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Module 7 (Critical Care) > Hepatic > Flashcards

Hepatic Flashcards

1
Q

What percentage of metabolism does the liver do?

A

90%

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2
Q

If the drug is hepatotoxic, what does the nurse need to know about that?

A

the drug does not metabolize

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3
Q

The liver is located on what side of the body

A

right

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4
Q

Functions of the Liver

A

“People Drink So Much”
- Produces clotting factors, proteins, and bile (Vitamin K)
- Detox: remove byproducts of medications and bacteria in the blood (alcohol, bilirubin storage)
- Storage of glycogen, vitamins and minerals (gluconeogenesis and low immunity)
- Metabolism of nutrients from food (fats)

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5
Q

If the liver is impaired and can not metabolize, what wil increase

A

ammonia
- AMS and crazy

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6
Q

Liver failure is

A

inability of liver to function normally

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7
Q

Liver failure starts out as

A

inflammation of the liver cells
- acute or chronic

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8
Q

Chronic inflammation of the liver results in

A

scar tissue formation
no blood flow and necrosis
-cirrhosis

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9
Q

What happens to the BP in liver failure

A

increases

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10
Q

Acute

A

< 6 months

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11
Q

Chronic

A

> 6 months

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12
Q

What can cause acute liver failure?

A

~Viruses – hepatitis A, B, & C
~Drug use, often coupled with alcohol use
- Acetaminophen overdose
- Tuberculosis medications
~Wilson’s disease – excess copper and liver cannot metabolize (brown ring around iris)
~Ingestion of poisonous substances
- Mushrooms

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13
Q

What is the maximum amount of Tylenol for a day

A

4000 mg = hepatotoxic

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14
Q

Ibuprofen pt teaching

A

take with meals and milk
low clotting

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15
Q

EARLY S/S of acute liver failure

A

Fatigue
Jaundice w/ or w/o pruritus – excess bilirubin
Change in mentation (cognitive function)
Hematologic disorders
- prolonged coagulation
- easy bruising
Encephalopathy
Nausea and poor appetite

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16
Q

Acute liver failure complications

A

Cerebral edema
Hypoglycemia
Renal failure
Sepsis
Metabolic acidosis
MODS

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17
Q

What is the priority when suspecting acute liver failure?

A

neuro assessment

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18
Q

What follows after the neuro exam in a suspected liver failure?

A

fluid and electrolyte for K (malnutrition)
GI Bleed exam (acid and alcohol and stress the body causes them to eat their lining)
Infection risk (due to lack of vitamins and minerals)

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19
Q

Cirrhosis patho

A
  • chronic liver disease greater than 6 months
  • Chronic alcoholism
  • Chronic viral hepatitis
  • Nonalcoholic fatty liver disease (NAFLD) that = leads to Nonalcoholic - Steatohepatitis (NASH)
  • Cardiac cirrhosis
  • Biliary cirrhosis
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20
Q

What is the goal of cirrhosis?

A

preserve the healthy part of the liver

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21
Q

Steatosis

A

fatty deposits in the liver

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22
Q

Can you reverse nonalcoholic fatty liver disease?

A

yes

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23
Q

What are phases of the liver?

A

Healthy
fatty liver
fatty deposits
fibrosis
cirrhosis

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24
Q

Where is the best place to find jaundice?

A

sclera
- next is fingernails, mucosa

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25
Q

Ascites

A

fluid in the interstitial cavity

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26
Q

S/S of cirrhosis

A

Jaundice
Ascites
general fatigue
peripheral edema
= respiratory distress

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27
Q

What can occur as a sign of ascites?

A

general fatigue
peripheral edema
as the belly grows and pushes the diaphragm and making it harder to breath
= respiratory stress

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28
Q

Nursing priority for ascites patient

A

High fowlers HOB 45+

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29
Q

Tx for ascites

A

Albumin and diuretic therapy
- Paracentesis
- TIPS

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30
Q

Albumin MOA

A

pulls the interstitial fluid back into the intravascular vessels

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31
Q

What do you need to check regularly from diuretic therapy?

A

K (hypo)

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32
Q

Paracentesis is a

A

temporary fix

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33
Q

TIPS

A

foley of the peritoneal cavity

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34
Q

Paracentesis is the

A

The removal of fluid from the abdominal cavity using a large bore needle

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35
Q

Paracentesis Complications

A

Hypotension
Hypokalemia

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36
Q

Ascites cases what in the BP

A

HTN

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37
Q

Nursing Mgmt for Liver Failure
Paracentesis Care (Acute)

A

Patient void immediately before – don’t puncture the bladder
Monitor for hypovolemia & electrolyte imbalances
Monitor BP & heart rate
Monitor dressing for bleeding/leakage

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38
Q

After a paracentesis, the patient starts having hematuria, what does this show?

A

puncture the bladder

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39
Q

After a paracentesis, the patient starts having abd pain. this could mean?

A

abd puncture

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40
Q

excess bilirubin can cause what to the patient’s skin

A

dry
itchy
jaundice

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41
Q

Minimal urine output for a patient

A

30 mL/hr
ICU 0.5 mL/kg/hr

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42
Q

Impact of LF on the Endocrine System

A

Decreased metabolism of hormones
Testosterone
Estrogen
Aldosterone

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43
Q

Decreasing metabolism of hormones can result in what s/s in men

A

Gynecomastia – man boobs
Impotence

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44
Q

Decreasing metabolism of hormones can result in what s/s in females

A

Elevated testosterone in women
Menopause can start bleeding again
Amenorrhea in young

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45
Q

S/S of liver failure
- hematologic disorders

A

Thrombocytopenia
Leukopenia
Anemia
Coagulation disorders
splenomegaly

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46
Q

Bleeding Precautions

A

No ASA
Limit needles sticks
electric razor
22 g needle
protect from injury = bedrest
no contact sports
soft bristle toothbrush

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47
Q

Low platelets

A

<150,0000
- no clotting

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48
Q

<20,000 platelets means

A

bedrest
I know it is not a mobility issue, but

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49
Q

Observe for what on bleeding precautions

A

hematuria
nosebleeds
gum bleeds
bruising

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50
Q

S/S of liver failure and cirrhosis
- neuro

A

hepatic encephalopathy
peripheral neuropathy
asterixis

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51
Q

Asterixis

A

weird flappy hand (lactulose given as a laxative to get rid of ammonia)

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52
Q

S/S of liver failure and cirrhosis
- skin

A

jaundice
spider angioma
palmar erythema
purpura
petechiae
caput medusae
heroism - excessive hair growth in wrong places

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53
Q

S/S of liver failure and cirrhosis
- metabolic

A

LOW K, Na, Albumin in the blood

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54
Q

S/S of liver failure and cirrhosis
- CV

A

fluid retention
peripheral edema
ascites

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55
Q

S/S of liver failure and cirrhosis
- GI

A

anorexia
dyspepsia
N/V
change in bowel habits
dull abd pain
fetor hepaticus
esophageal and gastric varices
gastritis
hematemesis
hemorrhoidal varices

56
Q

S/S of liver failure and cirrhosis
- reproductive

A

amenorrhea
testicular atrophy
gynecomastia
impotence

57
Q

What labs increase do to liver failure/cirrhosis?

A

Ammonia
AST / ALT
Bilirubin
Lactic Acid
PTT, PT, INR

58
Q

What labs decrease do to liver failure/cirrhosis?

A

Albumin
Glucose
K, Na, Mg
Platelets
RBCs
WBCs

59
Q

Alkaline Phosphatase labs in liver failure

A

Acute - low
Chronic high

60
Q

AST

A

disease or damage

61
Q

ALT

A

how damaged and diseases it is

62
Q

> 80 ammonia =

A

neuro changes
- hepatic encephalopathy

63
Q

increase in bilirubin is due to

A

liver inability to excrete or store in the liver

64
Q

Lactic acid =

A

tissue hypoxia

65
Q

Dx studies for liver

A

Ultrasound
Fibro scan – degree of cirrhosis and fatty changes
Upper endoscopy – inside stomach to upper intestine
Radioisotope liver scan
Liver Biopsy – definitive test and dx

66
Q

What is the only definitive test and dx of liver failure or cirrhosis?

A

liver biopsy

67
Q

What is the patient at risk for with a liver biopsy

A

bleeding
- no clotting and taking a part of their liver

68
Q

The liver biopsy should lay on what side

A

right
- pressure

69
Q

What other s/s of the liver biopsy could occur that the nurse needs to monitor?

A

Diaphoretic and pallor, increase infection and peritonitis

70
Q

Antidotes for Acetaminophen OD

A

activated charcoal (NG tube)
N-acetylcysteine

71
Q

Medications possible for a liver failure pt

A

Benzo - lorazepam and midazolam
with Beer
Propofol with a secure airway
FFP and whole blood transfusions
- Albumin and platelets

72
Q

What medications would they given an alcoholic with liver failure?

A

Benzo - lorazepam and midazolam
with Beer

73
Q

Benzo is given for

A

acute anxiety for alcoholic trying to quit
- delirium tremors and seizures at the end of withdrawals
- give with beer to help wean off

74
Q

Before giving Benzo and Propofol, what do you need to ensure

A

baseline neuro
- SE = sleeping

75
Q

Complications of cirrhosis

A

portal HTN
peripheral edema
hepatic encephalopathy
hepatorenal syndrome
metabolic acidosis
sepsis
multiorgan failure

76
Q

Portal HTN

A

Esophageal &/or Gastric varices
Splenomegaly
Ascites

77
Q

Hepatic encephalopathy is known for

A

elevated ammonia levels

78
Q

Compensated organ failure

A

1 organ system down

79
Q

DeCompensated organ failure

A

3+ organ systems fail

80
Q

Varices

A

Enlarged or swollen veins

81
Q

Varices are caused by

A

high pressures

82
Q

Prevent varices bleeding

A

beta blockers

83
Q

How to stop a ruptured varices?

A

Vasopressor (vasopressin)
EGD for banding/sclerotherapy
Esophageal varices banding
Balloon tamponade therapy

84
Q

Ruptured varices are a medical

A

emergency
- Goal: stop the bleeding then give fluids after

85
Q

Sclerotherapy

A

going to preserve to go to figure out what to do
Suction to stabilize

86
Q

If a patient walks in drunk (N/V) with bright red bleeding, what should the nurse think is wrong

A

varices
- Large bore IVs

  • N/V not the main concern
87
Q

Balloon Tamponade Therapy is

A

tampon in the GI to stop the bleeding

88
Q

Nurse should do what for Balloon Tamponade Therapy

A

STABILIZE AND MAINTAIN AIRWAY
LARGE IVS
MEDICATIONS
SANDOSTATIN OR VASOPRESSIN (VASOCONSTRICTION)

89
Q

The balloon therapy uses what

A

SENGSTAKIN BLATMORE TUBE

90
Q

With the insert of the SENGSTAKIN-BLATMORE TUBE inserted, what should the nurse do if the pt RR increase and O2Sat decreases?

A

deflate and remove
-scissors at the bedside
Give O2

91
Q

After the Balloon Tamponade Therapy, what does the nurse educate the patient on?

A

DIET MODIFY –
STOP DRINKING – DECREASE IN AMOUNT OF FREQUENCY, DIFFERENT TYPE IN A LOWER CONCENTRATION OR PROOFS, LIMIT VISITS TO THE BAR, SUPPORT GROUPS
- a drink can cause the varice to bleed again

92
Q

Portacaval Shunt (TIPS) is used do to what complication?

A

portal HTN
- vein in the liver to inferior vena cava

93
Q

The portal vein in the liver gives what percentage of blood into the inferior vena cava

A

45% - deoxygenated

94
Q

The TIPS is only done if the patient has

A

normal blood flow blocked

95
Q

Hepatic Encephalopathy happens when the liver

A

unable to convert increased ammonia
- ammonia crosses blood-brain barrier

96
Q

Hepatic encephalopathy
patho s/s

A

Neurotoxic effects of ammonia
Abnormal neurotransmission
Astrocyte swelling
Inflammatory cytokines

97
Q

What can cause Hepatic encephalopathy

A

TIPS, portal vein thrombosis
infections (SBP)
AKI,electrolyte derangements (low k)
GI Bleed
hypoxemia, hypercapnia

98
Q

What is the pathology of HE?

A

gut flora (Ammonia, Glutamine, Methionine, Nitrogen, Serotonin, GADA
- goes to the liver and is failed to be metabolized ammonia
- portosystemic shunt bypasses the liver and goes into general circulation
toxins affect the brain

99
Q

HE AMS can affect what

A

brain function, structure, or both
- Low reaction time
- low BP and HR

100
Q

Stage 1 of HE
- consciousness
- intellect and behavior
- neurologic findings

A

mild lack of awareness
shortened attention span
impaired addiction or subtraction
mild asterixis or tremor
impaired handwriting

101
Q

Stage 2 of HE
- consciousness
- intellect and behavior
- neurologic findings

A

lethargic
disoriented, inappropriate behavior
obvious asterixis
slurred speech

102
Q

Stage 3 of HE
- consciousness
- intellect and behavior
- neurologic findings

A

somnolent but arousable
gross disorientation
bizarre behavior
muscular rigidity
clonus
hyperreflexia

103
Q

Stage 4 of HE
- consciousness
- intellect and behavior
- neurologic findings

A

coma
decerebrate posturing

104
Q

What stage of HE does the mental status changes start?

A

stage 2

105
Q

GCS assessed every _____ in HE

A

EVERY 1 hour to 15 MINUTES
depends on situation

106
Q

Stages of HE can be assessed using

A

GCS

107
Q

Decorticate

A

flexor
Cs
- arms and legs inside

108
Q

Decerebrate

A

extensor Es
outward and curved

109
Q

Which posturing is worse?

A

decerebrate

110
Q

Decorticate shows the problem with

A

cervical spinal tract or cerebral hemorrhage
- cord

111
Q

Decerebrate shows the problem with

A

within midbrain or pons
-lesions

112
Q

Will the posturing patient be stiff or flaccid

A

stiff tight

113
Q

S/S of HE

A

Confusion
Lethargy that may progress to a coma
Inappropriate behavior or personality changes
Asterixis
Problems with fine motor activities
Musty or “sweet breath” odor
Seizures – brain swelling (pads, side, suction)
Hyperventilation
Suppressed gag reflex

114
Q

How do you get rid of asterixis? (Tx)

A

(lactulose given as a laxative to get rid of ammonia)

115
Q

Ammonia is excreted through

A

feces

116
Q

Lactulose is considered therapeutic if the patient

A

increase in stools (3-5 per day) with lower ammonia levels

117
Q

SEvere Complications of HE

A

Brain swelling
Increased ICP >20
Brainstem herniation
Organ Failure

118
Q

How should the nurse manage the environment of a HE patient?

A

low stimulation environment
cluster care

119
Q

Tx of HE

A

Correct cause
Lower ICP
- Minimal stimulation
- Oxygenation & ventilation
- Osmotic diuretics (mannitol)
Lower ammonia levels
- Lactulose & rifaximin therapy
- Prevent constipation

120
Q

Mannitol is used for HE to

A

lower ICP

121
Q

What is the only diuretic to cross the blood brain barrier?

A

Mannitol

122
Q

Rifaximin decreases ammonia by

A

decreasing GI bacteria

123
Q

Acute Care Mgmt of HE

A

Safety
LOC
Sensory & motor abnormalities
Fluid/electrolyte imbalances
Acid-base balance
Effects of treatment measures
Minimize constipation
Control factors known to precipitate encephalopathy

124
Q

Nursing Assessment for Liver Failure

A

Fluid and electrolyte
Neuro
CV/PV
Respiratory
GI, Renal, MS, skin, psych

125
Q

Liver failure to renal failure due to

A

necrosis or dehydration
- Creatinine and BUN high
- edema and ascites

126
Q

Neuro assessment for Liver failure includes

A

every hour
Watch for seizures
Anticonvulsant – prevention
Avoid sedation
If x2 alert and oriented, then do not give benzo
Varices

127
Q

If the liver patient is itchy, what should the nurse do

A

no hot showers, sharp surfaces, no baths,
Skin care or infection due to low WBCs

128
Q

What is the priority for a liver failure patient?

A

Neuro
bleeding
infection

129
Q

Nutritional Therapy for Liver Patients

A

High in calories (3000 cal/day)
Protein supplement
Low Na – if ascites & edema
↑ Carbohydrate
Moderate to low fat
Total Parenteral Nutrition (TPN)
Consult dietician

130
Q

Why does the liver patient need a high calorie diet?

A

malnutrition - skinny with a beer belly

131
Q

Ammonia is a byproduct of

A

protein

132
Q

Ambulatory Care for Liver Failure

A

Be proactive & involve family
Lifestyle changes
Abstinence from alcohol
Community support programs – AA
Refer to home health & dietician

133
Q

Verbal and Written Instructions for Liver Failure

A

Medications – Rx & what to avoid
Skin care
Bleeding risks
Nutrition
Symptoms of complications
Avoidance of hepatotoxic OTC drugs
Lasix - daily wt

134
Q

A patient with advanced cirrhosis who has ascites is short of breath & has an increased respiratory rate. The nurse should
- Initiate oxygen therapy at 2 L/min to increase gas exchange.
- Notify the health care provider so that a paracentesis can be performed.
- Ask the patient to cough & breathe deeply to clear respiratory secretions.
- Place the patient in Fowler’s position to relieve pressure on the diaphragm.

A
  • Place the patient in Fowler’s position to relieve pressure on the diaphragm.
    Rationale: Dyspnea is a frequent problem for the patient with ascites, & a semi-Fowler’s or Fowler’s position allows for maximal respiratory efficiency. Oxygen administration is not indicated; SpO2 level less than 90% would be an indication for oxygen. The respiratory distress is caused by ascites (not by respiratory secretions); coughing & deep breathing will not alleviate the respiratory distress. A paracentesis may be performed to remove ascitic fluid; however, this procedure provides only temporary relief & is reserved for severe respiratory distress or abdominal pain.
135
Q

A nurse is admitting a patient who has bleeding esophageal varices. What should the nurse anticipate the HCP will order?
- Propranolol
- Metoclopramide
- Ranitidine
- Vasopressin

A
  • Vasopressin

Rational: Vasopressin will constrict blood vessels, especially the portal vein & decrease the bleeding. Propranolol – B-blocker used to lower pressure to prevent bleeding. Metoclopramide-treatment of GERD & gastroparesis. Ranitidine-an abx used for treatment of HE to decrease toxins from digested food

136
Q

A nurse is assessing a patient who has advanced cirrhosis. Which findings would be concerning for hepatic encephalopathy?
- Select all that apply.

Anorexia

Change on orientation

Asterixis

Ascitis

Shaky handwriting

A

Change on orientation
Asterixis
Shaky handwriting

Jaundice & anorexia are signs of liver dysfunction but not indicators of HE

137
Q

A nurse is caring for a patient who has cirrhosis. Which medications can the nurse expect to administer to this patient?
- Select all that apply.

Furosemide
Metoprolol
Morphine
Lactulose
Lorazepam

A

Furosemide
Metoprolol
Lactulose

Diuretics are used for ascitis beta-blockers lower portal HTN & prevent varices bleeding & lactulose aids in ammonia elimination

Morphine & lorazepam can sedate the patient & mask neuro changes. These should be avoided or used in lower doses if at all possible..

Module 7 (Critical Care) (22 decks)

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