Unit 3: Care Of The Hepatic Pt Flashcards
What are the functions of the liver?
Must know– think People Drink So Much
- Produces
- clotting factors, protiens & bile
- Detox
- Remove byproducts of medication
- Remove bacteria from blood
- In liver failure we will see a build up of bilirubin
- need smaller doses of medicaiton in liver failure
- Storage
- Glycogen vitamins & minerals
- Metabolize
- Nutrients from food
- if we can’t metabolize we will end up with a build up of ammonia which is bad because it can cross the BBB and cause altered LOC and increases risk of infection.
What is liver failure?
Inability of liver to function “normally” starts out as inflammation of the liver cells. It can be acute or chronic.
Chornic inflammation of the liver results in …
Scar tissue formation
Cirrhosis of the liver…
Damage is done.. prevention is key… cannot live without liver. This cant be fixed
What is the etiology of acute (less than 6 months) liver failure?
- Viruses
- Hep A,B,C
- Drug use, often coupled with alcohol use
- ** #1 cause acetaminophen overdose ** remember 4000mg is max dose for adult in a day
- TB meds
- Genetic diseases
- Wilson’s disease: Not common, when a pt has excess copper and liver cant metabolize. Pt will have brown ring around iris
- Ingestion of poisonous substances
- Mushrooms
What are some viruses that can cause acute liver failure?
Hep A, B, C
What are some drugs that can cause acute liver failure
- Tylenol which is the number one cause of acute liver failure in general
- TB meds
What genetic disease can cause acute liver failure?
Wilson’s disease
Ingestion of what poisonous substance can cause acute liver failure?
Mushrooms
What are early signs of acute liver failure?
- Fatigue
- Nausea, poor appetite
- Jaundice w/ or w/o pruritus
- r/t extra bilirubin
- Change in mentation (cognitive function)
- ** 1st sign this is gunna be what brings then into the ED. However it is often missed because friends believe they drank to much if caused by alcohol **
- Hematologic disorders
- Prolonged coagulation- covered in bruses
- Encephalopathy
What are some complications of liver acute liver failure?
- cerebral edema
- hypoglycemia
- renal failure
- sepsis
- metabolic acidosis
- MODS
What is are our priorities in a patient with acute liver failure?
Assessment for and treatment of
1. Fluid and electroloytes: specifically k+ due to its effect on the heart.
2. GI bleeding: r/t not eating and just drinking and the acid in stomach
3. Infection: r/t not being able to store vitamins
Whats one of the first assessments we want to do in a patient suspected of acute liver failure?
Neuro- we want a baseline
What is the etiology of cirrhosis of the liver?
- Longer than 6 months
- Any chronic liver disease
- Chronic alcoholism
- Chronic viral hepatitis
- Nonalcoholic fatty liver disease (NAFLD) that leads to nonalcoholic steatohepaptitis (NASH)
- Cardiac cirrhosis
- Biliary Cirrhosis
Where is the #1 place to assess for jaundice?
Scelera
What is important to know about ascitites and how it can affect the resp. system.
- As the belly grows it affects the pts breathing butting them at an increased risk of breathing issues.
- 1st thing we want to do sit them up and then apply oxygen if they are still having problems.
How do we treat ascites?
- Albumin & diuretic therapy
- must check k+ levels prior to admin 2.Paracentesis
- the removal of fluid from the abdominal cavity using a large bore needle.
- must check k+ levels prior to admin 2.Paracentesis
What do we need to know about acute liver failure and the use of tylenol?
- No tylenol will be given they will be switched to ibuprofen. Need to give something with it to coat the stomach like milk.
What are patients at risk for after having an abdominal paracentsis?
- Hypotension
- Fluid and electrolyte imbalance
What should we know about paracentesis prep and postop care?
- Usually done at bedside. If pt had adverse reaction to previous paracenteisis might be done in OR
- Have patient void immediately before
- ** hematuria ** #1 signs that the bladder was nicked during the procedure
- Monitor for hypovolemia and electrolyte imbalances THIS IS MOST IMPORTANT
- Monitor BP & HR
- Monitor dressing for bleeding/leakage.
How does LF impact the endocrine system?
Decreased metabolism of hormones
1. Increased testosterone
- In young women this will cause absent periods or elderly menopausal women to bleed.
2. Estrogen
- Increase in males will cause man boobs, loss of hair were there should be hair, testicular atrophy
3. Aldosterone
- Increase in water and sodium.
What hematologic disorders will we see as a s/s of liver failure?
- Thrombocytopenia
- ** if you have less than 20k platelets this is a medical emergency do NOT let that patient get out of bed**
- Leukopenia (LOW WBCs)
- r/t storage deficeincy in the liver
- Anemia
- This also results in low oxygen perfusion. transfuse at 7
- Coagulation disorders
- Patient will bruise easy
What do we want to teach our patinet with liver failure about?
- No contact sports
- Avoid large crowds
- Soft toothbrush
- Avoid asprin
- Electric razors
- Small gauge needs
- bleeding percautions- which includes alot of the above
What are neurological manifestations of LF & cirrhosis
- Hepatic encephalopathy
- Peripheral neuropathy
- Asterixis (hand flap)
What are gastrointestinal manifestations of LF & cirrhosis?
- Anorexia (r/t drinking not eating)
- dyspepsia (indegestion)
- N/V
- Change in bowel habits
- Dull abdominal pain
- Fector hepaticus
- Esophagea and gastric varices
- Gastritis
- Hematemesis (blood in voimit)
- Hemmorrhodial varices
What are some reporductive manifestations of LF & Cirrhosis?
- Amenorrhea
- Testicular Atrophy
- Gynecomastia (male)
- Impotence
Remember the inability to metabolize hormones
What are integumentary manifestations of LF and cirrhosis?
- Jundice
- Spider angioma
- Palmar erythema
- Purpura
- Petechiae
- Caput medusae(abdominal veins)
What are hematologic manifestations of LF & cirrhosis?>
- Anemia
-
Thrombocytopenia
3.** Leukopenia**
4.** Coagulation disorders** - Splenomegaly
What are some metabolic manifestations of LF & cirrhosis
- Hypokalemia
- Hyponatremia
- Hypoalbuminemia
What are some cardiovascular manifestations of LF & cirrhosis?
- Fluid rentnetion
- Peripheral edema
- Acities
What lab values are typically increased in LF?
- Ammonia (normal 10-80)
- AST/ALT
- Bilirubin (assess jaundice in eyes)
- Lactic acid (tells us if we have tissue hypoxia)
- PTT, PT, INR (r/t coagulation issues)
What lab levels are typically decreased in LF?
- Albumin (r/t not eating and body not making it)
- Glucose (cant store)
- K, Na, Mg
- Platelets (less than 20k is emergent)
- RBCs
- WBCs (increased risk of infection)
What lab levels tend to vary in LF?
- Alkaline phos
- Increased in cirrhosis and lower in LF
- Cr
- Hepatorenal faiure– liver failing can cause kidney to fale
- AST &ALT
- ast tells us if there is disease or damage
- ALT: tells us how much damage there is
What are some diagnositic studies for LF?
- Ultrasound
- Fibro Scan
- Upper Endoscopy
- Radioisotope liver scan
- Liver biopsy
What is our golden standard test to dx liver failure?
Liver biopsy
What are patients at risk for after a liver biopsy and what are some interventions to prevent it?
- Increased risk for bleeding & Infection & Paratinitis
- Pt will be on bed rest immediately after surgery and will stay this way until MD says otherwise (usually 5-6 hours)
- Pt will lay on right side this will hold pressure on the liver
How can we tell if a patient who just underwent a liver biospy is bleedng?
- Diaphoretic
- Pale
- Increased HR
- Low BP
What are medications used in LF?
- Antidotes
- Activated charcoal, N-acetylcystine
- Benzodiazepine
- Lorazepam, midazolam
- Good for alcoholics who are trying to quit
- Must have a neuro assessment so we know if LOC changes are a result of this med or not
- Anesthetic agent
- Propofol for the vented pt.
- Transfusions
- FFP & or Whole Blood
- Albumin & platelets
What are complications of Cirrhosis?
- Portal hypertension
- esophageal &/or gastric varices
- Splenomegaly
- Ascites
- Peripheral edema
- Hepatic encephalopathy
- Elevated ammonia levels
- hepatorenal syndrome
- Metabolic acidosis
- Sepsis
- Multiorgan failure
What do we need to know about Varices?
- Enlarged or swollen veins
- Caused by high pressures
3.Prevent bleeding- Beta blockers
- Stop bleeding
- Vasopressor (vasopressin)
- Egd for banding/sclerotherapy
- Esophageal varices banding
- Balloon tamponade therapy (stabilization)
What is the most life threatening complication of cirrohosis?
Varices r/t not being able to stop the bleeding
If a patient with a hx of liver failure comes into the ED vomiting bright red bleeding our first thought should be?
Varices- Immediately place large for IV
What medications are used for varices?
- Sandostatin
- Vasopressin
What do we need to know about the portacaval shunt in LF
Helps make a pathway to inferior venia cava if it cannot get thorugh the portal vein
look at this weekend
What is hepatic encephalopathy?
- Liver unable to convert increased ammonia
- Ammonia crosses the blood brain barrier
- Alteration of brain structure, function or both
Hepatic encephlaopathy leads too
- Neurotoxic effects of ammonia
- Abnormal transmission
- Astrocyte swelling
- Inflammatory cytokines
What should we know about stage 1 of HE (consciousness, intellect/behavior, neuro findings)
Consciousness: Mild lack of awareness
Intellect/behavior: Shortened attention span
Neurologic findings: Impaired addition or subtraction, mild asterixis or tremor
What should we know about stage 2 of HE? (consciousness, Intellect & behavior, neuro findings)
Consciousness: Lethargic
Intellect & behavior: disoriented, inappropriate behavior
Neuro findings: Obvious asterixis, slurred speech
What should we know about stage 3 of HE
(consciousness, intellect & behavior, Neuro findings)
Consciousness: Somnolent but arousable
Intellect & behavior: gross disorientation, bizarre behavior
Neuro findings: Muscular rigidity & clonus Hyperreflexia
What should we know about stage 4 HE? (consicousness, intellect & behavior, Neuro findings)
Consicousness: Coma
Intellect & Behavior: Coma
Neuro findings: Decerebrate posturing
How often shoudl we be doing neuro checks on a LF patient?
Every hour unless something major has happened then every 15
Decorticate is indication of…
Severe brain injury– problems with cervical spinal. tract or cerebral hemisphere
Flexor (c towards the C)
Decerebrate (extensor) is a sign of..
Lesion on the lower brain stem, problems with the midbrain or pons
very stiff
What are symptoms of HE
- confusion
- Lethargy that may progress to coma
- Inappropriate behavior or personality changes
- Asterixis- flappy hand!! KEY symptoms
- Problems with fine motor activities
- Musty or sweet breath odor
- seizures
- Hyperventilation
- supressed gag reflex
What would we anticipate doing if a patient has asterixis?
- Prepare to give lactalose to help poop out ammonia
- We want to see an increase in poop
What is a severe complication of HE
- Brain swelling
- increased ICP
- Brainsteam herniation
- Organ failure
How do we treat HE?
- Correct cause
- Lower ICP
- Minimal stim
- Oxygenation & ventilation
- Osmotic diuretics (mannitol)
- Mannitol is the the only diuretic that crosses the BBB
- Lower ammonia levels
- lactulose & rifaxmin therapy
- Prevent constipation
- we want to see 3-5 stools a day
- Refaxmin will decrease ammonia production by eliminating bacteria in the intestines (might be wrong)
What is the nursing managment for HE?
Acute care
1. Safety
2. loc
3. sensory & motor abnormalities
4. Fluid & electrolyte imbalances
5. Acid-base balance
6. Effects of tx measures
7. Minimize constipation
8. Control factors known to precipitate encephalopathy
What should we know about nutritional therapy in LF
- High in calories (3000cal/day)
- Protien supplement
- Low na- if ascities & edema
- Increase carbs
- Mod to low fat diets
- TPN
- Consult dietician
Is NAFLD reversible?
Yes with diet change
What is the TIPS procedure?
Transjugular intrahepatic portosystemic shung (TIPS) is a procedure that involves inserting a stent to connect the portal veins to blood vessels that have lower pressure. This relieves the pressure of the blood flowint through the diseased liver and can help stop bleeding and fluid back up.
It is the preferred treatment method because it is less invasive and easier.
What is the portacaval shunt?
A shunt that diverts part of your blood flow from the liver. This improves blood flow in your stomach, esophagus, and intestines. Portacaval sunting is more often done when transjugular intrahepatic portosystem shunging (TIPS) has not worked
What is portal HTN
Develops when resistance to portal blood flow increases. This resistance often occurs within the liver, as in cirrhosis. Portal hypertension is a complication caused by obstruction of the blood flow. In liver cirrhosis, increased intrahepatic vascular resistance to the portal flow elevates portal pressure and leads to portal htn
