Hepatic Flashcards
What percentage of metabolism does the liver do?
90%
If the drug is hepatotoxic, what does the nurse need to know about that?
the drug does not metabolize
The liver is located on what side of the body
right
Functions of the Liver
“People Drink So Much”
- Produces clotting factors, proteins, and bile (Vitamin K)
- Detox: remove byproducts of medications and bacteria in the blood (alcohol, bilirubin storage)
- Storage of glycogen, vitamins and minerals (gluconeogenesis and low immunity)
- Metabolism of nutrients from food (fats)
If the liver is impaired and can not metabolize, what wil increase
ammonia
- AMS and crazy
Liver failure is
inability of liver to function normally
Liver failure starts out as
inflammation of the liver cells
- acute or chronic
Chronic inflammation of the liver results in
scar tissue formation
no blood flow and necrosis
-cirrhosis
What happens to the BP in liver failure
increases
Acute
< 6 months
Chronic
> 6 months
What can cause acute liver failure?
~Viruses – hepatitis A, B, & C
~Drug use, often coupled with alcohol use
- Acetaminophen overdose
- Tuberculosis medications
~Wilson’s disease – excess copper and liver cannot metabolize (brown ring around iris)
~Ingestion of poisonous substances
- Mushrooms
What is the maximum amount of Tylenol for a day
4000 mg = hepatotoxic
Ibuprofen pt teaching
take with meals and milk
low clotting
EARLY S/S of acute liver failure
Fatigue
Jaundice w/ or w/o pruritus – excess bilirubin
Change in mentation (cognitive function)
Hematologic disorders
- prolonged coagulation
- easy bruising
Encephalopathy
Nausea and poor appetite
Acute liver failure complications
Cerebral edema
Hypoglycemia
Renal failure
Sepsis
Metabolic acidosis
MODS
What is the priority when suspecting acute liver failure?
neuro assessment
What follows after the neuro exam in a suspected liver failure?
fluid and electrolyte for K (malnutrition)
GI Bleed exam (acid and alcohol and stress the body causes them to eat their lining)
Infection risk (due to lack of vitamins and minerals)
Cirrhosis patho
- chronic liver disease greater than 6 months
- Chronic alcoholism
- Chronic viral hepatitis
- Nonalcoholic fatty liver disease (NAFLD) that = leads to Nonalcoholic - Steatohepatitis (NASH)
- Cardiac cirrhosis
- Biliary cirrhosis
What is the goal of cirrhosis?
preserve the healthy part of the liver
Steatosis
fatty deposits in the liver
Can you reverse nonalcoholic fatty liver disease?
yes
What are phases of the liver?
Healthy
fatty liver
fatty deposits
fibrosis
cirrhosis
Where is the best place to find jaundice?
sclera
- next is fingernails, mucosa
Ascites
fluid in the interstitial cavity
S/S of cirrhosis
Jaundice
Ascites
general fatigue
peripheral edema
= respiratory distress
What can occur as a sign of ascites?
general fatigue
peripheral edema
as the belly grows and pushes the diaphragm and making it harder to breath
= respiratory stress
Nursing priority for ascites patient
High fowlers HOB 45+
Tx for ascites
Albumin and diuretic therapy
- Paracentesis
- TIPS
Albumin MOA
pulls the interstitial fluid back into the intravascular vessels
What do you need to check regularly from diuretic therapy?
K (hypo)
Paracentesis is a
temporary fix
TIPS
foley of the peritoneal cavity
Paracentesis is the
The removal of fluid from the abdominal cavity using a large bore needle
Paracentesis Complications
Hypotension
Hypokalemia
Ascites cases what in the BP
HTN
Nursing Mgmt for Liver Failure
Paracentesis Care (Acute)
Patient void immediately before – don’t puncture the bladder
Monitor for hypovolemia & electrolyte imbalances
Monitor BP & heart rate
Monitor dressing for bleeding/leakage
After a paracentesis, the patient starts having hematuria, what does this show?
puncture the bladder
After a paracentesis, the patient starts having abd pain. this could mean?
abd puncture
excess bilirubin can cause what to the patient’s skin
dry
itchy
jaundice
Minimal urine output for a patient
30 mL/hr
ICU 0.5 mL/kg/hr
Impact of LF on the Endocrine System
Decreased metabolism of hormones
Testosterone
Estrogen
Aldosterone
Decreasing metabolism of hormones can result in what s/s in men
Gynecomastia – man boobs
Impotence
Decreasing metabolism of hormones can result in what s/s in females
Elevated testosterone in women
Menopause can start bleeding again
Amenorrhea in young
S/S of liver failure
- hematologic disorders
Thrombocytopenia
Leukopenia
Anemia
Coagulation disorders
splenomegaly
Bleeding Precautions
No ASA
Limit needles sticks
electric razor
22 g needle
protect from injury = bedrest
no contact sports
soft bristle toothbrush
Low platelets
<150,0000
- no clotting
<20,000 platelets means
bedrest
I know it is not a mobility issue, but
Observe for what on bleeding precautions
hematuria
nosebleeds
gum bleeds
bruising
S/S of liver failure and cirrhosis
- neuro
hepatic encephalopathy
peripheral neuropathy
asterixis
Asterixis
weird flappy hand (lactulose given as a laxative to get rid of ammonia)
S/S of liver failure and cirrhosis
- skin
jaundice
spider angioma
palmar erythema
purpura
petechiae
caput medusae
heroism - excessive hair growth in wrong places
S/S of liver failure and cirrhosis
- metabolic
LOW K, Na, Albumin in the blood
S/S of liver failure and cirrhosis
- CV
fluid retention
peripheral edema
ascites
S/S of liver failure and cirrhosis
- GI
anorexia
dyspepsia
N/V
change in bowel habits
dull abd pain
fetor hepaticus
esophageal and gastric varices
gastritis
hematemesis
hemorrhoidal varices
S/S of liver failure and cirrhosis
- reproductive
amenorrhea
testicular atrophy
gynecomastia
impotence
What labs increase do to liver failure/cirrhosis?
Ammonia
AST / ALT
Bilirubin
Lactic Acid
PTT, PT, INR
What labs decrease do to liver failure/cirrhosis?
Albumin
Glucose
K, Na, Mg
Platelets
RBCs
WBCs
Alkaline Phosphatase labs in liver failure
Acute - low
Chronic high
AST
disease or damage
ALT
how damaged and diseases it is
> 80 ammonia =
neuro changes
- hepatic encephalopathy
increase in bilirubin is due to
liver inability to excrete or store in the liver
Lactic acid =
tissue hypoxia
Dx studies for liver
Ultrasound
Fibro scan – degree of cirrhosis and fatty changes
Upper endoscopy – inside stomach to upper intestine
Radioisotope liver scan
Liver Biopsy – definitive test and dx
What is the only definitive test and dx of liver failure or cirrhosis?
liver biopsy
What is the patient at risk for with a liver biopsy
bleeding
- no clotting and taking a part of their liver
The liver biopsy should lay on what side
right
- pressure
What other s/s of the liver biopsy could occur that the nurse needs to monitor?
Diaphoretic and pallor, increase infection and peritonitis
Antidotes for Acetaminophen OD
activated charcoal (NG tube)
N-acetylcysteine
Medications possible for a liver failure pt
Benzo - lorazepam and midazolam
with Beer
Propofol with a secure airway
FFP and whole blood transfusions
- Albumin and platelets
What medications would they given an alcoholic with liver failure?
Benzo - lorazepam and midazolam
with Beer
Benzo is given for
acute anxiety for alcoholic trying to quit
- delirium tremors and seizures at the end of withdrawals
- give with beer to help wean off
Before giving Benzo and Propofol, what do you need to ensure
baseline neuro
- SE = sleeping
Complications of cirrhosis
portal HTN
peripheral edema
hepatic encephalopathy
hepatorenal syndrome
metabolic acidosis
sepsis
multiorgan failure
Portal HTN
Esophageal &/or Gastric varices
Splenomegaly
Ascites
Hepatic encephalopathy is known for
elevated ammonia levels
Compensated organ failure
1 organ system down
DeCompensated organ failure
3+ organ systems fail
Varices
Enlarged or swollen veins
Varices are caused by
high pressures
Prevent varices bleeding
beta blockers
How to stop a ruptured varices?
Vasopressor (vasopressin)
EGD for banding/sclerotherapy
Esophageal varices banding
Balloon tamponade therapy
Ruptured varices are a medical
emergency
- Goal: stop the bleeding then give fluids after
Sclerotherapy
going to preserve to go to figure out what to do
Suction to stabilize
If a patient walks in drunk (N/V) with bright red bleeding, what should the nurse think is wrong
varices
- Large bore IVs
- N/V not the main concern
Balloon Tamponade Therapy is
tampon in the GI to stop the bleeding
Nurse should do what for Balloon Tamponade Therapy
STABILIZE AND MAINTAIN AIRWAY
LARGE IVS
MEDICATIONS
SANDOSTATIN OR VASOPRESSIN (VASOCONSTRICTION)
The balloon therapy uses what
SENGSTAKIN BLATMORE TUBE
With the insert of the SENGSTAKIN-BLATMORE TUBE inserted, what should the nurse do if the pt RR increase and O2Sat decreases?
deflate and remove
-scissors at the bedside
Give O2
After the Balloon Tamponade Therapy, what does the nurse educate the patient on?
DIET MODIFY –
STOP DRINKING – DECREASE IN AMOUNT OF FREQUENCY, DIFFERENT TYPE IN A LOWER CONCENTRATION OR PROOFS, LIMIT VISITS TO THE BAR, SUPPORT GROUPS
- a drink can cause the varice to bleed again
Portacaval Shunt (TIPS) is used do to what complication?
portal HTN
- vein in the liver to inferior vena cava
The portal vein in the liver gives what percentage of blood into the inferior vena cava
45% - deoxygenated
The TIPS is only done if the patient has
normal blood flow blocked
Hepatic Encephalopathy happens when the liver
unable to convert increased ammonia
- ammonia crosses blood-brain barrier
Hepatic encephalopathy
patho s/s
Neurotoxic effects of ammonia
Abnormal neurotransmission
Astrocyte swelling
Inflammatory cytokines
What can cause Hepatic encephalopathy
TIPS, portal vein thrombosis
infections (SBP)
AKI,electrolyte derangements (low k)
GI Bleed
hypoxemia, hypercapnia
What is the pathology of HE?
gut flora (Ammonia, Glutamine, Methionine, Nitrogen, Serotonin, GADA
- goes to the liver and is failed to be metabolized ammonia
- portosystemic shunt bypasses the liver and goes into general circulation
toxins affect the brain
HE AMS can affect what
brain function, structure, or both
- Low reaction time
- low BP and HR
Stage 1 of HE
- consciousness
- intellect and behavior
- neurologic findings
mild lack of awareness
shortened attention span
impaired addiction or subtraction
mild asterixis or tremor
impaired handwriting
Stage 2 of HE
- consciousness
- intellect and behavior
- neurologic findings
lethargic
disoriented, inappropriate behavior
obvious asterixis
slurred speech
Stage 3 of HE
- consciousness
- intellect and behavior
- neurologic findings
somnolent but arousable
gross disorientation
bizarre behavior
muscular rigidity
clonus
hyperreflexia
Stage 4 of HE
- consciousness
- intellect and behavior
- neurologic findings
coma
decerebrate posturing
What stage of HE does the mental status changes start?
stage 2
GCS assessed every _____ in HE
EVERY 1 hour to 15 MINUTES
depends on situation
Stages of HE can be assessed using
GCS
Decorticate
flexor
Cs
- arms and legs inside
Decerebrate
extensor Es
outward and curved
Which posturing is worse?
decerebrate
Decorticate shows the problem with
cervical spinal tract or cerebral hemorrhage
- cord
Decerebrate shows the problem with
within midbrain or pons
-lesions
Will the posturing patient be stiff or flaccid
stiff tight
S/S of HE
Confusion
Lethargy that may progress to a coma
Inappropriate behavior or personality changes
Asterixis
Problems with fine motor activities
Musty or “sweet breath” odor
Seizures – brain swelling (pads, side, suction)
Hyperventilation
Suppressed gag reflex
How do you get rid of asterixis? (Tx)
(lactulose given as a laxative to get rid of ammonia)
Ammonia is excreted through
feces
Lactulose is considered therapeutic if the patient
increase in stools (3-5 per day) with lower ammonia levels
SEvere Complications of HE
Brain swelling
Increased ICP >20
Brainstem herniation
Organ Failure
How should the nurse manage the environment of a HE patient?
low stimulation environment
cluster care
Tx of HE
Correct cause
Lower ICP
- Minimal stimulation
- Oxygenation & ventilation
- Osmotic diuretics (mannitol)
Lower ammonia levels
- Lactulose & rifaximin therapy
- Prevent constipation
Mannitol is used for HE to
lower ICP
What is the only diuretic to cross the blood brain barrier?
Mannitol
Rifaximin decreases ammonia by
decreasing GI bacteria
Acute Care Mgmt of HE
Safety
LOC
Sensory & motor abnormalities
Fluid/electrolyte imbalances
Acid-base balance
Effects of treatment measures
Minimize constipation
Control factors known to precipitate encephalopathy
Nursing Assessment for Liver Failure
Fluid and electrolyte
Neuro
CV/PV
Respiratory
GI, Renal, MS, skin, psych
Liver failure to renal failure due to
necrosis or dehydration
- Creatinine and BUN high
- edema and ascites
Neuro assessment for Liver failure includes
every hour
Watch for seizures
Anticonvulsant – prevention
Avoid sedation
If x2 alert and oriented, then do not give benzo
Varices
If the liver patient is itchy, what should the nurse do
no hot showers, sharp surfaces, no baths,
Skin care or infection due to low WBCs
What is the priority for a liver failure patient?
Neuro
bleeding
infection
Nutritional Therapy for Liver Patients
High in calories (3000 cal/day)
Protein supplement
Low Na – if ascites & edema
↑ Carbohydrate
Moderate to low fat
Total Parenteral Nutrition (TPN)
Consult dietician
Why does the liver patient need a high calorie diet?
malnutrition - skinny with a beer belly
Ammonia is a byproduct of
protein
Ambulatory Care for Liver Failure
Be proactive & involve family
Lifestyle changes
Abstinence from alcohol
Community support programs – AA
Refer to home health & dietician
Verbal and Written Instructions for Liver Failure
Medications – Rx & what to avoid
Skin care
Bleeding risks
Nutrition
Symptoms of complications
Avoidance of hepatotoxic OTC drugs
Lasix - daily wt
A patient with advanced cirrhosis who has ascites is short of breath & has an increased respiratory rate. The nurse should
- Initiate oxygen therapy at 2 L/min to increase gas exchange.
- Notify the health care provider so that a paracentesis can be performed.
- Ask the patient to cough & breathe deeply to clear respiratory secretions.
- Place the patient in Fowler’s position to relieve pressure on the diaphragm.
- Place the patient in Fowler’s position to relieve pressure on the diaphragm.
Rationale: Dyspnea is a frequent problem for the patient with ascites, & a semi-Fowler’s or Fowler’s position allows for maximal respiratory efficiency. Oxygen administration is not indicated; SpO2 level less than 90% would be an indication for oxygen. The respiratory distress is caused by ascites (not by respiratory secretions); coughing & deep breathing will not alleviate the respiratory distress. A paracentesis may be performed to remove ascitic fluid; however, this procedure provides only temporary relief & is reserved for severe respiratory distress or abdominal pain.
A nurse is admitting a patient who has bleeding esophageal varices. What should the nurse anticipate the HCP will order?
- Propranolol
- Metoclopramide
- Ranitidine
- Vasopressin
- Vasopressin
Rational: Vasopressin will constrict blood vessels, especially the portal vein & decrease the bleeding. Propranolol – B-blocker used to lower pressure to prevent bleeding. Metoclopramide-treatment of GERD & gastroparesis. Ranitidine-an abx used for treatment of HE to decrease toxins from digested food
A nurse is assessing a patient who has advanced cirrhosis. Which findings would be concerning for hepatic encephalopathy?
- Select all that apply.
Anorexia
Change on orientation
Asterixis
Ascitis
Shaky handwriting
Change on orientation
Asterixis
Shaky handwriting
Jaundice & anorexia are signs of liver dysfunction but not indicators of HE
A nurse is caring for a patient who has cirrhosis. Which medications can the nurse expect to administer to this patient?
- Select all that apply.
Furosemide
Metoprolol
Morphine
Lactulose
Lorazepam
Furosemide
Metoprolol
Lactulose
Diuretics are used for ascitis beta-blockers lower portal HTN & prevent varices bleeding & lactulose aids in ammonia elimination
Morphine & lorazepam can sedate the patient & mask neuro changes. These should be avoided or used in lower doses if at all possible..
