Cirrhosis

Question 1

Function of liver

Answer 1

• 🩸 glucose regulation
• bile drainage
• synthesis/storage of amino acids, protein, vitamins and fats
• detoxification
• 🩸 circulation and filtration

Question 2

What is cirrhosis

Answer 2

• End-stage liver disease
• Extensive degeneration and destruction of liver cells
• Results in replacement of liver tissue by fibrous and regenerative nodules
• Usually happens after decades of chronic liver disease

Typically see nutritional deficiencies with reduced protein intake
- contributes to liver destruction

Question 3

Who is at risk

Answer 3

•Affects men more

- 40-60 years of age

Question 4

What causes cirrhosis

Answer 4

• Excessive alcohol is the major factor

- or hepatitis C

Question 5

What happens to the liver in cirrhosis

Answer 5

• Liver inflammation progresses to necrosis and finally fibrotic scarring.
• Liver cells try and regenerate however the process is disorganized.
• Results in abnormal blood vessel and bile duct architecture.
• The overgrowth of new and fibrous connective tissue distorts the liver’s normal lobular structure, resulting in an irregular shape and impeded blood flow.
• Eventually this disorganized and irregular liver generation, poor cellular nutrition, and hypoxia results in decreased liver function.

Question 6

Cirrhosis early signs

Answer 6

Fatigue and enlarged liver

Question 7

Cirrhosis late signs
(start of decompensation)

3 main signs and others ?

Answer 7

1) jaundice
2) peripheral edema
3) ascites

Other
•Skin lesions, hematologic problems , endocrine problems , and peripheral neuropathies
•Liver becomes smaller, nodular

Question 8

Jaundice in cirrhosis results from

Answer 8

•Overgrowth of connective tissue in liver compresses bile ducts

• Leads to obstruction
• Increase in bilirubin in vascular system
• May be minimal or severe

Question 9

2 Skin conditions in cirrhosis

What causes them?

Answer 9

1) Spider angiomas (telangiectasia): abnormal collection of blood vessels near the surface of the skin
2) Palmar erythema: redness of palms

Due to increase in circulating estrogen due to inability of liver to metabolize steroid hormones

Question 10

Endocrine disorders (late sign of cirrhosis)

Answer 10

1) In men—gynecomastia, loss of axillary and pubic hair, testicular atrophy, impotence and loss of libido
2) in women—amenorrhea or vaginal bleeding
3) Hyperaldosteronism in both sexes

Question 11

Peripheral neuropathy (late sign of cirrhosis)

Answer 11

•Common finding in alcoholic cirrhosis 🍺
- From dietary deficiencies of thiamine, folic acid, and cobalamin

•Sensory symptoms may predominate

Question 12

Portal hypertension

A complication- what does it cause?

Answer 12

•Increased venous pressure in portal circulation

It causes: 
•Splenomegaly
•Large collateral veins
•Ascites
•Gastric and esophageal varices

Question 13

Varicosities

Complication of cirrhosis

Answer 13

1) Esophageal varices: complex of tortuous enlarged veins at lower end of esophagus
2) Gastric varices: dilated veins by upper part of stomach

•Both are very fragile, bleed easily;
Most life-threatening complication

Question 14

Peripheral edema

Complication of cirrhosis

Answer 14

-caused by increase pressure from portal vein HTN

Occur in lower extremity 🦶🏻

Question 15

Ascites

Complication of cirrhosis

Answer 15

• accumulation of serous fluid in peritoneal or abdominal cavity

Painful
Don’t eat well- small frequent meals
Hyperaldosteronism

Question 16

Hepatic encephalopathy (HE)

Complication of cirrhosis

What causes this to happen and 4 signs?

Answer 16

•Liver unable to convert increased ammonia to urea

• Ammonia crosses blood-brain barrier
• Ammonia can be neurotoxic

1) Changes in neurologic and mental responsiveness
2) Inappropriate behavior
3) Sleep disturbances, trouble concentrating
4) Impaired LOC—hepatic coma

Question 17

Complications causes by Hepatic encephalopathy

Answer 17

•Asterixis: flapping tremors (arms and hands when extended forward) means trending towards coma
- Impairment in writing

• Apraxia: lost ability to carry out purposeful movement (flip comb and brush hair with wrong side)
• Fetor hepaticus: musty sweet smell of breath

Question 18

Hepatorenal syndrome

Complication of cirrhosis

What are the signs?

Answer 18

•Development of renal failure in pts with advanced liver disease
•S/S: 
1) azotemia- Elevated levels of urea
2) oliguria
3)  intractable ascites
•No structural abnormality of kidneys

Question 19

Diagnostic Liver enzyme tests

Answer 19

1) aspartate aminotransferase (AST)
2) alanine aminotransferase (ALT)
- (will be increased)

Question 20

Diagnostic lab values

Answer 20

• bilirubin, ammonia 🔼
• Total protein, albumin 🔽
• Cholesterol 🔽
• Prothrombin time (prolonged)

Question 21

Diagnostic studies for cirrhosis

Answer 21

• Ultrasound- detects the difference in density of parenchymal cells and scar tissue)
• CT, MRI, radioisotope liver scan- give information about liver size, hepatic blood flow and obstruction.
• Liver biopsy- confirms diagnosis

Question 22

Care of patient with cirrhosis

Answer 22

1) Rest
2) Administration of B-complex vitamins
- liver not metabolizing them so malnourished
3) Avoidance of alcohol!!
4) Minimization or avoidance of aspirin, acetaminophen, and NSAIDs
- risk of bleed

Goal is to slow the progression and prevent complications.

Question 23

Acute care of ascites

3 things the nurse can do/ give ?

Answer 23

1) Sodium restriction
- 2g/day (water follow salt)
2) Diuretics
3) Albumin
- helps blood volume (volume expander)

Question 24

Most important management of Esophageal and gastric varices is to:

Answer 24

Prevent bleeding/hemorrhage

Question 25

Acute Bleeding Varices care/ treatment What’s the supportive care ( what can the nurse give that the doctor proscribed)

Answer 25

stabilize patient, manage airway, start IV therapy and blood products ``` Supportive measures for acute bleed: •Fresh frozen plasma •Packed RBCs •Vitamin K •Zantac* ```

Question 26

Long Term Care: Bleeding Varices Decompensated cirrhosis Medications ?

Answer 26

Each bleed increases the chances for another Medications: •Beta-blockers: Propranolol(Inderal)

Question 27

Medications for Hepatic Encephalopathy Reduce ammonia formation:

Answer 27

* Lactulose (Cephulac), which traps ammonia in gut and as a laxative excretes it (pts often will have many BMs/day) * Rifaximin (Xifaxan) antibiotic given to those unresponsive to Lactulose.

Question 28

Nutritional Therapy for Cirrhosis

Answer 28

High Calories & Carbs Low fat Small, frequent meals •Protein supplements for malnutrition - Restrict protein IF hepatic encephalopathy cannot be managed with Lactulose •Low-sodium and fluid restriction for patients with ascites and edema •1-2 cups of probiotic yogurt TID reduces intestinal flora imbalance by 🔽 E Coli counts •Water soluble forms of fat-soluble vitamins A, D, and E •Folic acid and iron to prevent anemia. •Enteral or parenteral nutrition if vomiting or eating poorly.

Question 29

Nursing Management of Pruritis secondary to Jaundice Measures to relieve pruritus?

Answer 29

* Cholestyramine or Hydroxyzine * Baking soda or Alpha Keri baths (oil) * Lotions, soft or old linen * Temperature control * Short nails; rub with knuckles to avoid bleeding

Question 30

Nursing management ascites What to measure ?

Answer 30

Daily weight I&O Abdominal girth measurements (umbilicus) Monitor for edema Monitor for oliguria

Question 31

Paracentesis nurses responsibility How to have them sit? What to monitor ?

Answer 31

* High Fowler’s position or sitting on side of bed * Monitor for - hypovolemia / electrolyte imbalances - BP and heart rate - dressing for bleeding/leakage

Question 32

Risk of Bleeding secondary to Varices What to look for ?

Answer 32

•Hematochezia: blood in stool •Hematemesis: blood in vomit 🤮 - throwing up! Not coughing which would be from 🫁

Question 33

Management of altered LOC secondary to hepatic encephalopathy What to assess for ?

Answer 33

1) Maintain safe environment - Prevent falls and injuries 2) Assess carefully (LOC) - Sensory and motor abnormalities - Fluid/electrolyte imbalances - Acid-base imbalances - Response to treatment measures like meds - Assess neurologic status every 2 hour 3) Minimize constipation 4) Encourage fluids

Question 34

DC Planning What do they need to know?

Answer 34

* Proper diet * Rest * Avoiding potentially hepatotoxic OTC drugs like Tylenol * Abstinence from alcohol

Question 35

Decompensated cirrhosis * 6 major complications

Answer 35

- portal hypertension - esophageal and gastric varices** - peripheral edema - abdominal ascites - hepatic encephalopathy - hepatorenal syndrome

Question 36

Nursing care for Dyspnea

Answer 36

Semi or high fowlers C&DB Rest

Question 37

Skin care

Answer 37

Special mattress to relive pressure Turn q2h ROM Elevate lower extremity

Question 38

Drug therapy for varices bleeding

Answer 38

•Octreotide (used more often due to fewer side effects). •Vasopressin produces vasoconstriction, decreases portal blood flow, and decreases portal HTN

Question 39

Acute surgery for bleeding varices

Answer 39

Endoscopic therapy * *Endoscopic variceal ligation(EVL) - a rubber band around vein to cut off blood supply * Sclerotherapy-solution is injected directly into a vein, causing the lining of the blood vessel to swell and stick together * Balloon tamponade

Question 40

Long term care of bleeding varices Surgery? Non surgical?

Answer 40

Surgery: •Repeated EVL (Endoscopic variceal ligation) •Portosystemic shunts--goal is to decrease portal HTN (after 2nd bleed) •portacaval and distal splenorenal shunt* Nonsurgical: •trans-jugular intrahepatic portosystemic shunt (TIPS)