cirrhosis

Question 1

cirrhosis

Answer 1

chronic progressive disease of the liver characterized by extensive degeneration and destruction of liver cells

Question 2

disorganized regeneration

Answer 2

liver cells attempt to regenerate but the process is not organized and results in abnormal blood vessels and abnormal bile duct architecture

Question 3

overgrowth of connective tissue

Answer 3

distorts liver’s normal lobular structure and results in lobules that are irregular in size and shape (impede blood flow)

Question 4

etiology and pathophysiology of cirrhosis

Answer 4

most common causes are chronic hep C and alcohol-induced liver disease

protein malnutrition
environmental factors and genetic disposition
chronic inflammation and cell necrosis
synergistic factors accelerates damage

Question 5

risk factors for cirrhosis

Answer 5

alcohol abuse
obesity (NAFLD)
chronic viral hep B and C
cardiac cirrhosis - right sided heart failure

Question 6

neurologic manifestations of cirrhosis

Answer 6

hepatic encephalopathy
peripheral neuropathy
asterixis (flapping tremors)

Question 7

GI manifestations of cirrhosis

Answer 7

anorexia
dyspepsia
N/V
change in bowel habits
dull abdominal pain
fector hepaticus (musty smelling breath)
esophageal and gastric varices
gastritis
hematemesis
hemorrhoidal varices

Question 8

reproductive manifestations of cirrhosis

Answer 8

amenorrhea
testicular atrophy
gynecomastia
impotence

Question 9

integumentary manifestations of cirrhosis

Answer 9

jaundice
spider angioma
palmar erythema
purpura
petechiae
caput medusae

Question 10

hematologic manifestations of cirrhosis

Answer 10

anemia
thrombocytopenia
leukopenia
coagulation disorders
splenomegaly

Question 11

metabolic manifestations of cirrhosis

Answer 11

hypokalemia
hyponatremia
hypoalbuminemia

Question 12

CV manifestations of cirrhosis

Answer 12

fluid retention
peripheral edema
ascites

Question 13

complications of cirrhosis

Answer 13

jaundice
portal HTN
esophageal varices 
hematological problems
peripheral edema and ascites 
hepatic encephalopathy
endocrine alterations
peripheral neuropathy
hepatorenal syndrome

Question 14

esophageal varices

Answer 14

collateral circulation develops in attempt to reduce high pressure and reduce plasma volume
complex veins at lower end of esophagus that are enlarged and swollen
little elastic ability; very fragile
most life threatening complication of cirrhosis

Question 15

hepatic encephalopathy

Answer 15

increase in ammonia levels in the brain
mental and personality changes
abnormal neurotransmission, astrocyte swelling, inflammation
treat with lactulose

Question 16

portal hypertension

Answer 16

structural changes in the liver result in compression and deconstruction of the portal hepatic veins

changes cause obstruction in the normal flow of blood that goes through the portal system

characterized by increased venous pressure, splenomegaly, enlarged collatoral veins, ascites, gastric varices, esophageal varices

at risk for bleeding

Question 17

portal hypertension can lead to

Answer 17

pooling of blood - thrombocytopenia, leukopenia, anemia

Question 18

peripheral edema and ascites

Answer 18

decreased intravascular oncotic pressure secondary to decreased production of plasma proteins (albumin) - causes ascites

increased capillary filtration pressure secondary to portal HTN

altered metabolism of hormones

Question 19

ascites

Answer 19

transfer of fluid from intravascular space to extravascular space

Question 20

patients with ascites are at risk for _____

Answer 20

spontaneous bacterial peritonitis (SBP)

Question 21

as albumin levels _____, fluid accumulation _______

Answer 21

decrease

increase

Question 22

neuropsychiatric manifestation of end-stage liver disease

Answer 22

hepatic encephalopathy

Question 23

symptoms of hepatic encephalopathy

Answer 23

sleep disturbances
asterxis
confusion
drowsiness to coma
personality changes
irritability
disoriented
slowed speech
forgetfulness, memory loss

Question 24

endocrine dysfunction in cirrhosis

Answer 24

gynecomastia
loss of body hair
testicular atrophy
vaginal bleeding
impotence and decreased libido

Question 25

skin lesions in cirrhosis

Answer 25

palmar erythema - blanchable | spider angioma - small, dilated blood vessels present on nose, cheeks, upper trunk, neck, shoulders

Question 26

skin lesions appear due to

Answer 26

increase of estrogen circulating in the blood stream

Question 27

diagnostic studies related to cirrhosis

Answer 27

``` alkaline phosphatase - initially elevated AST - may be normal ALT - may be normal GGT - initially elevated total protein - decreased globulins - increased cholesterol levels - decreased prothrombin time - prolonged liver biopsy - liver cell damage ascites fluid differential analysis - establish diagnosis ```

Question 28

care for cirrhosis

Answer 28

``` ascites esophageal and gastric varices hepatic encephalopathy conservative therapy with rest administration of B vitamins minimize hepatotoxic drugs avoid alcohol ```

Question 29

assessment of ascites and edema

Answer 29

``` fluid volume deficit hypokalemia abdominal girth spontaneous bacterial peritonitis acute respiratory decompensation (PE) ```

Question 30

abdominal girth

Answer 30

measure every day and mark belly with permanent marker to ensure measurement in the same place

Question 31

care for ascites and edema

Answer 31

``` sodium restrictions diuretics (spironolactone and furosemide) fluid removal (parecentesis) skin care respiratory care medical management (diuretics/albumin) peritoneovenous shunt TIPS ```

Question 32

peritoneovenous shunt

Answer 32

allows continuous redirection of acidic fluid into venous system

Question 33

paracentesis

Answer 33

large bore needle stuck into the abdominal cavity to remove a large amount of fluid

Question 34

pre-procedure for paracentesis

Answer 34

obtain baseline assessment, instruct patient to void prior, position patient sitting upright or in high fowlers, assess abdominal girth, check VS and breath sounds

Question 35

intraprocedure for paracentesis

Answer 35

measure, collect, and describe fluid | monitor VS

Question 36

post-procedure for paracentesis

Answer 36

maintain dry sterile dressing, monitor for hematuria, monitor for leakage at site, monitor for fluid volume deficit (hypovolemia and electrolyte imbalances)

Question 37

TIPS

Answer 37

standard of care for ascites that is unable to get treated by diuretics non-surgical reduces portal venous pressure and decompresses the varices, thus controlling bleeding does not interfere with liver function or liver transplantation

Question 38

prevention for varices

Answer 38

avoid meds that may lead to bleeding (aspirin, NSAIDs) avoid constipation avoid activities that increase portal HTN endoscopy used to diagnose varices

Question 39

patients with varices at risk of bleeding are started on

Answer 39

beta blockers

Question 40

acute intervention

Answer 40

stabilize patient and protect airway manage bleed and fluid volume deficit risk for recurrence for bleeds

Question 41

drug therapy

Answer 41

goal is to stop bleeding so treatment can be initiated beta-blockers vasopressin IV octreotide

Question 42

EGD band ligation and sclerotherapy

Answer 42

if there's large bleed seen with endoscopy, a ligation or banding can be done on varices sclerotherapy - sclerose the bleeding vessel

Question 43

balloon tamponade

Answer 43

sits in the esophagus and inflates and puts continuous pressure on the bleed to stop it used in patients who have acute esophageal or gastric varices that are not controlled with initial endoscopy 2 balloons - esophageal and gastric 3 lumens - gastric balloon, esophageal balloon, gastric aspiration gastric balloon inflated to 250 cc of air and if pt is still bleeding, the esophageal balloon will be inflated use sphygmometer to maintain pressure between 20-40mL check balloon position with XR

Question 44

endoscopy pre-procedure

Answer 44

NPO ~ 8 hours informed consent signed education

Question 45

endoscopy intraprocedure

Answer 45

administer meds | monitor VS and airway

Question 46

endoscopy post-procedure

Answer 46

keep NPO until gag returns position patient in high fowlers or side-lying monitor for complications

Question 47

nursing considerations for balloon tamponade

Answer 47

protect airway label each lumen explain to patient the procedure deflate balloon per hospital policy (usually 5 mins every 8-12 hours) observe for skin breakdown monitor for complications always have a scissor at the bedside in case you need to cut the balloon to open up the airway oralpharyngeal suction

Question 48

complications of balloon tamponade

Answer 48

rupture, erosion of esophagus, regurgitation, aspiration of gastric contents, occlusion of airway

Question 49

assessment for hepatic encephalopathy

Answer 49

assess neuro/mental status every 2 hours medications (narcotics) safety assessment asterixis

Question 50

medical management for hepatic encephalopathy

Answer 50

rifaximin, lactulose -- reduces amount of ammonia formed in the intestines; traps ammonia in the gut; pass out flatulence = pass out ammonia

Question 51

avoid triggers of hepatic encephalopathy

Answer 51

dehydration/infection/GI bleed/constipation | controlling GI bleeding and removing blood from GI tract to decrease protein in the intestine

Question 52

diet for patients without complications

Answer 52

high in calories (3000/day) increase in carbs moderate to low fat protein restriction rarely justified

Question 53

diet for patients with ascites and edema

Answer 53

low sodium

Question 54

nursing care plans for cirrhosis

Answer 54

``` imbalanced nutrition impaired skin integrity ineffective self-health management dysfunctional family processes altered body image fluid volume excess fluid volume deficit risk for falls ```

Question 55

nursing management: implementation

Answer 55

``` reduce or eliminate risk factors treat alcoholism maintain adequate nutrition identify and treat acute hepatitis bariatric surgery for obese pts ```

Question 56

measures to relieve pruritis

Answer 56

``` cholestyramine or hydroxyzine baking soda or alpha keri baths lotions, soft or old linen temperature control rub with knuckles ```

Question 57

symptoms of hypokalemia

Answer 57

dysrhythmias, hypotension, tachycardia, muscle weakness

Question 58

symptoms of fluid volume excess

Answer 58

muscle cramping, weakness, lethargy

Question 59

action of spirinolactone (PO)

Answer 59

Antagonizes aldosterone in the distal tubules, increasing sodium and water excretion.

Question 60

action of vasopressin (IV)

Answer 60

Causes contraction of smooth muscle in the vascular bed and increases systemic vascular resistance and mean arterial BP and decreases HR and cardiac output.

Question 61

action of propranolol (PO, IV)

Answer 61

Reduces cardiac oxygen demand by blocking catecholamine-induced increases in HR, BP, and force of myocardial contraction. Drug depresses renin secretion and prevents vasodilation of cerebral arteries.

Question 62

action of lactulose (PO, rectal)

Answer 62

Produces an osmotic effect in colon; resulting distention promotes peristalsis. Also decreases ammonia, probably as a result of bacterial degradation, which lowers the pH of colon contents.

Question 63

adverse effects of spironolactone

Answer 63

Drowsiness, confusion, rash, nausea, vomiting, dizziness, diarrhea, hyperkalemia.

Question 64

considerations for spironolactone

Answer 64

warn patient to avoid excessive ingestion of potassium-rich foods (such as citrus fruits, tomatoes, bananas, dates, and apricots), salt substitutes containing potassium

Question 65

adverse effects of vasopressin

Answer 65

Hyponatremia, ventricular arrhythmias, rhabdomyolysis, nonspecific GI symptoms, peripheral, mesenteric, or coronary ischemia.

Question 66

adverse effects of propranolol

Answer 66

Bradycardia, cardiac failure, hypotension, bronchospasm.

Question 67

considerations for propranolol

Answer 67

Drug masks common signs and symptoms of shock and hypoglycemia.

Question 68

adverse effects of lactulose

Answer 68

abdominal cramps, belching, diarrhea, flatulence, gaseous distention, nausea, vomiting.

Question 69

considerations for lactulose

Answer 69

Monitor sodium level for hypernatremia, especially when giving in higher doses to treat hepatic encephalopathy Monitor mental status and potassium levels when giving to patients with hepatic encephalopathy.