Hepatic Flashcards
1
Q
What are the metabolic functions of the liver?
A
- Glucose metabolism
- Ammonia conversion
- Protein metabolism
- Fat metabolism
- Vitamin and iron storage
- Bile formation
- Bilirubin excretion
- Drug metabolism
These functions are crucial for maintaining homeostasis in the body.
2
Q
What must be considered for the geriatric patient in regards to hepatic function?
A
- Atypical presentation of biliary disease (More severe complications)
- Increased prevalance of gallstones
- Rapid progression of Hep C and decreased response to treatment
Decreased
* Clearance of Hep B Antigen
* Drug metabolism/clearance
* Intestinal/portal vein blood flow
* Gallbladder contraction
* Rate of repair of liver cells after injury
* Size/wt of liver: more dec. in women
3
Q
What is jaundice?
A
Yellow- or greenish-yellow sclera and skin caused by increased serum bilirubin levels
Bilirubin level exceeds 2 mg/dL, and it can be classified into hemolytic, hepatocellular, and obstructive types.
4
Q
Which diagnostic tests are considered Liver Function Studies?
A
- Serum amino transferase (ALT, AST, GGT, GGTP, LDH)
- Serum protein studies
- Direct and indirect serum bilirubin, urine bilirubin, and urobilinogen
- Clotting factors
- Serum alkaline phosphatase
- Serum ammonia
- Lipids
5
Q
What does alanine aminotransferase (ALT) indicate?
A
- Increased in liver disorders
- Used to monitor the course of hepatitis, cirrhosis
- Used to monitor effects of treatments that may be toxic to the liver
6
Q
What does aspartate aminotransferase (AST) indicate?
A
- Not specific to liver diseases
- Levels of AST may be increased in cirrhosis, hepatitis, and liver cancer
7
Q
What does gamma-glutamyl transferase (GGT) indicate?
A
- Associated with cholestasis
- Alcoholic liver disease
8
Q
What questions would be asked during a health history of the patient with alterations of the liver?
A
- Exposure to hepatotoxic drugs or infectious agents? (Hepatitis. tylenol,)
- Travel, alcohol, drug use?
- Lifestyle?
9
Q
What would a physical assessment of the patient with alterations of the liver be focused on?
A
- Skin (color, bruising, spider angiomas)
- Cognitive status
- Abdominal palpation, percussion, measurement
10
Q
What are some of the different classifications of liver dysfuntion?
A
- Acute or chronic, cirrhosis of the liver
- Hepatitis (inflammation of the liver)
- Infection
- Liver failure associated with alcohol use
- Fatty Liver Disease
- Nonalcoholic fatty liver disease
- Nonalcoholic steatohepatitis
11
Q
What are some common clinical manifestations of hepatic dysfunction?
A
- Jaundice
- Cirrhosis
- Encephalopathy
- Spider angiomas
- Lack of body hair
- Muscle wasting
- Widened blood vessels
- Ascites
- Red palms
12
Q
Fill in the blank: Hepatic encephalopathy is caused by the accumulation of _______ and other toxic metabolites in the blood.
A
ammonia
13
Q
What are the signs and symptoms associated with hepatocellular jaundice?
A
- Lack of appetite
- Nausea or vomiting
- Weight loss
- Malaise
- Fatigue
- Weakness
- Headache
- Chills
- Fever
- Infection
These symptoms can vary from mild to severe.
14
Q
What are signs and symptoms associated with obstructive jaundice?
A
- Dark orange-brown urine
- Clay colored stools
- Dyspepsia
- Intolerance of fats
- Impaired digestion
- Pruritis
15
Q
What is portal hypertension?
A
Obstructed blood flow through the liver results in increased pressure throughout the portal venous system
This condition can lead to complications such as ascites and esophageal varices.
16
Q
What are the causes of ascites?
A
- Portal hypertension (increased capillary pressure, obstruction of venous blood flow)
- Vasodilation of splanchnic circulation
- Changes in aldosterone metabolism (increasing fluid retention)
- Decreased synthesis of albumin (which decreases serum osmotic pressure)
- Movement of albumin into the peritoneal cavity (increasing osmotic pressure of the peritoneal cavity)
Ascites is characterized by fluid accumulation in the abdominal cavity.
17
Q
What should be assessed in a patient with suspected ascites?
A
- Record abdominal girth
- Daily weights
- Look for stretch marks, distended veins, and umbilical hernia
- Assess for fluid in abdominal cavity by percussion (dullness)
- Monitor for potential fluid and electrolyte imbalances
18
Q
True or False: Hepatitis A is transmitted through blood.
A
False
Hepatitis A is primarily transmitted via the fecal-oral route (poor hand hygiene)
19
Q
How long may a Hepatitis A infection last?
A
4 - 8 weeks
20
Q
What are the clinical manifestations of
Hepatitis A?
A
- Mild flu-like symptoms
- Low grade fever
- Anorexia
- Jaundice (late sign)
- Dark Urine (late sign)
- Indigestion
- Epigastric distress
- Enlargement of liver and spleen
21
Q
What is the incubation period of
Hepatitis A?
A
2 - 6 weeks
22
Q
Which other hepatitis virus resembles Hepatitis A?
A
Hepatitis E
Mild, abrupt onset, self-limiting
Not chronic
23
Q
What are the manifestations of
Hepatitis B?
A
- Insidious and variable symptoms
- Loss of appetite
- Dyspepsia
- Abdominal pain
- Generalized aching
- Malaise
- Weakness
- Jaundice may or may not be evident
Hepatitis B is a major worldwide cause of cirrhosis and liver cancer.
24
Q
How is the Hepatitis B virus spread?
A
- Blood
- Saliva
- Semen and vaginal secretions
- Sexually transmitted
- Transmitted to infant at time of birth
25
What is the incubation period for **Heptatits B**?
1 to 6 **months**
26
How is the
**Heptatits C** virus spread?
* Blood
* Sexual contact
* Needle sticks
* Sharing needles
## Footnote
Hepatitis C is the most common bloodborne infection and causes 1/3 of the cases of liver cancer.
It is also the most common reason for a liver transplant
27
What is the incubation period for
**Hepatitis C**?
15 to 160 days
## Footnote
Symptoms are usually mild, and chronic carrier state frequently occurs.
28
What are the symptoms of **Hepatitis C**?
* Typically mild
* Often causes a chronic carrier state
29
Who is at risk for
**Hepatitis D**?
* Only those that have Hepatitis B
It is transmitted by blood and sexual contact
## Footnote
Interferon alfa is the only licensed drug available in the treatment of Hepatitis D virus
30
List the types of liver cirrhosis
* Alcoholic *(scar tissue surrounds the portal areas)*
* Post-necrotic *(broad bands of scar tissue)*
* Biliary *(scarring occurs in the liver around the bile ducts)*
## Footnote
Each type has distinct characteristics related to scarring and liver damage.
31
What is the mortality rate for the first bleeding episode from esophageal varices?
10% to 30% depending on severity
## Footnote
This complication occurs in patients with cirrhosis.
32
What are the major alterations leading to hepatic encephalopathy?
* Hepatic insufficiency
* Portosystemic shunting
## Footnote
These alterations prevent the liver from detoxifying toxic by-products of metabolism.
33
What are two early signs of hepatic encephalopathy?
* Mental changes
* Motor disturbances *(shuffling gait)*
34
What are the common causes of non-viral hepatitis?
* Toxic hepatitis
* Drug-induced hepatitis
* Fulminant hepatic failure
## Footnote
These conditions can lead to acute liver injury.
35
How is the **Hepatitis E** virus spread?
Fecal-Oral
Contaminated water
36
What are common clinical manifestations of esophageal varices?
* Hematemesis
* Melena
* General deterioration
* Shock
37
How often should patients with cirrhosis undergo screening endoscopies?
Every 2-3 years
38
What are primary liver tumors associated with and what is the medical term?
**Hepatitis B and C**
***Hepatocellular carcinoma***
39
What are common clinical manifestations of
**Liver Cancer**?
* Dull, persistent pain in the RUQ, back, or epigastrum
* Weight loss, anorexia, anemia
* Weakness
* Jaundice, bile ducts occluded
* Ascites
* Obstructed portal veins
40
How are
**Esophageal Varices** emergently treated?
* Treat for shock
* Administer oxygen
* IV fluids, volume expanders, blood and blood products
* Electrolyte replacement
* Vasopressin, somatostatin, octreotide to decrease bleeding
* Nitroglycerin in combination with the vasopressin to reduce coronary vasoconstriction
* Propranolol and nadolol to decrease portal pressure
* Balloon tamponade
41
What are some non-emergent treatments for **Esophageal Varices**?
* Endoscopic sclerotherapy
* Endoscopic variceal ligation
* Transjugular intrahepatic portosystemic shunt (TIPS)
**Surgical management**
* Surgical bypass procedures
* Devascularization and transection
42
How is **Ascites** treated?
* **Low-sodium diet** *(less than 2 grams or less than 500mg in extreme cases)*: Pt. can use salt substitutes - lemon juice, oregano, thyme
* **Diuretics**: **Spironolactone** or cautiously, furosemide.
* **Bed Rest**: sitting up can activate the RAAS and SNS
* **Paracentesis**: Removal of fluid from the peritoneal cavity *(always check BP and HR after)*
* **Salt-poor Albumin**: Increases effective arterial blood volume *(in low BP patients)*
* **Transjugular intrahepatic portosystemic shunt (TIPS)**: creates a shunt between portal circulation and hepatic vein
43
What are the nursing interventions for
**Ascites**?
**Goal: Assess progression and/or response to treatment**
* Strict I&Os
* Abdominal girth
* Daily weights
**Monitor:**
* Respiratory status
* Labs: Ammonia, creatinine, electrolytes
* Response to therapy
* S/S of hepatic encephalopathy
44
What are the nursing interventions for a patient with
**Esophageal Varices**?
* Maintain safe environment: Prevent injury, bleeding, and infection *(d/t dec. clotting factors and higher risk of infection)*
* Administer prescribed treatments and monitor for complications *(BP)*
* Encourage deep breathing and position changes *(slow position changes)*
* Pt and family education
45
What is the medical management of
**Hepatic Encephalopathy**?
* Eliminate precipating cause
* Treat electrolyte imbalances
* Lactulose to reduce serum ammonia
* IV glucose to minimize protein catabolism
* Protein restriction - depending on level of altered mentation
* Reduction of ammonia from GI tract by gastric suction, enemas, and/or oral antibiotics
* Discontinue sedatives, analgesics, and tranquilizers
* Monitor or treat complications and infections with antibiotics
46
What are nursing interventions for
**Hepatic Encephalopathy**?
* Maintain safe environment
* Administer prescribed treatments to prevent complications
* Encourage deep breathing and position changes
* Communicate with and educate family about treatments, symptoms, recurrences, and diet
**Monitor**:
* Neuro status
* I&Os
* Vital signs at least Q4H
* Labs: Ammonia levels
47
What nutritional supplements do patients with hepatic dysfunction (especially alcohol related) need?
* Vitamin A, B-complex, C, K
* Folic Acid
* Thiamine (B1)
* Riboflavin (B2)
* Pyridoxine (B6)
48
**Hepatitis A**
Management
**Prevention!**
* Good handwashing, safe water, proper sewage disposal
* Vaccine
* Immunoglobulin to provide passive immunity to those exposed
**Bed rest during the acute stage**
**Nutritional Suppport**
49
**Hepatitis B**
Management
**Prevention!**
* Vaccine for persons at high risk, routine for infants
* Standard precautions and infection control measures
* Immunoglobulin for those exposed
* Screening of blood and blood products
**Bed rest and nutritional support**
**Medications**: alpha interferon, entecavir, tenofovir
## Footnote
***Cannot be cured. Can recover, but may develop into chronic condition leading to liver cirrhosis, failure, or cancer***
50
**Hepatitis C**
Management
**Prevention!**
* Public health programs *(clean needles to drug users)*
* Screening of blood supply
* Safety needles for health care workers
**Medications**: antivirals
* Avoid alcohol and any hepatotoxic medications
## Footnote
Hepatitis C **CAN** be cured
51
What are clinical manifestations of
**Decompensated Hepatic Cirrhosis**?
* Portal hypertension
* Ascites
* Esophageal varices
* Hepatic encephalopathy
## Footnote
**Due to failure of liver to be able to synthesize proteins and clotting factors**
52
What are nursing interventions for a patient with **Cirrhosis** of the liver?
* Promote rest
* Improve nutritional status
* Provide skin care
* Reduce risk of injury
* Monitor for and manage potential complications
53
What interventions will improve nutritional status for the patient with
**Cirrhois of the liver**?
* I&Os
* Encourage small frequent meals
* High-calorie diet
* Sodium restriction
* Protein modified or restricted if patient is at risk for encephalopathy
* Supplemental vitamins, minerals, B-complex
* Provide water soluble forms of fat soluble vitamins if patient has steatorrhea
* Consider patient preferences
54
What interventions will help with skin care for the patient with **Cirrhosis of the liver**?
* Frequent position changes
* Gentle skin care
* Reduce scratching related to pruritus
55
What interventions will help prevent injury to the patient with **Cirrhosis of the liver**?
* Fall precautions to prevent trauma and risk of bleeding
56
What are some non-surgical treatments for the patient with
**Liver Cancer**?
* Radiation therapy
* Chemotherapy
* Percutaneous biliary drainage
## Footnote
May be palliative
57
What are some surgical treatments for the patient with **Liver Cancer**?
* Lobectomy *(Treatment of choice if cancer is confined to one lobe and liver function is adequate)*
* Cyrosurgery
* Liver Transplant
## Footnote
**Liver has regenerative capacity**
58
What is the nursing care management for a patient undergoing a
**Liver transplant**?
**Preoperative:**
* support, education, and encouragement
**Postoperative:**
* Monitor respiratory
* Monitor for vascular complications *(bleeding in or out of abdomen)* **First sign: Low BP**
* Monitor neurological status
* Monitor closely for s/s of infection
* Consider caregiver stress
59
**You are caring for a patient with ongoing ascites. You know the best first choice diuretic is:**
**a.** Acetazolamide
**b.** Ammonium chloride
**c.** Furosemide
**d.** Spironolactone
**d. Spironolactone**
**Rationale:**
Spironolactone is most often the first-line therapy in patients with ascites from cirrhosis. Oral diuretics such as furosemide may be added but should be used cautiously. Ammonium chloride and acetazolamide are contraindicated because of the possibility of precipitating hepatic coma.
60
**You are the nurse giving patient education about Hepatitis D. You know the patient needs further teaching if they state which of the following:**
**a.** "Only persons with hepatitis B are at risk for hepatitis D."
**b.** "I don't use IV drugs, so I won't contract Hepatitis B or D"
**c.** "I know that if I have sexual contact with those who have hepatitis B, I could get Hepatitis B and D."
**d.** "I could get liver disease or chronic hepatitis and cirrhosis."
**b. "I don't use IV drugs, so I won't contract Hepatitis B or D"**
**Rationale:**
Only persons with Hepatitis B are at risk for hepatitis D. Hepatitis D is common among those who use IV or injection drugs, patients undergoing hemodialysis, and recipients of multiple blood transfusions. Sexual contact with those who have hepatitis B is considered to be an important mode of transmission of hepatitis B and D. Patients with Hepatitis D are likely to develop fulminant liver failure or chronic active hepatitis and cirrhosis.
61
**Which laboratory finding is most indicative of liver failure?**
**a.** Elevated liver enzymes
**b.** Prolonged prothrombin time
**c.** Low albumin levels
**d.** Elevated bilirubin levels
**b. Prolonged prothrombin time**
**Rationale:**
A prolonged prothrombin time indicates impaired liver function, as the liver is responsible for producing clotting factors. This is a critical indicator of liver failure.
62
**What is the primary nursing intervention to manage a patient's ascites?**
**a.** Administering diuretics
**b.** Encouraging increased fluid intake
**c.** Providing a high-sodium diet
**d.** Performing frequent abdominal massages
**a. Administering diuretics**
**Rationale:**
Diuretics, particularly aldosterone antagonists, are used to manage ascites by promoting fluid excretion and reducing fluid accumulation in the abdomen.
63
**Which complication is the patient with liver dysfunction/cirrhosis at highest risk for?**
**a.** Pulmonary embolism
**b.** Esophageal varices
**c.** Myocardial infarction
**d.** Deep vein thrombosis
**b. Esophageal varices**
**Rationale:**
Patients with liver failure and portal hypertension are at high risk for developing esophageal varices, which can lead to life threatening bleeding.
64
**Which dietary modification should be recommended to the patient with liver failure?**
**a.** High-protein diet
**b.** Low-sodium diet
**c.** High-fat diet
**d.** Low-carbohydrate diet
**b. Low-sodium diet**
**Rationale:**
A low-sodium diet is recommended to help manage fluid retention and ascites in patients with liver failure.
65
**Which medication should be avoided in a patient with liver failure?**
**a.** Acetaminophen
**b.** Ibuprofen
**c.** Aspirin
**d.** Metformin
**a. Acetaminophen**
**Rationale:**
Acetaminophen is hepatotoxic and should be avoided in patients with liver disease to prevent further liver damage
66
**What is the rationale for administering lactulose to a patient with liver failure?**
**a.** To reduce ammonia levels
**b.** To increase appetite
**c.** To manage ascites
**d.** To prevent infection
**a. To reduce ammonia levels**
**Rationale:**
Lactulose is used to reduce ammonia levels in the blood, which helps prevent or treat hepatic encephalopathy
67
**What assessment finding would indicate worsening hepatic encephalopathy?**
**a.** Decreased abdominal girth
**b.** Improved appetite
**c.** Increased confusion
**d.** Reduced jaundice
**c. Increased confusion**
**Rationale:**
Increased confusion is a sign of worsening hepatic encephalopathy, indicating elevated ammonia levels and further liver dysfunction
68
**What ethical consideration should the nurse keep in mind when discussing liver transplantation with a patient?**
**a.** The patient's ability to afford the procedure.
**b.** The patient's social support system
**c.** The patient's compliance with medical recommendations
**d.** The patient's age and gender
**c. The patient's compliance with medical recommendations**
**Rationale:**
Compliance with medical recommendations is crucial for successful liver transplantation outcomes, and ethical considerations include ensuring the patient understands and is willing to adhere to post-transplant care.
69
**What ethical consideration should the nurse keep in mind when discussion alcohol cessation with a patient?**
**a.** Ensuring patient autonomy
**b.** Maintaining patient confidentiality
**c.** Providing culturally sensitive care
**d.** Avoiding judgmental language
**d. Avoiding judgmental language**
**Rationale:**
When discussing alcohol cessation, it is important to avoid judgmental language to foster a supportive and non-threatening environment, encouraging the patient to engage in treatment
