Liver Problems and Care, Ch. 53 Flashcards
Priority Concepts for Liver Disorders
Impaired Cellular Reg. & Infection
Interrelated Concepts for Liver Disorders
Fluid and electrolyte balance
Inflammation
Pain
Nutrition
-Cirrhosis COMPLICATION, when fragile, thin-walled esophageal veins become distended and tortuous from ^ pressure (r/t portal hypertension)
-Bleeding=Lethal Emergency w/ RISK of shock from hypovolemia
-Sites: distal esophagus, rectum, stomach
-Treatment: Dec. Prothrombin time (LAB); AVOID NSAIDs and blood thinners
Esophageal Varices (EV)
-Complication of ESLF and Cirrhosis, complex cognitive syndrome
-SX: mood changes, LOC alt (respond only to pain), Sleep problems, Speech problems, Neuromuscular problems (ex. Asterixis: hand flapping)
-LAB: ^Serum Ammonia (bi-product of protein breakdown), ^bilirubin
-Treatment: LACTULOSE=laxative to dec. ammonia levels; Reversable if detected early
Hepatic Encephalopathy
a.k.a. Portal-Systemic Encephalopathy
Widespread inflammation and infection of liver cells
- ^ RISK: liver cancer or Cirrhosis, Chronic Viral Infection
- MUST REPORT case to health dept. and then CDC
- Types: A,B,C,D,E
Hepatitis
Liver enlargement, Palpatable, is common in Early Cirrhosis
Hepatomegaly
A rapidly growing liver DZ that is associated with obesity, DM type 2, and metabolic syndrome (aka insulin resistant syndrome; a group of conditions that together raise risk of Coronary Heart DZ, DM, Stroke, and other serious health problems)
Nonalcoholic Fatty Liver DZ (NAFLD)
An invasive PROCEDURE performed to ABD fluid in pt. who have massive ascites; Fluid Volume INTERVENTION
Paracentesis
Round, pinpoint, red-purple hemorrhagic lesions.
Petechiae
Major COMPLICATION of Cirrhosis.
Persistent ^ pressure in hepatic portal vein (>5mm Hg)
-Blood flow resistance or obstruction seeks alt. venous channels around the high-pressure area = Blood backflow into the spleen causing Splenomegaly
-results in ascites/esophageal varices (distended veins)
Portal Hypertension
Interventional radiologic PROCEDURE performed for pt. who has not responded to other modalities to MANAGE hemorrhage or long-term ascites
-Insert a stent (tube) to connect the portal veins to adjust blood vessels w/ low pressure
-dec. pressure through liver can stop bleeding and fluid back up
Transjugular Intrahepatic Portal-system Shunt (TIPS)
A DZ characterized by widespread fibrotic (scarred) bands of connective tissue that change the liver’s A&P
Cirrhosis
-Postnecrotic (Viral Hepatitis, Toxins)
-Laennec’s (Alcoholic)
-Biliary (Autoimmune disorder or chronic obstruction
Types of Cirrhosis
- Portal Hypertension
- Ascites/ Esophageal Varices
- Biliary Obstruction
- Hepatic Encephalopathy
Complications of Cirrhosis
COMPLICATION of Cirrhosis
-Obstruction of bile duct, either genetic, gallbladder DZ, or autoimmune DZ
-Prevents absorption of fat-soluble vit. (vit. A,D,E,K) = w/out vit. K clotting factors are dec. = possible bleeding and bruising
-S/SX: Jaundice r/t ^ bilirubin (body unable to excrete); Pruritus
Biliary Obstruction
a.k.a. Primary Biliary Cirrhosis (only r/t to autoimmune DZ)
Collection of free fluid w/in the peritoneal cavity caused by ^ hydrostatic pressure from Portal Hypertension, Painful and uncomfortable
Ascites
-Fatigue, weight changes, GI sx, Dyspnea (ascites)
-ABD assess: pain over liver or ABD, distended ABD; Ascites
-Jaundice and Icterus (yellow sclerae)
-Dry skin; Pruritus; Rashes
-Petechiae; Ecchymoses (bruises)
-Palmer Erythema (warm and red palms)
- Vascular lesions w/ red center and radiating branches (spider veins) on nose, cheeks, upper thorax, and shoulders
- Peripheral dependent edema
- Vit. def. esp. fat-soluble (A,D,E,K)
Cirrhosis ASSESSMENT: S/SX of Cirrhosis
Alcohol withdrawal: if pt. is dependent
Sleep, Behavioral changes, moods
Cirrhosis ASSESSMENT: Psychosocial
-AST, ALT, LDH: ^ r/t inflamation
-Alkaline Phosphatase: ^ = Obstructive jaundice or hepatic metastasis
- Serum Bilirubin: ^ =jaundice & Pruritus
-Serum Albumin: ^ = Severe Liver dz
- PT/INR: Clotting factor, Long time frame = dec. clotting fxn
-CBC: (RBC, H&H, Platelets) = hemorrhage
- Ammonia Level: ^ = altered mental state
Cirrhosis ASSESSMENT: LABS
PRIORITY PROBLEMS
-Fluid overload (ascites)
-Potential for Hemorrhage r/t Varices
-Acute Confusion r/t ^ammonia levels and/or alcohol withdrawal
-Pruritus r/t ^ Serum Bilirubin and Jaundice
ANALYZE CUES: Cirrhosis
- Managing Fluid Volume
- Preventing or Managing Hemorrhage
- Preventing or managing Confusion
- Managing Pruritis
PLANNING: Cirrhosis
-PREVENT additional accumulation & dec. existing fluid (RESTRICT Na (b/c Na ^ fluid retention and causes Polydipsia; and fluid intake)
- ^ HOB to min. SOA
-PROVIDE vit. supplements (B,A,C,K, folic acid, thiamine)
**- MONITOR Diuretics = I/O’s, edema, resp., electrolytes
-pt. wt. & measure girth
-Paracentesis = dec. resp. distress & ABD pain
INTERVENTIONS: Cirrhosis Fluid Volume
-Explain PROCEDURE
-ASK pt. to void before to avoid bladder damage
- MEASURE drainage and record characteristics: NEVER drain >2000mL = hypovolemic shock
- Send fluid to LAB ANALYSIS
- REMOVE cath. and dress; ASSESS for leakage
-WT. pt. before and after procedure
-MONITOR for SPONTANEOUS BACTERIAL PARATENITIS (fluid shift into bowels; analysis LAB Leukocyte count >250 PMN)
Pt. Safety and Care: Paracentesis
-Screened for Esophageal Varices (ENDO) before they bleed
- Bleeding Varices = EMERGENCY (sx: hematemesis, melena); RISK: Hypovolemic Shock = dramatic dec. BP
**- Propranolol = to dec. HR and hepatic venous pressure to reduce bleeding
- Endoscopic Variceal Ligation (EVL), Endoscopic Sclerotherapy (EST)
- Balloon Treatments, TIPS, Stents, Stents, Shunts
- MONITOR: H&H, PT/INR, BP, Resp.; ADMIN blood products
INTERVENTIONS: Cirrhosis Hemorrhage
-Slow or stop accumulation of ammonia
-DIETARY LIMITS = limit proteins, fatty foods, simple carbs
**- Lactulose = Laxitive; dec. intestinal production/ absorption of ammonia; diarrhea gets rid of excess and converts the rest to nonabsorbable NH4+
-OBSERVE: LOC, orientation, drug rxn, ammonia lvls, dehydration, electrolytes, & skin (LABS: ordered q12hr or q24hr)
-CHECK for asterixis = worsening of encephalopathy
INTERVENTION: Cirrhosis Confusion
- Risk: Crowds, poor sanitation/ no hand washing
- Transmission: Fecal/Oral, contaminated food, uncooked shellfish, water/ milk, poorly washed utensils; SX = Diarrhea
- Infectious: 2-3 weeks, curable, can resolve w/out treatment; TEST: HAV antibodies present
- Prevention: STRICT/ FREQUENT handwashing, stool and needle precautions, water treatments, AVOID contaminated food or water, Hep A VACCINE
Hepatitis A
-Risk: IV drug users, HC workers, Long-term Hemodialysis
- Transmission: blood/body fluid contact while infected
- Incubation: sx last 28-180 days ( some ppl are aSX), can resolve w/out treatment
- Testing: Blood test = presence of Hep B antibodies (pt. is infectious)
- Prevention: STRICT handwashing, Blood Screening, Testing all pregnancies, HEP B VACCINE
Hepatitis B
- Leading cause of ESLD in world; Most common bloodborne infection in US
- Risk: IV drug users (common), baby boomers, frequent transfusions
- Transmission: Blood to Blood, blood products and blood transfusions done before 1992
- Incubation: 2-6wks, most aSX and aren’t DX for months or years, CURABLE; Testing: HCV antibodies
- Prevention: NO VACCINE, strict handwashing, blood screening, needle precautions
Hepatitis C
Common among Mediterranean/ Middle East Areas
- Risk: drug users, hemodialysis, frequent blood transfusions
- Transmission: Blood to Blood
- Incubation: 2-26wks; Testing: Hep D antigen
- Prevention: HEP B VACCINE = HDV depends on HBV to replicate
Hepatitis D
Waterborne infection assoc. w/ epidemics in countries (fecal contamination of food and water), Travelers
- Incubation: 2-9wks
- Prevention: STRICT handwashing
Hepatitis E
- Fulminant Hepatitis = failure of liver cell regeneration, necrosis, severe acute and often FATAL form of hepatitis
- Chronic Hepatitis = >6mnths, results from Hep B&C; can lead to Cirrhosis and liver cancer
Hepatitis Complications
- Proper handwashing (esp. after handling shellfish)
- AVOID contaminated food or water
special Recommendations for HAV
Physical S/SX
-ABD pain, Icterus, Jaundice
- Palpation for tenderness, skin inspection
- depression, myalgia (muscle aches/ pain), renal issues, Cognitive Impairment, Heart DZ
Psychosocial
-Emotion of chronic illness, fatigue, social stigma, embarrassment, family afraid of getting DZ
ASSESSMENT: Hepatitis
-Wt loss r/t complications assoc. w/ liver inflammation
- Fatigue r/t Dec. Metabolic energy production and Infection
ANALYZE CUES/ HYPOTHESES: Hepatitis
PRIORITY: Rest the liver, promote regeneration, ^ immunity, prevent complications
- Diet: ^carbs and calories/ dec. Fats; small frequent meals; vit. supplements
- Manage fatigue: ^ ADL participation
**- Antiviral meds (“-vir): use sparingly to not overwork liver, Monitor Kidney fxn, pt. now a fall risk
-PREVENT SPREAD OF INFECTION
PLANNING/ IMPLEMENTATION: Hepatitis
++-Tenofovir, Adefovir: monitor kidney function, Tenofovir ( teach pt risk of falls, bc causes bone demineralization)
++-Lamivudine: Monitor Kidney function, teach pt do not Dc without notifying MD bc can cause flare up
++-Entecavir: monitor kidney function, teach pt to avoid ETOH to prevent serious interactions!
Hepatitis B ANTIVIRAL MEDS “-vir”
All can weaken immune system and cause pt to be susceptible to infections
++-Grazoprevir, Simprevir, partaprevir = Monitor labs, common reactions like HA, itching, nausea
++-Elbasvir: can cause Hep B to reactivate if pt had it previously
++-Ledipasvir: cannot be taken with amiodarone (Cardiac Med)
Hepatitis C ANTIVIRAL MEDS
-Maintain an adequate nutritional status for body requirements.
-Report increasing energy levels as the liver rests.
OUTCOMES/ EVALUATION: Hepatitis
- Home Care Management – assess living situations (caregivers, bathroom, access)
- Self-Management Education – on diets, drugs, ETOH abstinence, home drains and care, bleeding education, s/s of encephalopathy
++-AVOID all OTC meds esp. NSAIDs, Acetaminophen - Health Care Resources – home health nurses, group therapies, social & community supports, hospice services
Cirrhosis: CARE for Coordination
