Week 11: HEPATIC DISORDERS

Question 1

Liver

Answer 1

• Supports digestion of proteins and fats
• Located in RUQ
• Regenerative
• Produces bile
• Made up of four lobes
• Functional unit: lobules (highly vascularized)
• Hepatocytes – cells of liver, found in lobules

Key functions:
- Protein metabolism
- Storage (carbs, fats)
- Detoxification
- Bile production
- Clotting factors

Question 2

Gallbladder

Answer 2

Stores bile:
o Dark yellow/green fluid
o Produced by liver, stores and concentrated in gallbladder
o Makes stool brown, emesis yellow
o Contains: water, lytes, fatty acids, cholesterol, bilirubin, bile salts

Question 3

Pancreas

Answer 3

• Exocrine functions:
  o Amylase to carbs
  o Trypsin to proteins
  o Lipase to fats
  o Increase pH of digestive system to normal amount

Endocrine functions:
- Secrete hormones that assist with blood glucose levels

Question 4

Liver Disease

Answer 4

Disturbance in liver function (acute or chronic)

Stressors include:
- Fats (non-alcoholic fatty liver disease)
- Alcohol (fatty liver, cirrhosis)
- Viruses (hep c)
- Hepatotoxic substances (Tylenol overdose)

Question 5

Stages of liver disease:

Answer 5

Inflammation
- Stress causes inflammation in the liver, damaging hepatocytes

Necrosis
- Poor perfusion destroys hepatocytes

Fibrosis and scarring
- Tissue is replaced with fibrous scar tissue and abnormal lobules, irreversible

Question 6

Damaged hepatocytes:

Answer 6

• Can’t filter or absorb/store
• Increased waste buildup in the body
• Increased pressure through CV system (bp)
• Poor nutrition (cannot break down nutrients)

Question 7

Disrupted liver perfusion:

Answer 7

Blood cannot move through hepatic vessels

Pressure increases through hepatic vessels

Pressure backs up into GI system, can cause varices, edema, bleeding, and
ruptures

Question 8

Disrupted production of albumin

Answer 8

Fluid is not retained in the intravascular space (exits out of the capillaries, edema, congestion think traffic, less exits to get off highway)

Edema, ascites

Question 9

Health History: Liver disease

Answer 9

Risk factors:
Medication use – hepatotoxicity

Infectious diseases – hepatitis, HIV

Comorbidities – jaundice, hepatitis, biliary tract disorders

Family history – increase risk for diagnosis in immediate family

Genetics – may impact liver function

Lifestyle – diet, exercise, smoking, alcohol

Question 10

Physical assessment: Liver disease Nutritional deficiencies

Answer 10

• Fat-soluble vitamins (A, D, E, K)

Low vitamin K – bleeding risk

Liver is enlarged from inflammation and cannot filter, waste builds up,
pressure builds, fluid moves out, pressure backs up into GI vessels, varices

Question 11

Physical assessment: liver disease cardiovascular

Answer 11

Cardiovascular – blood flow is obstructed through the liver, and pressure rises:

• Hepatic portal hypertension
• Splepnomegaly
• Ascites
• Collateral circulation – varices
• Cardiac dysrhythmias
• Abnormal angiogenesis (new blood vessel formation)

Question 12

Nursing Assessment: liver disease Integumentary

Answer 12

Integumentary – cause of waste buildup, pressure buildup:
 Jaundice
 Edema
 Petechiae, ecchymosis
 Spider angiomas
 Palmer erythema
 Pruritis

Question 13

Nursing assessment: liver disease neuro - waste buildup

Answer 13

 Confusion
 Sleepiness
 Tremor (asterixis)
 Hyperactive deep tendon reflex
 Hepatic encephalopathy

Question 14

Nursing assessment: liver disease Respiratory

Answer 14

pressure rises and backs up through vessels:

 Platypnea (SOB relieved by laying)
 Dyspnea
 Clubbing fingers
 Cyanosis
 Decrease SpO2

Question 15

Nursing assessment: liver disease Renal

Answer 15

pressure rises and backs up through vessels, decreased perfusion:

 Symptoms of hypoperfusion
 Cognitive changes
 U/O changes
 Weight gain
 Ascites
 Fluid/lytes imbalances

Question 16

Nursing assessment: liver disease other findings

Answer 16

Palpitation for hepatomegaly – extended liver, tender/hard

Ascites – fluid in abdomen

Stool – clay coloured, blood

Hematemesis – esophageal varices

Question 17

Complications of Liver Disorders

Answer 17

Ascites- Abnormal build-up of fluid in the peritoneal space

Question 18

Causes of Ascites

Answer 18

 Hepatic portal hypertension
 Increased aldosterone, decreased albumin

Question 19

S&S of Ascites

Answer 19

 Increased abdominal girth
 Increased weight
 Abdominal discomfort
 SOB
 Fluid & lyte imbalances
 Umbilical herniation

Question 20

Nursing Management: Ascites

Answer 20

 Nutritional therapy – low Na diet
 Pharmacologic therapy – diuretic therapy (spironolactone, IV albumin)
 Paracentesis

 Transjugular Intrahepatic Portosystemic Shunt (TIPS)
- Treatment in patients with ascites needing frequent paracentesis
- A tract is creased between the higher-pressure portal vein and the
lower-pressure hepatic vein – decreasing the portal venous
pressure causes a decrease in ascites

Question 21

Pharmacological treatment: Ascites

Answer 21

spironolactone or furosemide or norfloxacin

Question 22

Esophageal Varices

Answer 22

Esophageal Varices

Enlarged and additional veins with poor integrity in esophagus and stomach o Risk – GI bleeding

Can be an emergency – depending on size of bleed

Nursing management:
Monitor for S&S of GI hemorrhage
Pharmacologic therapy

Endoscopy Banding Therapy (Ligation)
- Treats varices
- Endoscope is loaded with rubber bands to wrap the varices – shrink and fall off over time

• TIPS

Question 23

Esophageal Varices pharmacological intervention

Answer 23

vit K or OLOLs (metor-, Carvedi-)

Question 24

Hepatic encephalopathy

Answer 24

Depressed CNS causes neurological changes - EMERGENCY

Causes:
 Elevated ammonia levels leads to increased GABA, worsening the CNS depression

S&S:
 Mental status changes
 Disturbed sleep
 Asterixis (tremors)
 Difficulty handwriting
 Hyperactive deep tendon reflexes
 Flaccidity and coma

Question 25

Nursing Assessment: Hepatic encephalopathy

Answer 25

Monitor – VS, neuro status, serum ammonia, respiratory depression

 Nutritional therapy – low protein diet (avoid meat and eggs)

 Pharmacologic therapy – lactulose and antibiotic therapy

Question 26

Pharmacologic therapy Hepatic encephalopathy

Answer 26

rifaximin or lactulose

Question 27

Nursing priorities: Hepatic encephalopathy

Answer 27

Monitor for progression & complications
 Ascites, bleeding, hepatic encephalopathy, hepatopulmonary syndrome

 Medical management
Medications for symptoms management, complications

Health teaching
 Lifestyle, treatment
 Alcohol
 Infection prevention
 Bleeding precautions

Question 28

Pancreatitis

Answer 28

Inflammation of the pancreas (acute or chronic)

Can lead to autodigestion of the pancreas

Question 29

Causes of pancreatitis

Answer 29

o Excessive alcohol use
o Viral/bacterial infections (mumps)
o Gallstones
o Trauma/tumors
o Hypercalcemia, hypercholesterolemia
o Cystic fibrosis

Question 30

Health history – risk factors: Pancreatitis

Answer 30

Infectious diseases – mumps

Genetics – cystic fibrosis

Comorbidities – gallstones, tumours

Lifestyle – smoking, alcohol

Signs and symptoms of disorder

Question 31

Labs & Investigations: Pancreatitis

Answer 31

Increased amylase and lipase

Increased blood glucose (not making insulin)

Question 32

Pancreatitis Pain

Answer 32

Pain:
 LUQ
 Lef side of back
 Pain worsens when laying down, better when sitting up and bent forward
 Pain can be worse with eating or drinking

Question 33

Pancreatitis: GI

Answer 33

Pain location, tenderness, guarding on palpation

 N/V
 Decreased bowel sounds
 Weight loss, diarrhea, steatorrhea (increase in fat in stool), diabetes
development (long-term)

Question 34

Pancreatitis: CV

Answer 34

Hemodynamic instability

Increased HR – pain

Decreased BP – dehydration, bleeding

Question 35

Pancreatitis Integumentary:

Answer 35

Cullen’s sign (bruising near belly button)

Grey Turners sign (bruising on one or both sides (waist) of body)

Question 36

Nursing Priorities of Pancreatitis

Answer 36

Monitor for progression & complications
- Respiratory, nutritional, lyte imbalances, hemorrhagic necrosis (shock risk)

Medical management
- Pain management

• Health teaching

Question 37

Pharmacological Interventions: Pancreatitis

Answer 37

opioids

Question 38

Cholecystitis

Answer 38

• Inflammation of gallbladder
• Causes:
  o Cholelithiasis (gall stones, 80%)
  o Bile flow obstruction
• Risk factors:
  o Comorbidities – gall stones, sickle cell disease
  o Lifestyle – smoking, alcohol, obesity
  o S&S of disorder

Question 39

Physical assessment: Cholecystitis

Answer 39

o Pain:
 RUQ
 Right side of back, lower part of scapula
 Worsens with eating or drinking
 Constant or colicky

o GI:
 Pain location, tenderness, guarding on palpation
 N/V
 Avoids deep breathing – pain
 Pale coloured stool

o Integumentary
 Jaundice

o Murphy’s Sign
 Acute cholecytitis

Question 40

Labs & Investigations: Cholecystitis

Answer 40

Endoscopic retrograde cholangiopancreatography

Question 41

Nursing priorities: Cholecystitis

Answer 41

Surgical intervention care – surgical pre and post care

o Health teaching – lifestyle (diet)