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Critical Care > Hepatic Failure > Flashcards

Hepatic Failure Flashcards

1
Q

Etiology of acute liver failure

A

Hepatitis (#1 priority, usually r/t alcohol)
Inflammation
Hepatotoxic drugs
Decreased profusion

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2
Q

Etiology of chronic liver failure

A

Cirrhosis
Fatty liver disease (lowest priority b/c it’s rare)

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3
Q

Clinical manifestations of acute liver failure

A

Chills
Convulsions
Decreased LOC
Insomnia
Irritability
Lethargy
Jaundice
N/V
Sudden onset high fever

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4
Q

What are the behavior / neural symptoms of acute liver failure due to?

A

Release of ammonia

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5
Q

Which of the clinical manifestations of liver failure are caused by ammonia? are they each behavior related or neuro related?

A

Convulsions (neuro)
Decreased LOC (behavior)
Insomnia (behavior)
Irritability (behavior)
Lethargy (behavior)

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6
Q

What causes the ammonia released during acute liver failure?

A

Liver can’t break down protein so it builds up
By product of protein breakdown is ammonia
Liver can’t dissolve ammonia

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7
Q

What causes the N/V with acute liver failure?

A

Abdomen is overwhelmed by fluid shifting to it (ascites)

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8
Q

Complications of acute liver failure

A

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

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9
Q

How does portal hypertension occur?

A

Happens with right sided heart failure, liver is backed up with too much blood

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10
Q

How does impaired clotting occur?

A

Liver produces, synthesizes, and breaks down parts of the clotting process
So pt is more likely to bleed out at some point

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11
Q

What causes the jaundice seen with liver failure?

A

Impaired bile flow

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12
Q

How much longer does it take for drugs to leave the system with acute liver failure?

A

Drugs stay around 2-3 times longer

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13
Q

What happens with impaired filtration of blood?

A

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)

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14
Q

What will the patient’s vital signs look like in general?

A

They will show fluid volume overload (while the rest of their symptoms show low fluid volume)

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15
Q

Is the patient wet or dry on their vascular side?

A

Dry because the fluid is in the wrong place (even though it will look like the patient is wet)

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16
Q

Which diuretic is actually helpful for a patient with liver failure? Why won’t others help?

A
  • 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).
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17
Q

Are patients with liver failure given IV fluids? Why or why not?

A

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

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18
Q

General clinical manifestations of a patient with liver failure

A

Anorexia
Malnutrition
Weight loss
Weakness
Fatigue
Vitals showing fluid volume overload
pt will have a big trunk with skinny extremities

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19
Q

Neuro S/S of liver failure

A

Altered sensorium
*Asterixis (flapping tremors of hands)

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20
Q

Respiratory S/S of liver failure

A

*decreased ventilation (b/c fluid in gut)
Decreased perfusion
Hypoxemia
Hypoxia
Dyspnea

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21
Q

Cardiovascular s/s of liver failure

A

Hyperdynamic circulation
HTN then hypotension
Dysrhythmias
Edema

22
Q

GI s/s of liver failure

A

Discomfort
Diarrhea
Nausea
Vomiting
Ascites
*Fetor hepaticus (“breath of the dead” very bad breath)
Varices

23
Q

*Nursing care for fetor hepaticus

A

Providing oral care
(Will not cure, but is palliative)

24
Q

Renal s/s of liver failure

A

Renal failure
Oliguria
*Azotemia (elevated bun and creatinine)
Dark foamy urine (smells like death, has crystals in it)

25
Q

Endo s/s of liver failure

A

Increased aldosterone
Increased ADH
Increased glucocorticoids

26
Q

Immune system s/s of liver failure

A

Leukopenia
Low-grade fever
Increased susceptibility to infection (immune system is shot)

27
Q

*Skin s/s of liver failure

A

*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)

28
Q

Heme s/s of liver failure

A

Anemia
Impaired coagulation
Thrombocytopenia

29
Q

Fluid/electrolyte s/s of liver failure

A

Hypokalemia (may be low or high)
Hyponatremia
Hypocalcemia

All related to fluid overload

30
Q

Diagnostic testing results found with liver failure

A

*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)

31
Q

Supportive therapy for pts with liver failure

A

Fluids
Prevent injury and bleeding (pts will be wild d/t ammonia)
Treat hypoglycemia

32
Q

Why would a pt with liver failure have hypoglycemia?

A

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

33
Q

Aggressive therapy for pts with liver failure

A

Liver transplant
Extracorporeal liver assist

34
Q

What is an extracorporeal liver assist?

A

Like LVAD in cardiac pt
Difference: once you do this, pt cannot be on the transplant list

35
Q

Pathophysiology of ascites from liver failure

A

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)

36
Q

How would you assist with a paracentesis procedure?

A

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

37
Q

What is the major concern about pulling off too much liquid with paracentesis ?

A

Rebound hypotension

38
Q

Why does the fluid pulled during a paracentesis need to be tested in the lab?

A

Checking for infection (*peritonitis)

39
Q

S/S of peritonitis

A

Fever
Chills
WBC >11,000
Abdominal pain
Fluid would be more cloudy (b/c visible WBCs)
Site would be red, irritated, inflamed

40
Q

Management of ascites

A

Bedrest (HOB semi fowlers)
Sodium and fluid restriction
Albumin
Diuretics
Potassium (small doses if value is low)
Paracentesis
LeVeen (peritoneovenous shunt)
Nutritional support

41
Q

What nutritional support would a pt with ascites need?

A

Low protein b/c protein will increase ammonia levels
Low sodium
Fluid restriction
Consult dietary to help with malnourishment (ensure shakes, tube feeding)

42
Q

What is procedural shunting?

A
  • 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)
43
Q

What is systemic encephalopathy?

A

Cerebral toxicity from elevated ammonia levels

44
Q

Precipitating factors of systemic encephalopathy

A

F & E imbalances
Increased protein intake
Portal systemic shunts
Blood transfusion
GI bleed
Drugs

45
Q

Stages of encephalopathy

A

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

46
Q

When is encephalopathy usuallly caught ?

A

Usually around end of stage 2, beginning of stage 3
Flapping tremors are usually first sign (asterixis)

47
Q

Medical management of encephalopathy

A

Limit protein intake
Neomycin
Lactulose
Restrict toxic medications
Prevent GI bleeding
Dialysis
Sedation (Valium or Ativan)

48
Q

What is neomycin used for in encephalopathy?

A

Tablets (PO) that treat overgrowth of bacteria in gut
Need to kill b/c byproduct of this bacteria (H. pylori) is ammonia

49
Q

What is lactulose used for with encephalopathy?

A

(Lube-like texture) Traps ammonia so it can’t get back out into body system
Ammonia is pulled out via GI tract

50
Q

What is the typical dose of lactulose?

A

20-45 mL 3-4 times per day
Usually a total of 30-60 mL, not more

51
Q

What is something important to remember if a pt is being given sedation meds for encephalopathy?

A

Keep low because they’ll stay in the pt’s system longer

Critical Care (35 decks)

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