on palms, sclera, sometimes mucous membranes
Hepatocellular: Damaged liver can’t clear bilirubin
Obstructive: Blocked bile duct
Hemolytic: Excessive destruction of RBCs
Serum bilirubin exceeds 2.0 mg/dL
Nursing management: Rest, oral hygiene, dietary education, assess for jaundice, measures to relieve pruritus, short nails, monitor color of urine and stools
Portal hypertension
Blood enters liver through portal venous system
When damaged, it is hard for blood to pass through, fluid and electrolytes find path of least resistance
Creates new vessels that leads to varices and ascites
Fluid volume imbalance
Transfer of fluid from intravascular space to extra vascular space
Leads to peripheral edema and ascites
BP drops, intravascularly depleted - I&Os
Clinical manifestations of ascites
Increased abdominal girth
Rapid weight gain
SOB
Discomfort
Striae and distended veins may be visible over abdominal wall (Caput Medusa)
Umbilical hernias
Fluid and electrolyte imbalances
Ascites management
Daily weights, measure abdomen, I&O
Paracentesis
Salt restrictions
Diuretics
Bed rest
Shunt placement
Paracentesis
Pre-procedure: Obtain baseline assessment, have PT void prior, position PT upright at side of bed or in high fowlers
Intra-procedure: Measure, collect, and describe fluid (cloudy = infection)
Monitor VS
Support PT
Post-procedure: Maintain dry sterile dressing, monitor for hematuria/leakage at side, fluid volume deficit
Esophageal Varices
Dilated, tortuous veins in lower esophagus and upper stomach caused by portal hypertension
Fragile, high risk for bleeding (bleeding precautions/suction at bedside)
50% of PTs with cirrhosis have varices
Prevention: Avoid meds that may lead to bleeding (anti-platelets, anti-coagulants), avoid constipation, avoid activities that increase portal hypertension
Assess: AIRWAY, fluid volume deficit, melena/hematemesis, CBC (hemoglobin), VS
Emergency: PROTECT AIRWAY, manage bleed and fluid volume deficit, place 2 large bore IVs, monitor labs, replace fluids and blood products, vitamin K, PPIs, lactulose and rifaximin, endoscopy, balloon tamponade
Balloon Tamponade
Puts pressure on bleed to stop bleeding
Protect airway
Cared for in ICU
Label each lumen
Observe for skin breakdown
Monitor for complications (aspiration pneumonia)
Scissors at bedside
Semi-fowlers
Oral-nasal care
Hooked up to traction
Sengstaken-Blakemore/Minnesota Tube
Medications for varices
IV Octreotide: Used during ACTIVE BLEED, decreases bleeding from varices, selectively causes splanchic vasoconstriction
Propanolol: Prophylaxis, decreases portal pressure
Vasopressin: Used in urgent situations, vasoconstricts splanchic arteries and reduces portal pressure. Monitor for: Myocardial and extremity ischemia, cardiac dysrhythmias (may use nitroglycerin)
Endoscopy: Nursing management
Pre-procedure: NPO, ensure informed consent signed and evaluate PT’s understanding of procedure, baseline labs, PT education
Intra-procedure: Position side lying with elevated HOB
Post-procedure: Keep NPO until gag reflex returns, position PT high fowlers or side-lying, monitor for complications
Transjugular Intrahepatic Portosystemic Shunt (TIPS)
Shunts blood around to prevent ascites and varices
Need to watch for bleeding
Hepatic Encephalopathy
Liver not able to breakdown ammonia, leading to toxic amounts of ammonia in the blood, progressive
Causes neurologic manifestations
Manifestations:
LOC ranges from confusion to coma
Sleep/motor disturbances
Seizures
Asterixis, flapping tremors
Fector hepaticus (rotten egg breath)
Acid-base imbalance
Management: Frequent neuro assessments:, VS, I&O, daily weights, electrolyte and ammonia levels, small frequent meals, eliminate precipitating cause and decrease ammonia
Medications: Lactulose, Riaximin
Normal ammonia level: 15-45
Lactulose
Goal: Reduction of ammonia formation
Produces osmotic effect in colon and decreases amount of ammonia in colon
Adverse effects: Abdominal cramps, diarrhea, flatulence
Monitor: Hypernatremia and hypovolemia
Rifaximin
Goal: Reduction of ammonia formation
Used to reduce ammonia forming bacteria in colon in PTs who do not respond to lactulose
May increase creatinine and ALT
Nutritional Therapy
Daily protein intake between 1.2-1.5 g/kg daily
High in calories
High carb
Moderate to low fat
Protein restrictions rarely justified
Low-sodium for ascites and edema
Needs supplements with vitamins A, B, C, K, folic acid
Hematological problems
Decreased production of clotting factors (plasma proteins) leads to coagulation disorders
Portal hypertension leads to pooling of blood which can lead to throbocytopenia, leukopenia, anemia
Give platelets at 10,000
Hepatitis
Systemic, viral infection causing inflammation of the liver cells producing clinical, biochemical, and cellular changes
Patho: Acute infection, liver damage, cholestasis (interruption of bile flow). Chronic infection can cause fibrosis (over decades) and progress to cirrhosis
Manifestations: Acute and chronic phases, many pts asymptomatic (with acute), or intermittent/ongoing symptoms: anorexia, weight loss, malaise, fatigue, myalgias/arthralgias, low-grade fever, heptomegaly, low-grade fever, heptomegaly
Viral hepatitis teaching
Dietary teaching
Activity restrictions/tolerance
Prevent transmission
S/S to report
Assess for complications
Regular follow up 1 year after diagnosis
No alcohol
Medication education (no tylenol or hepatotoxic drugs)
Cirrhosis
Chronic damage to liver cells, disorganized regeneration, overgrowth of connective tissue. Fibrotic, poorly functioning liver
Risk factors: Alcohol use disorder, chronic viral hepatitis (B, C, D), autoimmune hepatitis, steatohepatitis, chronic biliary hepatitis, cardiac cirrhosis
Manifestations:
Compensated: Abd pain, ankle edema, firm/enlarged liver, flatulent dyspepsia, intermittent mild fever, palmar erythema, splenomegaly, unexplained epistaxis, vague morning indigestion, vascular spiders
Decompensated: Ascites, clubbing of fingers, continuous mild fever, epistaxis, gonadal atrophy, hypotension, jaundice, muscle wasting, purpura, sparse body hair, spontaneous bruising, weakness, weight loss
Cirrhosis management
Diuretics
Beta blockers (propanolol)
Lactulose
Vitamins
Antacids
Milk thistle herb
Paracentesis
Endoscopic variceal ligation/banding therapy
Endoscopic sclerotherapy
TIPS
Transplant
