Ch. 53 Patients with Liver Problems

Question 1

Hepatitis

Answer 1

A widespread inflammation and infection of the liver cells

Health promotion - Hep vaccines for A&B; no vaccine for hep C or E

5 types of hepatitis

Question 2

Viral Hepatitis

Answer 2

Cause: environmental (chemicals, drugs, herbs)

Liver toxicity from drug therapy

Infection causes - Epstein Barr, Herpes simplex, varicella, CMV

Question 3

Hepatitis Risk Factors

Answer 3

Advanced age

High risk exposures, travel, crowds

Blood transfusions (<1992)

Question 4

Hepatitis A

Answer 4

Mild course

Flu-like symptoms, N/V/D

Fecal-oral route or food/water contamination

Cause: shellfish, direct contact or food exposure

Treatment: symptom control

Question 5

Hepatitis B

Answer 5

Blood route: sharing needles, needle sticks, blood transfusions, hemodialysis, birth canal, unprotected sex

Diagnosed by blood test (up to 6 months from exposure to +blood test)

Treatment: acute = none; chronic = antivirals

Question 6

Hepatitis C

Answer 6

Transmission: blood exposure, IV drug needle sharing, blood products, transplants, hemodialysis

Asymptomatic until routine lab tests

Treatment: antivirals

Question 7

Which hepatitis is the leading cause of end stage liver disease-cirrhosis or liver cancer?

Answer 7

Hep C

Question 8

Hepatitis Lab & Diagnostic

Answer 8

Hep A,B,C (lab test)

Hep C,D,E (antibody titers)

Elevated liver tests (AST, ALT, ALK phos, Bilirubin)

Liver biopsy
CT scan

Question 9

Viral Hepatitis Clinical Manifestations

Answer 9

Upper abdominal pain
Yellow sclera (icterus)
Joint pain or muscle pain
Diarrhea or constipation
Light colored stools
Dark or yellow urine
Jaundice, Fever, Fatigue
N/V, Itchy and dry skin

Question 10

Hepatitis Interventions

Answer 10

Promoting nutrition (HepA give carbs and calories)

Hydration

Prevention of spread of infection (universal precautions, hand washing, pt education)

Drug therapy

Managing fatigue w/ all hepatitis

Question 11

Cirrhosis

Answer 11

Extensive, irreversible scarring of the liver, usually caused by chronic hepatic inflammation and necrotic injury

Scarring impairs cellular regulation = end stage liver disease

Question 12

Cirrhosis Pathophysiology

Answer 12

Inflammation caused by toxins or disease with extensive degeneration/destruction of liver cells (hepatocytes)

Liver nodules blocks bile ducts and blood flow = decrease liver function over weeks to years

Question 13

Cirrhosis Causes

Answer 13

Most common is chronic alcoholism

Chronic viral hepatitis & bile duct disease

Hep B&C

Autoimmune hepatitis

Question 14

Cirrhosis Risk Factors

Answer 14

Age, obesity, DM, steatohepatitis (chronic inflammation from fatty liver disease), genetic

Drug - isoniazid and flutamide can cause post necrotic cirrhosis

Question 15

Alcohol Withdrawal S/S

Answer 15

Tremors, jitters, delirium, confusion, anxiety, tachycardia, odd behaviors, high BP, sweating

Question 16

Cirrhosis Physical Assessment (early signs)

Answer 16

Fatigue
GI symptoms - nausea, abd pain
Abdominal assessment (hepatomegaly, splenomegaly)
Daily wt. or changes in weight, girth measurements
Asterixis: coarse tremors w/ flexion
Anxiety, jitters, tremors
Confusion, agitation, altered LOC

Question 17

Cirrhosis Clinical Manifestations

Answer 17

Jaundice
Encephalopathy
Spider angioma
Lack of body hair
Muscle wasting
Widened blood vessels
Ascites
Red palms

Question 18

Jaundice

Answer 18

Cause: hepatocellular disease liver cells can’t excrete bilirubin, intrahepatic obstruction, edema, scarring on hepatic bile ducts interferes with excretion

Patients report itching excessively

Icterus

Question 19

Late Stage Cirrhosis

Answer 19

Jaundice & Icterus
Itchy and dry skin
Rashes
Petechiae or ecchymoses
Red, hot bright palms of hands (palmar erythema)
Spider angiomas on face, nose, chest
Ascites
Peripheral edema

Question 20

Cirrhosis Lab

Answer 20

Increased AST, ALT, LDH

Increased Alk phos

Increased total bili

Decreased albumin

Increased ammonia level

Decreased serum sodium

Increased creatinine (late)

Decreased WBC

Question 21

Complications of Cirrhosis

Answer 21

Ascites & Esophageal varices

Hepatic Encephalopathy

Portal HTN

Biliary Obstruction

Question 22

Nursing Priorities w/ Cirrhosis

Answer 22

Monitor respiratory status, skin integrity, fluid and electrolyte balance, neurologic status, overall nutrition, pain med, GI assessment

Question 23

Ascites

Answer 23

Collection of free fluid within the peritoneal cavity caused by increased hydrostatic pressure from portal HTN

Fluid shifts from vascular system to third spacing

Complications: hypovolemia and edema

Question 24

Esophageal Varices

Answer 24

Fragile thin-walled esophageal veins get distended from pressure

Elevated BP in veins carrying blood from intestines to liver

Location: distal esophagus, stomach, or rectum

Life threatening medical emergency causing hypovolemic shock

Question 25

Hepatic Encephalopathy

Answer 25

Complex cognitive syndrome from liver failure/cirrhosis (late) Shunts portal venous blood into central circulation so liver is bypassed Labs: elevated ammonia (>45)

Question 26

Hepatic Encephalopathy Clinical Manifestations

Answer 26

Confusion, mental status changes, mood changes , insomnia, speech difficulties (early) Altered LOC, impaired thinking, neuromuscular problems (late)

Question 27

Lactulose

Answer 27

Indications: hepatic encephalopathy PO or Rectal MOA: excretes ammonia to improve levels (poop it out) Side effects: can cause diarrhea which can lead to hypokalemia, cramps, distention

Question 28

Metabolic Encephalopathy Interventions

Answer 28

Strict I&O Monitor VS trends Assess pain and nutrition

Question 29

Portal Hypertension

Answer 29

Obstruction/blockage of blood flow in portal vein causing splenomegaly Dilated veins in esophagus, stomach, intestines, abdomen, and rectum Complications: ascites and esophageal varices

Question 30

Splenomegaly

Answer 30

From backup of blood into the spleen > enlarged spleen destroys platelets causing thrombocytopenia

Question 31

What is the early sign of liver disease?

Answer 31

Low Platelets

Question 32

Biliary Obstruction

Answer 32

Genetic Obstruction of the bile duct that leads to biliary cirrhosis Production of bile is decreased which prevents clotting factors to produce

Question 33

Biliary Obstruction Causes

Answer 33

Gallbladder (stones) disease or autoimmune disease

Question 34

Biliary Obstruction Intervention

Answer 34

Prevention of vitamin K absorption

Question 35

Managing Fluid Volume

Answer 35

Nutrition therapy - low Na diet, malnutrition w/ IV infusion with vitamins (banana bag) Drug therapy - diuretic (furosemide or spironolactone); PO potassium or IV potassium Paracentesis

Question 36

Paracentesis

Answer 36

Invasive procedure to remove abdominal fluid US guided (at bedside) HOB 30 degrees w/ oxygen as needed Excessive fluid can cause respiratory problems w/ intra-abdominal pressure Excessive fluid removal can cause fluid shifts

Question 37

Preventing/Managing Hemorrhage

Answer 37

Preventative med - beta blocker Emergent Bleeding - Vasoactive drugs (beta blockers and vasopressin or octreotide)

Question 38

Managing Confusion

Answer 38

Fall risk precautions Lactulose to remove ammonia in the blood

Question 39

Managing Pruritic

Answer 39

Due to high bilirubin in blood Drug therapy - corticosteroids or sertraline