Hepatic Failure Flashcards
Etiology of acute liver failure
Hepatitis (#1 priority, usually r/t alcohol)
Inflammation
Hepatotoxic drugs
Decreased profusion
Etiology of chronic liver failure
Cirrhosis
Fatty liver disease (lowest priority b/c it’s rare)
Clinical manifestations of acute liver failure
Chills
Convulsions
Decreased LOC
Insomnia
Irritability
Lethargy
Jaundice
N/V
Sudden onset high fever
What are the behavior / neural symptoms of acute liver failure due to?
Release of ammonia
Which of the clinical manifestations of liver failure are caused by ammonia? are they each behavior related or neuro related?
Convulsions (neuro)
Decreased LOC (behavior)
Insomnia (behavior)
Irritability (behavior)
Lethargy (behavior)
What causes the ammonia released during acute liver failure?
Liver can’t break down protein so it builds up
By product of protein breakdown is ammonia
Liver can’t dissolve ammonia
What causes the N/V with acute liver failure?
Abdomen is overwhelmed by fluid shifting to it (ascites)
Complications of acute liver failure
Portal hypertension
Impaired metabolism
Impaired clotting
Impaired bile flow
Inability to detoxify drugs and toxins (including ammonia)
Impaired filtration of blood
Decreased storage of vitamins A, D, E, K, B complex
How does portal hypertension occur?
Happens with right sided heart failure, liver is backed up with too much blood
How does impaired clotting occur?
Liver produces, synthesizes, and breaks down parts of the clotting process
So pt is more likely to bleed out at some point
What causes the jaundice seen with liver failure?
Impaired bile flow
How much longer does it take for drugs to leave the system with acute liver failure?
Drugs stay around 2-3 times longer
What happens with impaired filtration of blood?
RBCs are broken apart (like they are with renal failure)
Pt will be overloaded with blood
(Will likely be giving them more blood when they don’t need it)
What will the patient’s vital signs look like in general?
They will show fluid volume overload (while the rest of their symptoms show low fluid volume)
Is the patient wet or dry on their vascular side?
Dry because the fluid is in the wrong place (even though it will look like the patient is wet)
Which diuretic is actually helpful for a patient with liver failure? Why won’t others help?
- Spironolactone b/c it pulls fluid off of the liver
- Others won’t help b/c where they pull fluid, there is no fluid for the med to pull off (it is all in the abdominal cavity).
Are patients with liver failure given IV fluids? Why or why not?
Yes, because even though their s/s will appear wet, but all the fluid is in their abdominal cavity, so they are actually dry everywhere else
General clinical manifestations of a patient with liver failure
Anorexia
Malnutrition
Weight loss
Weakness
Fatigue
Vitals showing fluid volume overload
pt will have a big trunk with skinny extremities
Neuro S/S of liver failure
Altered sensorium
*Asterixis (flapping tremors of hands)
Respiratory S/S of liver failure
*decreased ventilation (b/c fluid in gut)
Decreased perfusion
Hypoxemia
Hypoxia
Dyspnea
Cardiovascular s/s of liver failure
Hyperdynamic circulation
HTN then hypotension
Dysrhythmias
Edema
GI s/s of liver failure
Discomfort
Diarrhea
Nausea
Vomiting
Ascites
*Fetor hepaticus (“breath of the dead” very bad breath)
Varices
*Nursing care for fetor hepaticus
Providing oral care
(Will not cure, but is palliative)
Renal s/s of liver failure
Renal failure
Oliguria
*Azotemia (elevated bun and creatinine)
Dark foamy urine (smells like death, has crystals in it)
Endo s/s of liver failure
Increased aldosterone
Increased ADH
Increased glucocorticoids
Immune system s/s of liver failure
Leukopenia
Low-grade fever
Increased susceptibility to infection (immune system is shot)
*Skin s/s of liver failure
*Jaundice
*spider angiomas (bleeding under skin r/t clot)
Pruritus (due to bile frost)
Palmar erythema (bright red shiny palms)
Paper money skin (thin & delicate, tears & bruises easily)
Heme s/s of liver failure
Anemia
Impaired coagulation
Thrombocytopenia
Fluid/electrolyte s/s of liver failure
Hypokalemia (may be low or high)
Hyponatremia
Hypocalcemia
All related to fluid overload
Diagnostic testing results found with liver failure
*Elevated ammonia (can be decreased with intervention)
(The following cannot be helped with intervention)
Elevated AST, ALT
Elevated bilirubin
Prolonged PT & PTT (will always be elevated)
Decreased albumin (may/may not be checked)
Supportive therapy for pts with liver failure
Fluids
Prevent injury and bleeding (pts will be wild d/t ammonia)
Treat hypoglycemia
Why would a pt with liver failure have hypoglycemia?
Related to endocrine and the natural glucocorticoid production
The liver is failing and cannot process them
Pt will look like they’ve had long term steroids
Aggressive therapy for pts with liver failure
Liver transplant
Extracorporeal liver assist
What is an extracorporeal liver assist?
Like LVAD in cardiac pt
Difference: once you do this, pt cannot be on the transplant list
Pathophysiology of ascites from liver failure
Low albumin/obstruction of flow
Fluid in peritoneal cavity
Increased aldosterone (sodium and water retention)
Peripheral edema and further ascites (this is a late stage and will only see if pt is dying)
How would you assist with a paracentesis procedure?
Glass bottles to create negative vacuum (2-3)
Prep with betadine whichever side Dr tells you
Puncture will give temporary relief
Your job is to clamp tube and switch jars
(Dr will pull off more fluid than you think they should)
Cover bottles, label them, and take to lab
What is the major concern about pulling off too much liquid with paracentesis ?
Rebound hypotension
Why does the fluid pulled during a paracentesis need to be tested in the lab?
Checking for infection (*peritonitis)
S/S of peritonitis
Fever
Chills
WBC >11,000
Abdominal pain
Fluid would be more cloudy (b/c visible WBCs)
Site would be red, irritated, inflamed
Management of ascites
Bedrest (HOB semi fowlers)
Sodium and fluid restriction
Albumin
Diuretics
Potassium (small doses if value is low)
Paracentesis
LeVeen (peritoneovenous shunt)
Nutritional support
What nutritional support would a pt with ascites need?
Low protein b/c protein will increase ammonia levels
Low sodium
Fluid restriction
Consult dietary to help with malnourishment (ensure shakes, tube feeding)
What is procedural shunting?
- Device that can be put in abdomen to avoid paracentesis being done every day
- Valve opens when there is a lot of pressure in abdomen and fluid is shunted up into SVC
(The fluid does not leave the body, is just rerouted)
What is systemic encephalopathy?
Cerebral toxicity from elevated ammonia levels
Precipitating factors of systemic encephalopathy
F & E imbalances
Increased protein intake
Portal systemic shunts
Blood transfusion
GI bleed
Drugs
Stages of encephalopathy
Stage 1: tremors, slurred speech, impaired decision making
Stage 2: drowsiness, loss of sphincter control, asterixis
Stage 3: dramatic confusion, somnolent
Stage 4: profound coma, no response to pain
When is encephalopathy usuallly caught ?
Usually around end of stage 2, beginning of stage 3
Flapping tremors are usually first sign (asterixis)
Medical management of encephalopathy
Limit protein intake
Neomycin
Lactulose
Restrict toxic medications
Prevent GI bleeding
Dialysis
Sedation (Valium or Ativan)
What is neomycin used for in encephalopathy?
Tablets (PO) that treat overgrowth of bacteria in gut
Need to kill b/c byproduct of this bacteria (H. pylori) is ammonia
What is lactulose used for with encephalopathy?
(Lube-like texture) Traps ammonia so it can’t get back out into body system
Ammonia is pulled out via GI tract
What is the typical dose of lactulose?
20-45 mL 3-4 times per day
Usually a total of 30-60 mL, not more
What is something important to remember if a pt is being given sedation meds for encephalopathy?
Keep low because they’ll stay in the pt’s system longer
