Hepatic Flashcards
(137 cards)
1
Q
What percentage of metabolism does the liver do?
A
90%
2
Q
If the drug is hepatotoxic, what does the nurse need to know about that?
A
the drug does not metabolize
3
Q
The liver is located on what side of the body
A
right
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)
5
Q
If the liver is impaired and can not metabolize, what wil increase
A
ammonia
- AMS and crazy
6
Q
Liver failure is
A
inability of liver to function normally
7
Q
Liver failure starts out as
A
inflammation of the liver cells
- acute or chronic
8
Q
Chronic inflammation of the liver results in
A
scar tissue formation
no blood flow and necrosis
-cirrhosis
9
Q
What happens to the BP in liver failure
A
increases
10
Q
Acute
A
< 6 months
11
Q
Chronic
A
> 6 months
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
13
Q
What is the maximum amount of Tylenol for a day
A
4000 mg = hepatotoxic
14
Q
Ibuprofen pt teaching
A
take with meals and milk
low clotting
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
16
Q
Acute liver failure complications
A
Cerebral edema
Hypoglycemia
Renal failure
Sepsis
Metabolic acidosis
MODS
17
Q
What is the priority when suspecting acute liver failure?
A
neuro assessment
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)
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
20
Q
What is the goal of cirrhosis?
A
preserve the healthy part of the liver
21
Q
Steatosis
A
fatty deposits in the liver
22
Q
Can you reverse nonalcoholic fatty liver disease?
A
yes
23
Q
What are phases of the liver?
A
Healthy
fatty liver
fatty deposits
fibrosis
cirrhosis
24
Q
Where is the best place to find jaundice?
A
sclera
- next is fingernails, mucosa
25
Ascites
fluid in the interstitial cavity
26
S/S of cirrhosis
Jaundice
Ascites
general fatigue
peripheral edema
= respiratory distress
27
What can occur as a sign of ascites?
general fatigue
peripheral edema
*as the belly grows and pushes the diaphragm and making it harder to breath
= respiratory stress*
28
Nursing priority for ascites patient
High fowlers HOB 45+
29
Tx for ascites
Albumin and diuretic therapy
- Paracentesis
- TIPS
30
Albumin MOA
pulls the interstitial fluid back into the intravascular vessels
31
What do you need to check regularly from diuretic therapy?
K (hypo)
32
Paracentesis is a
temporary fix
33
TIPS
foley of the peritoneal cavity
34
Paracentesis is the
The removal of fluid from the abdominal cavity using a large bore needle
35
Paracentesis Complications
Hypotension
Hypokalemia
36
Ascites cases what in the BP
HTN
37
*Nursing Mgmt for Liver Failure*
Paracentesis Care (Acute)
Patient void immediately before – don’t puncture the bladder
Monitor for **hypovolemia & electrolyte imbalances**
Monitor BP & heart rate
Monitor dressing for bleeding/leakage
38
After a paracentesis, the patient starts having hematuria, what does this show?
puncture the bladder
39
After a paracentesis, the patient starts having abd pain. this could mean?
abd puncture
40
excess bilirubin can cause what to the patient's skin
dry
itchy
jaundice
41
Minimal urine output for a patient
30 mL/hr
ICU 0.5 mL/kg/hr
42
Impact of LF on the Endocrine System
Decreased metabolism of hormones
Testosterone
Estrogen
Aldosterone
43
Decreasing metabolism of hormones can result in what s/s in men
Gynecomastia – man boobs
Impotence
44
Decreasing metabolism of hormones can result in what s/s in females
Elevated testosterone in women
Menopause can start bleeding again
Amenorrhea in young
45
S/S of liver failure
- hematologic disorders
Thrombocytopenia
Leukopenia
Anemia
Coagulation disorders
splenomegaly
46
Bleeding Precautions
No ASA
Limit needles sticks
electric razor
22 g needle
protect from injury = bedrest
no contact sports
soft bristle toothbrush
47
Low platelets
<150,0000
- no clotting
48
<20,000 platelets means
bedrest
I know it is not a mobility issue, but
49
Observe for what on bleeding precautions
hematuria
nosebleeds
gum bleeds
bruising
50
S/S of liver failure and cirrhosis
- neuro
hepatic encephalopathy
peripheral neuropathy
asterixis
51
Asterixis
weird flappy hand (lactulose given as a laxative to get rid of ammonia)
52
S/S of liver failure and cirrhosis
- skin
jaundice
spider angioma
palmar erythema
purpura
petechiae
caput medusae
heroism - excessive hair growth in wrong places
53
S/S of liver failure and cirrhosis
- metabolic
LOW K, Na, Albumin in the blood
54
S/S of liver failure and cirrhosis
- CV
fluid retention
peripheral edema
ascites
55
S/S of liver failure and cirrhosis
- GI
anorexia
dyspepsia
N/V
change in bowel habits
dull abd pain
fetor hepaticus
esophageal and gastric varices
gastritis
hematemesis
hemorrhoidal varices
56
S/S of liver failure and cirrhosis
- reproductive
amenorrhea
testicular atrophy
gynecomastia
impotence
57
What labs increase do to liver failure/cirrhosis?
Ammonia
AST / ALT
Bilirubin
Lactic Acid
PTT, PT, INR
58
What labs decrease do to liver failure/cirrhosis?
Albumin
Glucose
K, Na, Mg
Platelets
RBCs
WBCs
59
Alkaline Phosphatase labs in liver failure
Acute - low
Chronic high
60
AST
disease or damage
61
ALT
how damaged and diseases it is
62
>80 ammonia =
neuro changes
- hepatic encephalopathy
63
increase in bilirubin is due to
liver inability to excrete or store in the liver
64
Lactic acid =
tissue hypoxia
65
Dx studies for liver
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
What is the only definitive test and dx of liver failure or cirrhosis?
liver biopsy
67
What is the patient at risk for with a liver biopsy
bleeding
- no clotting and taking a part of their liver
68
The liver biopsy should lay on what side
right
- pressure
69
What other s/s of the liver biopsy could occur that the nurse needs to monitor?
Diaphoretic and pallor, increase infection and peritonitis
70
Antidotes for Acetaminophen OD
activated charcoal (NG tube)
N-acetylcysteine
71
Medications possible for a liver failure pt
Benzo - lorazepam and midazolam
with Beer
Propofol with a secure airway
FFP and whole blood transfusions
- Albumin and platelets
72
What medications would they given an alcoholic with liver failure?
Benzo - lorazepam and midazolam
with Beer
73
Benzo is given for
acute anxiety for alcoholic trying to quit
- delirium tremors and seizures at the end of withdrawals
- give with beer to help wean off
74
Before giving Benzo and Propofol, what do you need to ensure
baseline neuro
- SE = sleeping
75
Complications of cirrhosis
portal HTN
peripheral edema
hepatic encephalopathy
hepatorenal syndrome
metabolic acidosis
sepsis
multiorgan failure
76
Portal HTN
Esophageal &/or Gastric varices
Splenomegaly
Ascites
77
Hepatic encephalopathy is known for
elevated ammonia levels
78
Compensated organ failure
1 organ system down
79
DeCompensated organ failure
3+ organ systems fail
80
Varices
Enlarged or swollen veins
81
Varices are caused by
high pressures
82
Prevent varices bleeding
beta blockers
83
How to stop a ruptured varices?
Vasopressor (vasopressin)
EGD for banding/sclerotherapy
Esophageal varices banding
Balloon tamponade therapy
84
Ruptured varices are a medical
emergency
- Goal: stop the bleeding then give fluids after
85
Sclerotherapy
going to preserve to go to figure out what to do
Suction to stabilize
86
If a patient walks in drunk (N/V) with bright red bleeding, what should the nurse think is wrong
varices
- Large bore IVs
- N/V not the main concern
87
Balloon Tamponade Therapy is
tampon in the GI to stop the bleeding
88
Nurse should do what for Balloon Tamponade Therapy
STABILIZE AND MAINTAIN AIRWAY
LARGE IVS
MEDICATIONS
SANDOSTATIN OR VASOPRESSIN (VASOCONSTRICTION)
89
The balloon therapy uses what
SENGSTAKIN BLATMORE TUBE
90
With the insert of the SENGSTAKIN-BLATMORE TUBE inserted, what should the nurse do if the pt RR increase and O2Sat decreases?
deflate and remove
-scissors at the bedside
Give O2
91
After the Balloon Tamponade Therapy, what does the nurse educate the patient on?
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
Portacaval Shunt (TIPS) is used do to what complication?
portal HTN
- vein in the liver to inferior vena cava
93
The portal vein in the liver gives what percentage of blood into the inferior vena cava
45% - deoxygenated
94
The TIPS is only done if the patient has
normal blood flow blocked
95
Hepatic Encephalopathy happens when the liver
unable to convert increased ammonia
- ammonia crosses blood-brain barrier
96
Hepatic encephalopathy
patho s/s
Neurotoxic effects of ammonia
Abnormal neurotransmission
Astrocyte swelling
Inflammatory cytokines
97
What can cause Hepatic encephalopathy
TIPS, portal vein thrombosis
infections (SBP)
AKI,electrolyte derangements (low k)
GI Bleed
hypoxemia, hypercapnia
98
What is the pathology of HE?
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
HE AMS can affect what
brain function, structure, or both
- Low reaction time
- low BP and HR
100
Stage 1 of HE
- consciousness
- intellect and behavior
- neurologic findings
mild lack of awareness
shortened attention span
impaired addiction or subtraction
mild asterixis or tremor
**impaired handwriting**
101
Stage 2 of HE
- consciousness
- intellect and behavior
- neurologic findings
lethargic
disoriented, inappropriate behavior
obvious asterixis
slurred speech
102
Stage 3 of HE
- consciousness
- intellect and behavior
- neurologic findings
somnolent but arousable
gross disorientation
bizarre behavior
muscular rigidity
clonus
hyperreflexia
103
Stage 4 of HE
- consciousness
- intellect and behavior
- neurologic findings
coma
decerebrate posturing
104
What stage of HE does the mental status changes start?
stage 2
105
GCS assessed every _____ in HE
EVERY 1 hour to 15 MINUTES
depends on situation
106
Stages of HE can be assessed using
GCS
107
Decorticate
flexor
**Cs**
- arms and legs inside
108
Decerebrate
extensor **Es**
outward and curved
109
Which posturing is worse?
decerebrate
110
Decorticate shows the problem with
cervical spinal tract or cerebral hemorrhage
- cord
111
Decerebrate shows the problem with
within midbrain or pons
-lesions
112
Will the posturing patient be stiff or flaccid
stiff tight
113
S/S of HE
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
How do you get rid of asterixis? (Tx)
(lactulose given as a laxative to get rid of ammonia)
115
Ammonia is excreted through
feces
116
Lactulose is considered therapeutic if the patient
increase in stools (3-5 per day) with lower ammonia levels
117
SEvere Complications of HE
Brain swelling
Increased ICP >20
Brainstem herniation
Organ Failure
118
How should the nurse manage the environment of a HE patient?
low stimulation environment
cluster care
119
Tx of HE
Correct cause
Lower ICP
- Minimal stimulation
- Oxygenation & ventilation
- Osmotic diuretics (mannitol)
Lower ammonia levels
- Lactulose & rifaximin therapy
- Prevent constipation
120
Mannitol is used for HE to
lower ICP
121
What is the only diuretic to cross the blood brain barrier?
Mannitol
122
Rifaximin decreases ammonia by
decreasing GI bacteria
123
Acute Care Mgmt of HE
Safety
**LOC**
Sensory & motor abnormalities
**Fluid/electrolyte imbalances**
Acid-base balance
Effects of treatment measures
Minimize constipation
Control factors known to precipitate encephalopathy
124
Nursing Assessment for Liver Failure
Fluid and electrolyte
Neuro
CV/PV
Respiratory
GI, Renal, MS, skin, psych
125
Liver failure to renal failure due to
necrosis or dehydration
- Creatinine and BUN high
- **edema and ascites**
126
Neuro assessment for Liver failure includes
every hour
Watch for seizures
Anticonvulsant – prevention
Avoid sedation
If x2 alert and oriented, then do not give benzo
Varices
127
If the liver patient is itchy, what should the nurse do
no hot showers, sharp surfaces, no baths,
Skin care or infection due to low WBCs
128
What is the priority for a liver failure patient?
Neuro
bleeding
infection
129
Nutritional Therapy for Liver Patients
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
Why does the liver patient need a high calorie diet?
malnutrition - skinny with a beer belly
131
Ammonia is a byproduct of
protein
132
Ambulatory Care for Liver Failure
Be proactive & **involve family**
Lifestyle changes
Abstinence from alcohol
Community support programs – **AA**
Refer to home health & dietician
133
Verbal and Written Instructions for Liver Failure
Medications – Rx & what to avoid
Skin care
Bleeding risks
Nutrition
Symptoms of complications
Avoidance of hepatotoxic OTC drugs
Lasix - daily wt
134
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.
- 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
A nurse is admitting a patient who has bleeding esophageal varices. What should the nurse anticipate the HCP will order?
- Propranolol
- Metoclopramide
- Ranitidine
- Vasopressin
- 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
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
Change on orientation
Asterixis
Shaky handwriting
Jaundice & anorexia are signs of liver dysfunction but not indicators of HE
137
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
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..
