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Liver > Liver > Flashcards

Liver Flashcards

1
Q

Blood supply to the liver

A
  1. 75% from Portal Vein (drains GI tract); high in nutrients
  2. Hepatic Artery - high in O2
  3. Hepatic Vein - empties into inferior vena cava
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2
Q

Where is bile made?

A

Liver

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3
Q

Where is bile stored?

A

Gall bladder

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4
Q

Functions of the Liver (9)

A
  1. Glucose metabolism
  2. Ammonia conversion
  3. Protein metabolism
  4. Fat metabolism
  5. Vitamin and Iron Storage
  6. Drug Metabolism
  7. Bile Formation
  8. Bilirubin Excretion
  9. Blood Resevoir
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5
Q

Ammonia conversion

A

Gluconeogenesis and intestinal bacteria produce ammonia; liver converts ammonia to urea for urine excretion
*Ammonia is toxic to the brain

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6
Q

Protein metabolism

A

Synthesizes plasma proteins (albumin, globulins, clotting factors, transport proteins, plasma lipoproteins)
*Requires vitamin K for synthesis of prothrombin and other clotting factors

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7
Q

What is the function of albumin?

A

It holds our fluid in vascular space; when albumin is low third spacing occurs “santa claus belly”

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8
Q

Vitamin and Iron Storage

A

Vitamins A, B12, D, B complex, E, K, and Fe and copper stored in the liver

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9
Q

First Pass Effect

A

Drug Metabolism in the Liver

Meds are absorbed from GI tract and metabolized by liver before reaching systemic circulation

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10
Q

Bioavailability

A

Drug Metabolism in the Liver

% of administered drug reaching systemic circulation

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11
Q

Bile Formation in the Liver

A
  1. Composed of H20 and electrolytes
  2. Produces 700 mL/day
  3. Stored in gall bladder
  4. Excretes bilirubin
  5. Empties into duodenum for digestion
  6. Aids digestion by emulsifying fats by bile salts
  7. Aids absorption of fat soluble vitamins ADEK
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12
Q

Bilirubin Excretion by the Liver

A
  1. It is a pigment derived from breakdown of hemoglobin
  2. Excreted in feces and urine
  3. Bilirubin excretion increases with liver disease, gall stones, and destruction of RBC
  4. Not H2O soluble (unconjugated/indirect)
  5. Liver converts it to H2O soluble (conjugated/direct)
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13
Q

Blood Reservoir in the Liver

A
  1. Vascular storehouse

2. Expelled during hemorrhage

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14
Q

Geriatric Considerations concerning the liver

A
  1. The liver decreases in size in weight as a person ages
  2. LFTs don’t change with aging
  3. Decreased immunity which means there is an increased incidence of hepatitis B
  4. Medication metabolism decreases. There is an increased risk of toxicity with anticonvulsants, psychotropics, PO anticoagulants (When med metabolism decreases this would show up on a liver function test)
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15
Q

How will the liver appear during assessment if the patient has cirrosis?

A

Small and hard

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16
Q

How will the liver appear during assessment if the patient has acute hepatitis

A

Soft, mobile, tender

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17
Q

How will the liver appear during assessment if the patient has alcoholic hepatitis?

A

Nontender

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18
Q

Liver Function Tests are measured how?

A

By serum enzyme activity (blood draw)

[serum protein concentration (albumin, globulins), bilirubin, ammonia, clotting factors, lipids]

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19
Q

What is the best indicator for liver function?

A

Liver biopsy

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20
Q

Pre-Procedure for Percutaneous Needle Biopsy

A
  1. Signed consent obtained by the MD

2. Blood pressure, pulse, respirations, temperature, and coagulation studies done before the procedure

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21
Q

During the Procedure of a Percutaneous Needle Biopsy

A
  1. Support the patient
  2. Patient exposes RUQ
  3. Have patient inhale/exhale several times
  4. Have the patient exhale and hold it
  5. The biopsy needle is inserted, aspirate, and withdrawn
  6. Have patient resume breathing
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22
Q

Post Procedure for Percutaneous Needle Biopsy

A
  1. Have patient lay on their right-side on a pillow immobile for 3-4 hours after procedure
  2. Avoid coughing and straining
  3. VS Q15min X 4, Q30min X 2 until stable
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23
Q

Complications of Percutaneous Needle Biopsy

A
  1. Bile Peritonitis

2. Bleeding

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24
Q

S/Sx of bile peritonitis

A
  1. Increase BP
  2. Increase temperature
  3. Rigid, board-like abdomen
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25
Q

S/Sx of bleeding

A
  1. Decreased BP

2. Rigid, board-like abdomen

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26
Q

Radioisotope Liver Scan (HIDA)

A

Assesses the size, flow, and obstruction of liver

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27
Q

Laparoscopy

A

Examines the liver endoscopically (makes an incision and inserts a camera)

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28
Q

Causes of hepatic dysfunction

A
  1. Liver disease
  2. Obstruction of bile flow
  3. Alteration in hepatic circulation
  4. Malnutrition (from alcoholism)
  5. Infection
  6. Anoxia
  7. Metabolic disorder
  8. Toxins/meds
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29
Q

The main S/Sx of hepatic dysfunction

A
  1. Jaundice
  2. Portal hypertension/ascites
  3. Nutritional deficiencies
  4. Encephalopathy/Coma
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30
Q

S/Sx of jaundice

A
  1. Yellow skin or sclera

2. High bilirubin

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31
Q

Pathophysiology of Portal HTN/Ascites

A

Obstruction of flow in liver = increase BP in portal venous system

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32
Q

Potential Complication of Portal HTN

A

Formation of esophageal, gastric, hemorrhoidal varicosities (varices) = rupture, hemorrhage
*Accumulation of fluid in the abdominal cavity (ascites)

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33
Q

S/Sx of Portal HTN/Ascites

A
  1. Increased abdominal girth
  2. SOB
  3. F/E imbalance
  4. Weight gain
  5. Striae
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34
Q

Physical Assessment of Portal HTN/Ascites

A
  1. Percuss abdomen
  2. Bulging flanks
  3. Measure abdominal girth
  4. Daily weights
  5. Auscultate bruits over abdomen
  6. Fluid waves
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35
Q

Treatment of Portal HTN/Ascites

A
  1. Diet - low sodium
  2. Diuretics - Spironalactone
  3. Daily Weights
  4. Paracentesis
  5. IV Salt Poor Albumin
  6. TIPS
  7. Home Care
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36
Q

What is paracentesis?

A

Treatment for Ascites

  1. Removal of peritoneal fluid via surgical puncture in abdominal wall
  2. Fluid used to diagnose
  3. Possibly 4-6 L of fluid removed via gravity
  4. Warranted with respiratory distress
  5. Patient needs to void
  6. Informed consent verified
  7. Sedation/Local anesthetic to numb
  8. Post procedure - sterile pressure dressing and frequent VS
37
Q

Potential Complications of paracentesis

A
  1. Bladder perforation

2. Hypovolemia

38
Q

Purpose of IV Salt Poor Albumin

A

Decrease edema/ascites; pulls fluid into the bloodstream; excreted by kidneys

39
Q

What is the TIPS procedure?

A

Shunt from the liver to the vena cava

40
Q

What is hepatic encephalopathy?

A

Results from accumulation of ammonia in the blood because liver can’t detox/convert ammonia to urea

41
Q

Causes of hepatic encephalopathy

A
  1. GI bleed
  2. High protein diet
  3. Bacterial infection
  4. Uremia
42
Q

S/Sx of hepatic encephalopathy

A
  1. Minor mental changes/motor disturbances
  2. Slight confusion
  3. Altered mood
  4. Unkept
  5. Change in sleep patterns
  6. Asterixis
  7. Constructional apraxia
  8. Deep tendon reflexes hyperactive first, then absent
  9. Fetor hepaticus
  10. Disorientation
  11. Coma/seizure
43
Q

Asterixis

A

“liver flap”

Involves flapping of hands on dorsiflexion

44
Q

Constructional apraxia

A

Inability to reproduce simple figures

45
Q

Diagnostic Test for hepatic encephalopathy

A

EEG will show slowed brain waves

46
Q

Medical Management of hepatic encephalopathy

A
  1. Treat to remove cause
  2. Neuro checks frequently
  3. I/O and daily weights
  4. VS q4h
  5. Assess lungs/peritoneum frequently
  6. Serum ammonia QD
  7. Restrict protein
  8. Monitor electrolytes
  9. DC sedatives/tranquilizers/analgesics because the liver can’t metabolize them
  10. Benzodiazepines to improve encephalopathy
  11. IV glucose to decrease protein breakdown
47
Q

Diet for hepatic encephalopathy

A
  1. Low protein (no animal) 20-60 g/day add gradually

2. High calorie

48
Q

Secondary s/sx of hepatic dysfunction

A
  1. Edema secondary to hypoalbuminemia
  2. Bleeding secondary to decrease production of clotting factors, absorption of vitamin K
  3. Vitamin deficiency secondary to secretion of bile salts
  4. Hypo/hyperglycemia
  5. Gynecomastia, irregular periods, disturbance in sexual function secondary to metabolism of estrogen
  6. Splenomegaly secondary to portal HTN
  7. Pruritis secondary to retained bile salts
  8. Spider angioma above waistline
  9. Palmar erythema
49
Q

What is hepatic cirrhosis?

A

Chronic disease in which normal liver tissue replaced by diffuse fibrosis (scarring) disrupts structure and function; liver bile ducts inflamed and occluded; attempt to form new bile channels; tissue overgrowth; scarring

50
Q

Types of hepatic cirrhosis

A
  1. Alcoholic - most common (scar tissue at portal site)
  2. Postnecrotic - scar tissue after repeated acute hepatitis
  3. Biliary - scarring secondary to obstruction/infection
51
Q

S/Sx of hepatic cirrhosis

A
  1. Liver enlargement
  2. Portal obstruction/ascites
  3. Infection/peritonitis
  4. GI varices
  5. Edema secondary to low albumin (Na and H20 retained)
  6. Vitamin deficiency/anemia
  7. Mental deterioration (high ammonia)
52
Q

Lab Results of hepatic cirrhosis patient

A
  1. Low albumin
  2. High serum globulin
  3. High AST
  4. High ALT
  5. High GGT
  6. High PT
53
Q

Diagnostic Test for hepatic cirrhosis

A
  1. U/S
  2. CT
  3. MRI
  4. Liver bx
54
Q

Medical Management of hepatic cirrhosis

A

Manage Symptoms

  1. GI distress - antacids
  2. Damaged liver cells - multivitamins
  3. Ascites - K sparing diuretic/IV salt poor albumin
  4. Diet - no alcohol/balanced diet
  5. Colchicine - anti gout/ increases survival time
  6. Neomycin - decrease GI bacteria to decrease ammonia formation (ototoxic)
55
Q

Nursing Management of hepatic cirrhosis

A
  1. Provide rest - I/O, daily weight, resp therapy, O2, turn 2h, mild exercise
  2. Improve nutrition - increase vitamins, small frequent meals, preferences, ADEK, TPN, low protein
  3. Skin care - edema, immobile, jaundice, lotion, tepid bath
  4. Reduce risk of injury - side rails up and padded, orient, explain, pressure after injection, soft toothbrush, no razor, melena, hematemesis
56
Q

Potential Complications of hepatic cirrhosis

A
  1. GI issues
  2. Hepatic encephalopathy
  3. CHF/Fluid volume excess
57
Q

Cause of bleeding esophageal varices

A

Portal HTN secondary obstruction in cirrhotic liver leads to collateral circulation

58
Q

Factors that contribute to hemorrhage of esophageal varices

A
  1. Lifting heavy objects
  2. Valsalva
  3. Sneeze
  4. Cough
  5. Vomit
  6. Poorly chewed foods
  7. Irritating fluids
  8. GERD
  9. Alcohol
  10. ASA
59
Q

S/Sx of bleeding esophageal varices

A
  1. Hematemesis
  2. Melena
  3. Deterioration of mental status
  4. Shock - cool, clammy skin, low BP, high HR
  5. Low GI bleed/hemorrhoids - bright red stool
  6. Upper GI bleed = black, tarry stool
60
Q

Diagnostic Test for esophageal varices

A
  1. Endoscopy - cause/site of bleed
  2. Portal HTN - dilated abdominal veins, rectal hemorrhoids, splenomegaly
    * Measured indirectly - via catheter inserted into femoral vein to hepatic vein
    * Measures directly - needle into spleen or insert catheter into portal vein
  3. LFTs
  4. Hepatic blood flow studies
  5. Splenoportography X-rays - detect collateral circulation in esophageal vessels
61
Q

Medical Management of esophageal varices

A
  1. Medications to reduce portal pressure
  2. Endoscopic injection sclerotherapy
  3. Variceal band ligation
  4. TIPS
  5. Balloon tampanade
62
Q

Endoscopic Injection Sclerotherapy

A

Inject medication directly into varices which collapses it

63
Q

Variceal Band Ligation

A

Mini rubber bands placed around variceal “stalk”

64
Q

Nursing Priorities for Balloon Tampanade

A
  1. Explain before procedure
  2. Monitor patient closely for displacement, airway obstruction, aspiration = offer oral suction
  3. May be irrigated - document amount/color of return
  4. Monitor for confusion - client may accidentally discontinue the apparatus
65
Q

S/Sx of liver cancer

A
  1. Dull ache in RUQ, epigastrium, and back
  2. Anorexia
  3. Generalized muscle weakness
66
Q

Lab Results for Liver Cancer

A
  1. High bilirubin, alk phos, AST, GGT, WBC, RBC, and Ca
  2. Low BG, cholesterol
  3. High AFP (alpha fetoprotein) tumor marker with primary liver cancer
  4. High CEA (carcinoembrionic antigen)
67
Q

Diagnostic Tests to confirm liver cancer

A
  1. X-ray
  2. CT
  3. Liver scan
  4. Laproscopy
  5. CT guided bx
  6. PET
68
Q

Risk Factors for Liver Cancer

A
  1. Cirrhosis from Hepatitis B/C
  2. Chemical toxins
  3. Cigarette smoking
  4. Alcohol
  5. Alphatoxins in nuts and grains
69
Q

Treatment for liver cancer

A
  1. Surgical resection early - remove lobe
  2. Radiation and Chemotherapy
  3. Percutaneous biliary drainage system to relieve pressure and pain
  4. Laser hyperthermia
  5. Liver transplant
70
Q

Normal range for ALT

A

2.4 - 17 units/L

71
Q

Why would ALT be elevated?

A
  1. Hepatitis
  2. Cirrhosis
  3. Liver tumor
  4. Hepatotoxic trugs
  5. Cholestasis
72
Q

Normal range for AST

A

4.8 - 19 units/L

73
Q

Why would AST be elevated?

A
  1. MI
  2. Hepatitis
  3. Cirrhosis
  4. Acute pancreatitis
  5. Skeletal muscle trauma
  6. Liver tumor
  7. Primary muscle diseases (myopathy)
74
Q

Why would AST be decreased?

A
  1. DKA

2. Pregnancy

75
Q

Normal range for serum ammonia

A

15 - 45 mcg/dL

76
Q

Why would serum ammonia be elevated?

A
  1. Hepatic disease
  2. Renal failure
  3. Reye’s syndrome
  4. Hepatic encephalopathy
  5. Coma
77
Q

Why would serum ammonia be decreased?

A
  1. Malignant hypertension
78
Q

Normal range for bilirubin

A

0 - 0.9 mg/dL

79
Q

Why would bilirubin be elevated?

A
  1. Cirrhosis
  2. Hepatitis
  3. Hemolytic anemia
  4. Jaundice
  5. Bile duct obstruction
  6. Transfusion reaction
80
Q

Normal range for serum albumin

A

3.5 - 5 g/dL

81
Q

Why would serum albumin be decreased?

A
  1. Liver disease
  2. Crohn’s disease
  3. Glomerulonephritis
  4. Ascites
  5. Burns
  6. Malnutrition
  7. Lupus
82
Q

Normal range for PT

A

9.5 - 12 seconds

83
Q

Why would PT be elevated?

A
  1. Cirrhosis
  2. Hepatitis
  3. Vitamin K deficiency
  4. Salicylate intoxication
  5. Bile duct obstruction
  6. Intake of warfarin
  7. Disseminated intravascular coagulation
84
Q

Normal range for aPTT

A

20 - 39 seconds

85
Q

Why would aPTT be elevated?

A
  1. Clotting factor deficiencies
  2. Cirrhosis
  3. Vitamin K deficiency
  4. Leukemia
  5. Disseminated intravascular coagulation
  6. Administration of heparin
  7. Hemophilia
86
Q

Normal range for cholesterol

A

150 - 200 mg/dL

87
Q

Why would cholesterol be elevated?

A
  1. Hyperlipidemia
  2. Hypothyroidism
  3. Uncontrolled diabetes
  4. HTN
  5. Atherosclerosis
  6. MI
  7. Binary cirrhosis
88
Q

Why would cholesterol be decreased?

A
  1. Malabsorption syndrome
  2. Malnutrition
  3. Hyperthyroidism
  4. Anemia
  5. Sepsis
  6. Liver disease

Liver (2 decks)

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