Hepatic Failure Flashcards by Katy Peterson

Etiology of acute liver failure

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

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Etiology of chronic liver failure

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

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Clinical manifestations of acute liver failure

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

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

Release of ammonia

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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)

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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

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What causes the N/V with acute liver failure?

Abdomen is overwhelmed by fluid shifting to it (ascites)

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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

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How does portal hypertension occur?

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

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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

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What causes the jaundice seen with liver failure?

Impaired bile flow

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

Drugs stay around 2-3 times longer

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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)

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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)

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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)

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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).

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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

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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

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Neuro S/S of liver failure

Altered sensorium
*Asterixis (flapping tremors of hands)

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Respiratory S/S of liver failure

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

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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