Unit 1 Chapter 53 Cirrhosis

Question 1

What is Cirrhosis

Answer 1

progressive deterioration of liver condition and function and scarring of liver tissue and necrosis
- Causes increased resistance to portal blood flow.

Question 2

What is the #1 sign of Cirrhosis?

Answer 2

Jaundice: yellowing of eyes and skin, indication of liver failure

-occurs when diseased liver does not remove enough
bilirubin from the blood. Jaundice causes yellowing of skin and
icterus (yellowing of eyes), and a darkening of the urine.

Question 3

What is the function of the Liver?

Answer 3

• synthesis of bile salts
• synthesis of clotting factors
• vitamin storage (esp. fat soluble vitamins)
• detoxification of drugs & toxic substances * cleanses the blood
• converts glucose to glycogen & stores it
• forms urea to remove ammonia
  *first pass occurs in liver

Question 4

What occurs if there is a decrease in portal blood flow?

Answer 4

- no clotting factors: risk for hemmroage
-no storage of Fats or vitamins
-no cleaning of the blood
-no removal of ammonia: hepatic encaptholy , fector hepaticus: fruity musky breath due to build of waste products in blood

Question 5

Risk factors for Cirrhosis

Answer 5

• Hepatitis * Alcohol * Biliary obstruction

Question 6

What are the types of Cirrhosis

Answer 6

• Postnecrotic cirrhosis (caused by viral hepatitis [especially hepatitis C] and certain drugs or other toxins)
• Laennec’s or alcoholic cirrhosis (caused by chronic alcoholism)
• Biliary cirrhosis (also called cholestatic; caused by chronic biliary
  obstruction or autoimmune disease)

Question 7

s/s of cirrhosis

Answer 7

• Jaundice and icterus (yellow coloration of the eye sclerae)
• Dry skin
• Pruritus (itchy skin)
• Rashes
• Purpuric lesions, such as petechiae (round, pinpoint, red-purple hemorrhagic lesions) or ecchymoses (large purple, blue, or yellow bruises)
• Warm and bright red palms of the hands (palmar erythema)
• Vascular lesions with a red center and radiating branches, known as spider angiomas (also called telangiectases, spider nevi, or vascular spiders), on the nose, cheeks, upper thorax, and shoulders
• Ascites
  *Splenomegaly
• Peripheral dependent edema of the extremities and sacrum
• Vitamin deficiency (especially fat-soluble vitamins A, D, E, and K)
  When performing an assessment of the abdomen, keep in mind that hepatomegaly (liver enlargement) occurs in many cases of early cirrhosis. Splenomegaly is common in nonalcoholic causes of cirrhosis. As the liver deteriorates, it may become hard and small.
• Fetor hepaticus - musty or sweet breath odor. Fruity, musty smell caused by high levels of dimethyl sulphide * -Altered level of consciousness: due to increase of ammonia
  *Asterixis
  *Amenorrhea (no menstrual period) may occur in women, and
  *men may exhibit testicular atrophy, *gynecomastia (enlarged breasts), and impotence as a result of inactive hormones.

Question 8

Your patient with Cirrhosis is exhibiting flappy hands. What is the name of this clinical manifestation?
A. Asterexis
B. Fector Hepaticus
C.Ascites
D. Portal hyperion

Answer 8

A. Asterexis

Monitor for asterixis —a coarse tremor characterized by rapid, nonrhythmic extensions and flexions in the wrists and fingers (hand flapping).

Question 9

Diagnostics and labs of Cirrhosis

Answer 9

Liver values
* AST, ALT, LDH
* Increased bilirubin
* Decreased albumin
* Protein studies
* Pigment studies (direct and indirect bilirubin)
* Ammonia levels
* Fat levels
* Prothrombin time; Hgb, Hct
* Prolonged PT/INR
* Decreased platelets
* X-rays
* MRI
* Ultrasound
* Liver biopsy
* EGD
* ERCP

Question 10

Your patient with cirrhosis exhibits a odd musky breath. What is the manifestation of this?
A. kussmal
B. Fector hepaticus
C. diabetes keto acidosis
D. metabolic alkalosis

Answer 10

B. Fector hepaticus

Question 11

What types of medications should you avoid for a patient with cIRRHOSIS?

Answer 11

-Tylenol
- liver toxic medications

Question 12

Complications of Cirhosis

Answer 12

• Portal hypertension
• Ascites
  *esophageal varices
• Biliary obstruction
• Hepatic encephalopathy
  *Thrombocytopenia
  *DIC

Question 13

What is Thrombocytopenia?

Answer 13

reduction of platlet count
-risk for bleeeding

Question 14

Nursing intervention and considerations for Thrombocytopenia

Answer 14

*Monitor for petechia, ecchymosis,
bleeding of gums, occult or frank blood in stool, urine, or vomitus
* Institute bleeding precautions
* Minimize the risk of trauma

Question 15

Bleeding Precautions

Answer 15

Use a soft toothbrush and do not use dental picks.
Avoid rectal suppositories, enemas, and thermometers.
Avoid vaginal douches and tampons.
*Avoid straining with bowel movements.**
avoid constipation
Avoid forceful coughing, sneezing, or blowing of the nose.
Use caution with sharp objects.
Use an electric razor instead of razor blades.
no contact sports

Question 16

What is Portal Hypertension

Answer 16

Due to pressure building up in the
portal vein, pressure builds up in the liver and prior to the liver.Blood flow backs into the spleen, causing splenomegaly (spleen enlargement). Veins in the esophagus, stomach, intestines, abdomen, and rectum become dilated. Portal hypertension can result in ascites (excessive abdominal [peritoneal] fluid), esophageal varices (distended veins), prominent abdominal veins (caput medusae), and hemorrhoids.

Question 17

What is Esophageal varicies

Answer 17

distention of veins in esophageal wall due to portal hypertension

Question 18

Which of the following medications are used to prevent bleeding for a patient diagnosed with Esophageal varices?
A. atropine
B.Epinephrine
C. Propranolol
D. diltiazem

Answer 18

.C. Propranolol

A nonselective beta-blocking agent such as propranolol is usually prescribed to prevent bleeding. By decreasing heart rate and the hepatic venous pressure gradient, the chance of bleeding may be reduced.

Question 19

Patient teaching for Portal hypertension and Esophageal varicies
hint- push

Answer 19

Avoid straining with bowel movements.

avoid dry hard foods

However, any activity that increases abdominal pressure may increase the likelihood of a variceal bleed, including heavy lifting or vigorous physical exercise. In addition, chest trauma or dry, hard food in the esophagus can cause bleeding.

avoid doing the Valsa maneuver
avoid lifting heavy weights

Avoid forceful coughing, sneezing, or blowing of the nose.

no contact sports

Question 20

What is a sign and symprtom of Esophageal varices?

A. bright red emesis
B. gray stool
C. greenish blue bruise on the umbilicus
C. ecchymosis on the flank

Answer 20

A. bright red emesis

Monitor for bright red blood
vomit or tarry stools

Question 21

What is Splenomegaly, and what occurs during this?

Answer 21

inflammation of the spleen. Splenomegaly results from the backup of blood into the spleen.

The enlarged spleen destroys platelets, causing thrombocytopenia (low serum platelet count) and increased risk for bleeding.

Thrombocytopenia is often the first clinical sign that a patient has liver dysfunction.. Also puts the patient at high risk for infection

Monitor for issues with RBCs such
as symptoms of anemia

Question 22

What is DIC-Disseminated intravascular coagulation

Answer 22

is a rare but serious condition that causes abnormal blood clotting throughout the body’s blood vessels.
- Widespread clotting depletes the
clotting factors so client has circulating clots AND is at risk for bleeding

Question 23

What should you monitor for a patient with Disseminated intravascular coagulation?
A. Jaundice
B. hemorrhage
C. increased cranial pressure
D. bradycardia

Answer 23

B. hemorrhage

Question 24

What is ammonia?

Answer 24

The waste product(toxic) of broken-down proteins.

Question 25

What is Hepatic encephalopathy

Answer 25

Build up of ammonia levels in brain and
causes mental status deterioration
and dementia

Hepatic encephalopathy (also called portal-systemic encephalopathy [PSE] ) is a complex cognitive syndrome that results from liver failure and cirrhosis.

-A loss of brain function due to
failure to remove toxins from blood

Question 26

What is the signs and symptoms of Hepatic encephalopathy?

Answer 26

• Altered loss of consciousness
• Forgetfulness,
  *confusion
  *Disorientation
• Problems in movement with abnormal tendon reflex (Asterxis
• Changes in moods, personality changes
• Jaundice
• Asterixis (hand flapping)
  *seizures
  *muscle rigidity

Question 27

What can worses Hepatic encapalothpy

Answer 27

Factors that may contribute to or worsen hepatic encephalopathy in patients with cirrhosis include:
* High-protein diet
* Infection
* Hypovolemia (decreased fluid volume)
* Hypokalemia (decreased serum potassium)
* Constipation
* GI bleeding (causes a large protein load in the intestines)
* Drugs (e.g., hypnotics, opioids, sedatives, analgesics, diuretics,
illicit drugs)

Question 28

Which of the following medications is a treatment for Hepatic Encalophy?
A. furosemide
B. insulin
C. magnesium
D. lactulose

Answer 28

D. lactulose

Antibiotics – to kill ammonia producing bacteria (Neomycin and
Metronidazole)

** * Cathartics – to inhibit ammonia production in the intestine and
accelerate defecation (Lactulose)**

Question 29

What is the action of Lactulose

Answer 29

it is a laxative that removes the build up of ammonia from the blood and may likely result in excessive soft stools

-This drug is a viscous, sticky, sweet-tasting liquid that is given either orally or by NG tube. The purpose is to obtain a laxative effect.

-monitor for fluid and electrolyte imbalances

Question 30

Mechanism of action of Lactulose

Answer 30

The purpose is to obtain a laxative effect..

Cleansing the bowels may rid the intestinal tract of the toxins that contribute to encephalopathy.

** It works by increasing osmotic pressure to draw fluid into the colon and prevents the absorption of ammonia in the colon.**

Question 31

Nursing Consideration for Lactulose

Answer 31

Observe for response to lactulose. The patient may report intestinal bloating and cramping. Serum ammonia levels may be monitored but do not always correlate with symptoms.

Monitor for Hypokalemia and dehydration that may result from excessive stools.

Remind assistive personnel to help the patient with skin care if needed to prevent breakdown caused by excessive stools.

increase patient fluid intake

Question 32

Which of the following would warrant immediate attention after administering lactulose?
A. soft stools
B. dehydration
C. serum potassium 2.0
D. thirst

Answer 32

C. serum potassium 2.0

Question 33

Expected amounts of stools after administration of lactulose per day

Answer 33

The desired effect of the drug is production of two or three soft stools per day and a decrease in patient confusion caused by this complication.

Question 34

Patient teaching for hepatic Encalophy

Answer 34

• Take medications as prescribed
  Drink lots of fluids**
  ** Do not include lots of meats in your diet
• Eat fiber-rich foods to prevent constipation
  *Do not consume alcohol

Question 35

What type of diet should NOT a patient be on when diagnosed with hepatic encalapothy?

A. high protein diet
B. low carb diet
C. small frequent meals
D. 1-3 g sodium diet

Answer 35

A. high protein diet

Question 36

Which of the following signs and symptoms of Hepatic encaph is indicative of the condition worsening?
A. aggressive behavior
B. Asterexis
C. disorientation
D. confusion

Answer 36

Frequently assess for changes in level of consciousness and orientation. Check for asterixis and fetor hepaticus. These signs suggest worsening encephalopathy.

**Thiamine supplements and benzodiazepines may be needed if the patient is at risk for alcohol withdrawal.

Question 37

What is Ascities

Answer 37

• Due to pressure building up in the
  portal vein, pressure builds up in the abdominal cavity
  -build up of fluid in the abdominal cavity

causes, dyspnea
Fluid leaks from organs to spaces around
organs in abdominal cavity. Causes
discomfort, difficulty breathing and
anorexia.

Question 38

Complication of Acities

Answer 38

Spontaneous Bacterial Peritonitis
* Spontaneous bacterial peritonitis is
* Specifically an infection of ascitic
fluid.
the development of bacterial infection in peritoneum.
Nursing Considerations

Question 39

What is the procedure of choice for Ascities?
A. Hemothorax
B. Thoracentesis
C. Paracentesis
D. Cardiac Catherization

Answer 39

C. Paracentesis

Question 40

What is Paracentesis

Answer 40

A paracentesis is an invasive procedure performed to remove abdominal fluid.

The procedure is performed at the bedside, in an interventional radiology department, or in an ambulatory care setting.

-health care provider inserts a trocar catheter or drain into the abdomen to remove the ascitic fluid from the peritoneal cavity. This procedure is done using ultrasound for added safety

Question 41

Preop care for paracentesis

Answer 41

-GET CONSENT
-HAVE PATIENT EMPTY BLADDER
-MEASURE ABDOMINAL GIRTH AND WEIGHT
-TAKE VITAL SIGNS

Question 42

The Patient Having a Paracentesis

Answer 42

• Explain the procedure and answer patient questions.
• Obtain vital signs, including weight, before the procedure.
  Ask the patient to void before the procedure to prevent injury to the bladder!
  Position the patient in bed with the head of the bed elevated.
• Monitor vital signs per protocol or primary health care provider request during the procedure.
• Measure the drainage and record accurately.
  Document the characteristics of the collected fluid.
• Label and send the fluid for laboratory analysis; document in the patient health record that specimens were sent.
  After the catheter is removed, apply a dressing to the site; assess for leakage.
  Maintain bedrest per protocol.
• Take vital signs and weigh the patient after the paracentesis; document in the patient record weight both before and after paracentesis. (The patient should experience a weight loss due to fluid removal.)

Question 43

What is the therapuetic effect of a paracentesis?
A. increased abdominal girth
B.weight loss
C. dyspnea
D. weight gain

Answer 43

B.weight loss

Question 44

What is rhe proper positioning for a patient during Paracentesis?
A.prone
B.supine
C. sims
D. head of bed elevated

Answer 44

D. head of bed elevated

Question 45

Post op Care Paracentesis

Answer 45

-MEASURE ABDOMINAL GIRTH AND WEIGHT
-TAKE VITAL SIGNS
-monitor for hypovolemia
-monitor for hypotension

Question 46

The nurse is caring for a client who has cirrhosis of the liver. What nursing action is
appropriate to help control ascites?
a. Monitor intake and output.
b. Provide a low-sodium diet.
c. Increase oral fluid intake.
d. Weigh the patient daily.

Answer 46

ANS: B
A low-sodium diet is one means of controlling abdominal fluid collection. Monitoring intake
and output does not control fluid accumulation, nor does weighing the client. These
interventions merely assess or monitor the situation. Increasing fluid intake would not be
helpful.

Question 47

The nurse is caring for a client with hepatic portal-systemic encephalopathy (PSE). The client
is thin and cachectic, and the family expresses distress that the patient is receiving little
dietary protein. How would the nurse respond?
a. <A low-protein diet will help the liver rest and will restore liver function.=
b. <Less protein in the diet will help prevent confusion associated with liver failure.=
c. <Increasing dietary protein will help the patient gain weight and muscle mass.=
d. <Low dietary protein is needed to prevent fluid from leaking into the abdomen.=

Answer 47

A low-protein diet is prescribed when serum ammonia levels increase and/or the client shows
signs of PSE. A low-protein diet helps reduce excessive breakdown of protein into ammonia
by intestinal bacteria. Encephalopathy is caused by excess ammonia. A low-protein diet has
no impact on restoring liver function. Increasing the patient9s dietary protein will cause
complications of liver failure and would not be suggested. Increased intravascular protein will
help prevent ascites, but clients with liver failure are not able to effectively synthesize dietary
protein

Question 48

The nurse is caring for a client who is prescribed lactulose. The client states, <I do not want to
take this medication because it causes diarrhea. How would the nurse respond?
a. <Diarrhea is expected; that9s how your body gets rid of ammonia.=
b. <You may take antidiarrheal medication to prevent loose stools.=
c. <Do not take any more of the medication until your stools firm up.=
d. <We will need to send a stool specimen to the laboratory as soon as possible.

Answer 48

ANS: A
The purpose of administering lactulose to this patient is to help ammonia leave the circulatory
system through the colon. Lactulose draws water into the bowel with its high osmotic
gradient, thereby producing a laxative effect and subsequently evacuating ammonia from the
bowel. The patient must understand that this is an expected and therapeutic effect for him or
her to remain compliant. The nurse would not suggest administering anything that would
decrease the excretion of ammonia or holding the medication. There is no need to send a stool
specimen to the laboratory because diarrhea is the therapeutic response to this medication.

Question 49

The nurse is caring for a client who is scheduled for a paracentesis. Which action is
appropriate for the nurse to take?
a. Have the client sign the informed consent form.
b. Get the patient into a chair before the procedure.
c. Help the client lie flat in bed on the right side.
d. Assist the client to void before the procedure.

Answer 49

ANS: D
For safety, the patient would void just before a paracentesis to prevent bladder damage to the
procedure. The primary health care provider would have the client sign the consent form. The nurses scope of practice is to witness the signature of the patient.8*The
proper position for a paracentesis is sitting upright in bed or, alternatively, sitting on the side
of the bed and leaning over the bedside table.