Week 6 - Cirrhosis Flashcards
what is cirrhosis
- liver disease where liver cells become extremely damaged due to long term/severe damage
= leading to the damaged cells being replaced with fibrous tissue (scarring of the liver) and hepatocyte dysfunction
what can cause cirrhosis (2)
- chronic liver diseases (ex. chronic hep)
- excessive alcohol intake
what are some early symptoms of cirrhosis (3)
- RUQ pain
- nonspecific symptoms
- GI symptoms
what are manifestations of advanced cirrhosis due to (2)
- portal HTN
- liver failure
what is portal HTN
- occurs when the portal vein becomes narrowed due to scar tissue in the liver
= restricts the flow of blood to the liver and increases pressure in the portal vein
= affect the organs connected to the portal vein –> spleen, GI tract, gallbladder, pancreas
what symptoms of cirrhosis occur d/t portal HTN (4)
- splenomegaly
- varicies
- edema and ascites
- gastropathy
what are varices
- toruous, enlarged, and swollen veins
what can varices occur during cirrhosis (4)
- esophageal
- gastric
- rectal varices –> hemorrhoids
- abdominal –> caput medusae
where are esophageal varices located
- lower end of the esophagus
where are gastric varices located
- upper portion (fundus) of stomach
what is the danger associated w varices (3)
- the varices are fragile and can rupture & bleed –> life threatening
- esophageal varices can cause upper GI bleed
- platelet count will be low along with clotting factors available AND levels of Vitamin-K…they are at risk for a total bleed out
why does edema and ascites occur in cirrhosis (3)
- decreased oncotic pressure d/t impaired liver synthesis of albumin
- venous congestion from portal HTN
- hyperaldosteronism
what symptoms occur in cirrhosis d/t liver & hepatocyte failure (9)
- ascites & edema
- jaundice
- coma
- fetor hepaticus
- asterixis
- skin lesions
- hematological problems
- endocrine problems
- peripheral neuropathy
why does jaundice occur in cirrhosis
- liver has decreased ability to conjugate bilirubin
- may also have obstruction of biliary tract
what 2 types of skin lesions occur in cirrhosis
- spider angiomas –> spider nevi
- palmar erythema
what are spider nevi
- small, dilated blood vessels w bright red center and spdier-like branches
what causes the skin lesions in cirrhosis
- increase in circulating estrogen d/t the damaged liver’s ability to metabolize steroid hormones
what hematological problems can occur in cirrhosis (4)
- thrombocytopenia
- leukopenia
- anemia
- coagulation disorders
what causes thrombocytopenia, anemia, and leukopenia in cirrhosis
- splenomegaly –> overactivity of enlarged spleen = increased removal of blood cells (esp. plts) from circulation
the coagulation problems in cirrhosis occur d/t (3)
- liver’s inability to produce prothrombin, low plts, low K
what coagulation problems can occur in cirrhosis
bleeding tendencies:
- epistaxis
- purpura
- petechiae
- easy bruising
- gum bleeding
- heavy menstrual bleeding
what impact does cirrhosis have on the endocrine system
- the liver’s inability to metabolize estrogen, testosterone and adrenocorticla hormones
what endocrine symptoms occur in cirrhosis (4)
- gynecomastia
- loss of body hair
- testicular strophy
- amenorrhea
what does hyperaldosteronism in cirrhosis cause (3)
- sodium retention
- water retention
- K loss
what is hepatic encephalopathy
- changes in neuro and mental function d/t build up of ammonia
- ranges from lethargy to coma
what are signs of hepatic encephalopathy (10)
- sleep disturbances
- lethargy
- changes in neuro and mental responsiveness
- coma
- memory loss
- irritability
- confusion
- droswiness
- asterixis
- fetor hepaticus
what is a serious complication of cirrhosis
- hepatorenal syndrome
what is hepatorenal syndrome
- functional kidney failure with advancing azotemia, oliguria, intractable ascites
what neuro S&S are present in cirrhosis (3)
- hepatic encephalopaty
- peripheral neuropathy
- asterixis
what GI symptoms are present in cirrhosis (9)
- anorexia
- NV
- change in bowel habits
- RUQ abdominal pain
- fetor hepaticus
- esophageal and gastric varices
- gastritis
- hematemesis
- hemorrhoidal varices
what reproductive symptoms are present in cirrhosis (4)
- amenorrhea
- testicular atrophy
- gynecomastia
- impotence
what integumentary symptoms are present in cirrhosis (6)
- jaundice
- spider nevi
- palmar erythema
- purpura
- petechiae
- caput medusae
what hematological symptoms are present in cirrhosis (5)
- anemia
- thrombocytopenia
- leukopenia
- coagulation disorders
- splenomegaly
what metabolic symptoms are present in cirrhosis (3)
- hypoalbumineria
- hyponatremia
- hypokalemia
what CVS symptoms are present in cirrhosis (3)
- fluid retention
- peripheral edema
- ascites
what diagnostic studies are used for cirrhosis (5)
- LFTs
- elevated liver enzymes
- PT or INR
- liver biopsy
- noninvasive fibrosis markers
what is goal of collaboartive care in cirrhosis
- treat complications and slow disease
what is treated/managed in collaborative care of cirrhosis (6)
- rest
- ascites
- esophageal varices
- hepatic encephalopathy
- nutrition therapy
management of ascites is focused on (4)
- sodium restriction (2g/day)
- diuretics –> spironolactone
- fluid removal –> paracentesis
- admin of salt-poor albumin
what should be monitered/assessed r/t mngmt of ascites (2)
- I&O
- electrolyte balance
when is paracentesis indicated in treatment of ascites? what is a con to paracentesis
- if diuretic therapy fails
- treatment of symptoms such as abdominal pain & troule breathing
- con: only a temporary solution bc fluid reaccumulates
what is the main therapeutic goal r/t esophageal and gastric varices
- prevent bleeding
pts w esophageal varices should avoid… (4)
- NSAIDs
- aspirin
- alcohol
- irritating foods
management of bleeding varices include (3)
- emergency
- therapeutic
- prophylactic interventions
when esophageal variceal bleeding occurs, what are the initial steps (4)
- stabilize pt and manage airway
- VS
- IV initiation
- vasopressin
how is variceal bleeding diagnosed
- endoscopy
what drug therapy is used for treatment of varices (5)
- non-selective beta blockers –> propranolol
- vasopressin (may be admin w nitro)
- blood products
- PPI
- lactulose
why is lactulose given as a treatment for variceal bleeding
- prevent hepatic encepalopathy from breakdown of blood & release of ammonia
what endoscopic treatment can be done for variceal bleeding (3)
- banding
- ligation
- sclerotherapy
what does sclerotherapy do
- thromboses and obliterates the distended veins
what is banding/ligation
- small rubber band is slipped around base of the varix –> essentially strangles the vein so it cant be bleed
what is an additional treatment for varices
- balloon tamponade
what is balloon tamponade? when is it used
- controls the hemorrhage by mechanical compression of the varices
- used if hemorrhage cannot be controlled on initial endoscopy
what effect does propanolol have on management of varices
- reduces risk of bleeding by decreasing portal HTN (prophylactic)
what procedure can be done for esophageal varcies
- surgical & nonsurgical shunting of blood away from the esophageal varices
it is important to ensure pts are on ______, if they have varices. why?
- stool softeners
- sudden rupture of vessels from increased abdominal pressure if straining can cause hemorrhage
what is the goal of mngmt for heptic encephalopathy
- reduction of ammonia formation
what can be used to reduce ammonia formation r/t hepatic encephalopathy (2)
- lactulose
- treatment of precipitating causes
what are some factors precipitating hepatic encephalopathy (10)
- GI hemorrhage
- constipation
- hypokalemia
- hypovolemia
- infection
- cerebral depressants
- metabolic alkolosis
- paracentesis
- dehydration
- increased metab
- uremia
what nutrition therapy is indicated for cirrhosis (4)
- high cal (3000/day)
- high carb
- mod to low fat
- if ascites and edema, low sodium
describe the acute intervention for cirrhosis (17)
- conserve energy –> rest
- maintain adequate nutrition
- tx NV
- assess jaundice
- relief of pruritis
- note color of urine and stools
- record I&O, daily weights (r/t ascites & edema)
- semi-fowlers for dyspnea (r/t ascites)
- monitor VS and dressing post-paracentesis
- turning schedule (q2h), skin care (edematous tissue prone to breakdown)
- ROM exercise, DB&C (ascites - move very little, prevent resp problems)
- elevate lower extremities
- monitor electrolytes & S&S of imbalance
- monitor signs of bleeding
- assess pts response to altered body image
- monitor cognition
- provide meds as ordered (& analgesics)
what interventions can help provide adequate nutrition for a pt with cirrhosis (4)
- small meals
- snacks
- good oral care
- food preferences available whenever possible
what can help relieve pruritis (5)
- cholestyramine
- baking soda baths
- lotions w antihistamines
- calamine
- short nails
if a pt is undergoing paracentesis, what should they do prior to the procedure and why
- void to prevent puncture of bladder
if the pt has esophageal or gastric varices, what should you monitor (2)
- signs of bleeding (hematemesis, melena)
- call physician if hematemesis present
what should you assess/monitor regarding hepatic encephalopathy (5)
- level of responsiveness
- sensory & motor abnormalities (asterixis)
- fluid & electrolyte
- acid-base imbalances
- effect of treatment
how often should assessment of neuro status be completed
- at least q2h
what pt education should be completed r/t cirrhosis
- avoid NSAIDs and ASA
- avoid alcohol
- avoid ACE-I (fluid retention)
- avoid sleeping pills & sedatives (r/t encephalopathy)
- low sodium diet
- higher risk of infection –> imp of vaccinations, infection prevention
- S&S of disease decomp
- U/S monitoring q6 mo.
- no heavy lifting (risk of hemorrhage)
a nursing diagnosis r/t cirrhosis is imbalanced nutrition. what nursing interventions can be done for this
- same as hepatitis
a nursing diagnosis for cirrhosis is impaired skin integrity. what pruritis management can be done to provide relief of pruritis and maintain skin integrity (2)
- keep fingernails trimmed short
- apply medicated creams and lotions
a nursing diagnosis for cirrhosis is impaired skin integrity. what skin care & topical treatments can be used to help maintain skin integrity (8)
- inspect skin daily for breakdown
- provide support to edematous areas (scrotal, pillows under arms)
- turn q2h
- keep bed linen clean, dry, wrinkle free
- use nonalkaline cleanser on skin
- provide nail care
- admin antipruritic med as ordered
- provide distractions
a nursing diagnosis for cirrhosis is excess fluid volume. what hypervolemia management interventions can be done to achieve normal fluid balance & maintain BP and urinary output within normal limits (4)
- weigh pt daily
- administer prescribed meds (diuretics)
- monitor I&O
- monitor changes in peripheral edema
a nursing diagnosis for cirrhosis is excess fluid vol. what fluid/electrolyte management interventions can be completed ? (2)
- provide prescribed diet (low sodium, fluid restriction, low protein, no added salt) to prevent additional fluid retention
- obtain lab specimens for monitoring of latered fluid & electrolytes to evaluate effectiveness of treatment
a nursing diagnosis of cirrhosis is ineffective health management r/t insufficient knowledge of therapeutic regimen. what substance use treatment can be implemented (4)
- encourage or praise pt efforts to accept responsibility for substance use-related dysfunction & treatment
- instruct pt on effects of substance used
- assist pt in developing health, effective coping mechanisms
- encourage pt to participate in self-help program during and after treatment
what self responsibility facilitation interventions can implemented during cirrhosis (6)
- hold pt responsible for own behavior to facilitate responsible behaviors
- discuss w pt the extent of responsibility for present health status
- discuss consequeces of not dealing w own responsibility to emphasize realistic outcomes
- set limits of manipulative behavior
- refrain from arguing or bargaining about the established limits w pt
- provide positive feedback for accepting additional responsibility and/or behavior change
a nursing diagnosis during cirrhosis is dysfunctional family process r/t ineffective coping strategies, substance misuse. what family therapy nursing interventions can be implemented (6)
- assess family communication to identify approp interventions
- identify family strengths and resources
- help members prioritize and select the most immediate family issue to address
- help family enhance existing positive coping strategies
- help family set goals towards more competenet way of handling dysfunctional behavior
- monitor for adverse therapeutic responses
a potenatial complication of cirrhosis is hepatic encephalopathy. what nursing interventions can be implemented for this (3)
- assess pts general behavior, orientation, speech
- provide laxatives and enemas as ordered to move toxins out of body
- watch for signs of infection to reduce risk of encephalopathy
a potential complication of cirrhosis is hemorrhage r/t altered clotting factors and rupture of varices. what nursing interventions can be implemented for this (9)
- monitor for hemorrhage to provide early inytervention
- provide gentle nursing care to reduce risk of tissue trauma
- watch for bleeding episodes –> hematuria, melena
- use smallest gauge needle possible when giving injection & apply gentle but prolonged pressure after
- use soft bristled toothbrush
- avoid irritating foods to reduce trauma (mucous membranes have increased risk of injury d/t high vascularity)
- teach pt to avoid straining at stool, vigorous blowing of nose, & coughing
- observe for bruising on skin to detect bleeding early
- monitor lab (hematocrit, hgb, PT time)
