Unit 6 Hepatic Diseases Flashcards
What are the functions of the liver?
CHO (glucose
Lipids
In charge (“bouncer” it detoxes Rx, etc)
Protein (breaks into amino acids, ammonia levels increased if not functioning properly)
Bile (half to 1 liter a day, aids in digestion)
Albumin (helps with oncotic pressure, w/o it you get edema, ascites)
Clotting (liver will have increased INR with liver dysfunction)
Kupffer cells (WBC’s specific to liver, they prevent infection)
If you CLIP it, it will grow BACK!
What are the four liver diseases and what are they?
Cirrhosis - scarring of the liver tissue, hepatocyctes die
Non Alcoholic Fatty Liver Disease (NAFLD) - fatty liver from being obese, diabetic
Cholecystitis - Gallstones
Pancreatitis - Inflamed pancreas
The latter 3 can result in Cirrhosis
What is bilirubin from?
RBC breakdown
What are the diagnostic lab testing/results of liver disease?
Liver Biopsy:
- Afterwards lay PT onto right side to prevent liver contents from leaking into body cavity
- Assess PT, if elevated BP after procedure notify MD
Clotting:
-Prolonged bleeding, thrombocytopenia, high INR
Chemistry:
- Low glucose
- High ammonia (should have 0)
- High osmolarity
- High bilirubin
CBC:
-Anemia
Liver function tests (LFT):
-Elevated AST,ALT, (normal is 35-45, over 45 is an issue)
What are imaging tests available to liver diseases?
Upper GI study (requires consent, IV sedation)
Lower GI study (requires consent, IV sedation, enemas to clean before procedure)
CT
MRI
Positron emission tomography (PET)
In liver failure what kind of bilirubin will be elevated?
Elevated indirect bilirubin
After upper imaging studies, what should you test for before eating?
Gag reflex
What causes Cirrhosis?
ETOH consumption
Hepatitis B and C (viral infections)
Repeated bouts of HF
Genetics
NASH (non-alcoholic steatohepatitis, NAFLD is the umbrella, this is more severe form)
Bile duct disease
Describe Alcoholic Liver Cirrhosis.
ETOH directly toxic to liver cells
Alcoholic liver:
- fatty liver
- has tissue changes
- Inflammation
Can be compensated (reversible) or
Uncompensated (irreversible, has scar tissue)
What are the early (compensated) signs and symptoms of Cirrhosis?
- Abdominal pain
- Palmar erythema (red hands)
- Spider vains (vascular spiders)
- Unexplained epistaxis (nosebleeds)
- Splenomegaly
- Firm, enlarged liver
What are the late (uncompensated) signs and symptoms of Cirrhosis? Explain them.
Jaundice (from high bilirubin levels)
Ascites (fluid in the peritoneal cavity, abdomen swelling)
Caput Medusa (crazy medusa abdominal veins)
Gynecomastia (large breast tissue on men, cirrhosis doesn’t allow liver to detoxify estrogen)
Portal hypertension (portal vein becomes narrow, increase BP, causes esophageal varicies, and more!)
Esophageal Varicies (hemorrhoids on esophagus)
What are two ways to assess/test for ascites?
Fluid thrill abdominal exam:
- Takes two ppl
- Palm of hand on abdomen and flick finger
Ascites shifting dullness:
- fluid = dullness on percussion
- fluid shifts when changing positions
What is the management of Ascites?
Medications:
-diuretics; [Lasix] furosemide (20-80mg dose) check K+ and BP before giving
Dietary modifications:
-Sodium restriction
Paracentesis:
-needle into area, pulls out fluid
(hang albumin to restore what was lost)
Procedures to control potral HTN:
- TIPS
- Splenorenal shunt
Describe TIPS.
Trans-Jugular Intra-Hepatic Portal Shunt
Through jugular vein though IVC and stick a stent into portal vein to lower portal hypertension and decrease narrowing and back-up which will prevent esophageal varicies.
Describe Splenorenal shunt.
Diverts fluid spleen into kidney
Sx of splenic vein that’s removed and put onto the left renal vein to decrease the amount of blood flow to the portal vein so there’s less back-up.
What is the collaborative management of Esophageal Varicies?
IV fluids
Blood Products
vasopressin drip (to constrict veins in esophagus
sandostatin (octreotide) drip (anti-diuretic hormone to retain fluids)
Endoscopy with Sclerosing agents of bands
Sengstaken-Blakemore tube (balloon that goes down esophagus to compress veins; last attempt to stop bleeding)
What is spontaneous bacterial peritonitis, describe the symptoms, and how is it treated?
Issue from ascites:
- Bacteria from the gut that reaches the ascitic fluid via lymphatics causing inflammation
- Fever, chills, abdominal pain, tenderness
- Fluid from paracentesis will show increased WBC in fluid and culture will show bacterial growth
- Treated with IV antibiotics
Due to the coagulation defects from liver disease, especially cirrhosis, what do you want to assess? What is decreased?
- Decreased absorption of fat soluble vitamins
- Decreased production of clotting factors
- Decreased platelets due to increased activity of spleen
Assess for: easy bruising, bleeding, petechiae
What are two end stage complications of Cirrhosis?
Hepatic Encephalopathy
Hepatorenal Syndrome
Describe Hepatic Encephalopathy. What are signs and symptoms of it?
Serious and late stage complication of Cirrhosis, that can result in a coma from the build up of ammonia
- Increased build up of ammonia
- MS changes, confused
- Asterixis (involuntary flapping of hand)
- Handwriting changes
- Fector Hepaticus (odor of breath smells like feces)
What are factors that precipitate/worsen Hepatic Encephalopathy?
- High protein diet
- GI bleeding
- Bacterial infections
- Hypovolemia
- Hypokalemia
- Constipation
- Drugs (hypnotics, opioids, diuretics, etc)
- Paracentesis
What is the collaborative management of Hepatic Encephalopathy? What is the goal?
Goal is to decrease ammonia formation
Treat hypokalemia
Medications:
- Cathartics; lactulose - increases elimination of ammonia
- Antibiotics; metronidazole, rifaximin, neomycin
Diet:
- Restricted protein
- Complex carbohydrates
What is Hepatorenal Syndrome? What is it manifested by?
Life-threatening condition that consists of rapid deterioration in kidney function in individuals with cirrhosis
- poor prognosis
- one of the leading causes of death of pt’s with cirrhosis
Manifested by:
- Sudden decrease in urine output
- Elevated BUN and creatinine
- Increase urine osmolality
What are nursing interventions for Hepatic Disease in general?
- Eliminate causative agent
- Assess Q2h MS
- Observe for bleeding tendencies and avoid causing bleeding
- Provide special skin care
- Monitor diet, fluids, and electrolytes
- Patient and family education
- Weight PT’s daily
- Abdominal girth daily
- Stool for occult blood
- Low sodium and no alcohol
What are signs and symptoms of Cholecystitis (gall bladder disease/inflammation)?
- RUQ post prandial pain
- RUQ tenderness
- Pain after fatty meals
- Abdominal guarding
- Fetal positioning
- N and V
- Epigastric pain
- Moderately obese
- Increased HR, RR, BP, Temp, and WBC
What are the five F’s, risk factors for Cholecystitis (gall bladder disease)?
Fair (caucasian)
Fat (BMI > 30)
Female
Fertile (one or more children)
Forty years of age or greater
What diagnostic tests could be ordered to assess for Cholecystitis?
ULTRASOUNDgold standard for Cholecystitis and Pancreatitis
CT
MRI
ERCP
CBC
Cholesterol levels
Oral Cholecystogram (oral contrast than x-rays under fluoroscopy)
What labs are important in regards to Cholecystitis?
Bilirubin
AST/ALT/ALP
WBC
Amaylase and Lipase
Liver function panel
What medications are used for Cholecystitis?
ursodiol:
- dissolving gallstones
- cholesterol management
metoclopramide:
- increases gastric emptying
- for nausea
hydromorphone:
-for severe pain
What is ERCP? What is important pre and post procedure?
Endoscopic retrograde cholangiopancreatography combines the use of endoscopy and fluoroscopy to diagnose and treat certain problems of the biliary or pancreatic ductal systems.
Pre:
- NPO
- Notify if taken tests w/barium in past 2-3 days
- Stop taking aspirin 5 days prior to procedure
Post:
- Sore throat 1-2 days
- NPO until POSITIVE gag reflex
What is the difference between laparoscopic and open cholecystectomy?
laparoscopic - 3 to 4 openings
Open - traditional slit/cut
What is the rational for a T tube insertion during cholecystectomy sx?
Drains bile while the duct heals
Drains to common bile duct directly out of stomach
What is the nursing care for a PT with a T tube?
- Semi fowlers to promote drainage
- Assess skin for infection
-400 to 700 ml in 24 hr period is normal
> 1000mL notify MD
Other than a cholecystectomy, what are other treatments for gallstones?
- Low fat diet
- Shockwave ESWL
- MTBE (methyl tertiary tirbutly ether; dissolves gallstones in minutes)
- ursodiol; Rx that dissolves gallstones
Describe Pancreatitis included signs and symptoms.
Inflammation of the pancreas.
Releases tripson into itself and activates, which leads to auto-digestion.
- Typically LUQ pain, fever, and distended abdomen
- Blush color at umbilicus (Cullen’s sign)
- Grey turners sign (grey flanks)
both signs indicate hemorrhage
What are the endocrine and exocrine functions of the pancreas?
Endocrine: Secret insulin and glucagon
Exocrine: Digestive enzymes
What are major complications of pancreatitis?
Pulmonary complications (ARDS, atelectasis)
Pancreatic absces
Shock
Diabetes
Malnutrition
Hypocalcemia
What are collaborative interventions for pancreatitis?
- IV fluids
- Pain management
- Dietary restrictions (low fat and carb, high protein diet)
- No alcohol or caffeine
- PPI’s
- NPO
-VS, mouth care, stabilize blood sugars, daily weights,
C and DB, monitor for hypocalcemia
What are signs of Chronic Pancreatitis?
- Reoccurring attacks
- Weight loss
- Urine color
- Jaundice
- Steatorrhea
- Increase amylase
- Xray shows calcification is the pancreas indicating necrosis
What is the collaborative care for chronic pancreatitis?
Pain relief
Pancreatic enzyme replacement
PPIs
Bile salts
What are Cullen’s sign and Grey turners sign?
Blush color at umbilicus (Cullen’s sign)
Grey flanks (Grey turners sign)
What liver tests indicate liver failure and what do they have to be over?
AST/ALT > 45
What is an indication of bleeding in severe cirrhosis?
Increased albumin levels
RBC are broken and absorbed as protein
What is a paracentesis?
Draining of fluid from abdomen
What is a complication the nurse needs to monitor for regarding a paracentesis?
Hypotension (fluid will move to area that is empty, causing drop in BP)
What indicates biliary obstruction?
Clay colored stools,
Report to MD.
