Podcast
Questions and Answers
Which of the following is a metabolic function of the liver?
Which of the following is a metabolic function of the liver?
Liver function tests are not helpful in detecting the clinical manifestations of liver dysfunction.
Liver function tests are not helpful in detecting the clinical manifestations of liver dysfunction.
False
Which type of jaundice is most commonly associated with liver disease?
Which type of jaundice is most commonly associated with liver disease?
What is the term for the increased pressure throughout the portal venous system that results from obstruction of blood flow into and through the damaged liver?
What is the term for the increased pressure throughout the portal venous system that results from obstruction of blood flow into and through the damaged liver?
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Which of the following is NOT a cause of ascites?
Which of the following is NOT a cause of ascites?
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What is the medical abbreviation for Transjugular Intrahepatic Portosystemic Shunt?
What is the medical abbreviation for Transjugular Intrahepatic Portosystemic Shunt?
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Which of these signs would you NOT typically assess for in a patient with ascites?
Which of these signs would you NOT typically assess for in a patient with ascites?
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Which diuretic medication is most often used to treat ascites?
Which diuretic medication is most often used to treat ascites?
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Hepatic encephalopathy is a life-threatening complication of liver disease that often occurs with what?
Hepatic encephalopathy is a life-threatening complication of liver disease that often occurs with what?
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Hepatic encephalopathy is characterized by the accumulation of bilirubin in the bloodstream.
Hepatic encephalopathy is characterized by the accumulation of bilirubin in the bloodstream.
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The earliest symptoms of hepatic encephalopathy include mental status changes and ______.
The earliest symptoms of hepatic encephalopathy include mental status changes and ______.
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Which of the following is NOT a factor that may precipitate hepatic encephalopathy?
Which of the following is NOT a factor that may precipitate hepatic encephalopathy?
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What is the characteristic odor often associated with hepatic encephalopathy called?
What is the characteristic odor often associated with hepatic encephalopathy called?
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The medical management of hepatic encephalopathy and coma is focused on addressing the underlying cause of liver failure and eliminating contributing factors.
The medical management of hepatic encephalopathy and coma is focused on addressing the underlying cause of liver failure and eliminating contributing factors.
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Esophageal varices are a common complication of portal hypertension.
Esophageal varices are a common complication of portal hypertension.
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Which of the following is NOT a common clinical manifestation of bleeding esophageal varices?
Which of the following is NOT a common clinical manifestation of bleeding esophageal varices?
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Endoscopic sclerotherapy is a procedure commonly used to treat bleeding esophageal varices.
Endoscopic sclerotherapy is a procedure commonly used to treat bleeding esophageal varices.
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What is the primary mode of transmission for Hepatitis A?
What is the primary mode of transmission for Hepatitis A?
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What is the incubation period for Hepatitis A, in weeks?
What is the incubation period for Hepatitis A, in weeks?
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A vaccine for hepatitis A is available.
A vaccine for hepatitis A is available.
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Which type of hepatitis is considered a major worldwide cause of cirrhosis and liver cancer?
Which type of hepatitis is considered a major worldwide cause of cirrhosis and liver cancer?
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Hepatitis B can be transmitted through saliva, semen, and vaginal secretions.
Hepatitis B can be transmitted through saliva, semen, and vaginal secretions.
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Which type of hepatitis is considered the most common bloodborne infection?
Which type of hepatitis is considered the most common bloodborne infection?
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Hepatitis C is usually a mild infection with minimal long-term consequences.
Hepatitis C is usually a mild infection with minimal long-term consequences.
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Which of the following is NOT a recommended preventive measure for Hepatitis B?
Which of the following is NOT a recommended preventive measure for Hepatitis B?
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What are the two primary preventive strategies for Hepatitis C?
What are the two primary preventive strategies for Hepatitis C?
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Hepatic cirrhosis is a reversible condition.
Hepatic cirrhosis is a reversible condition.
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Which type of cirrhosis is associated with scarring that occurs in the liver around the bile ducts?
Which type of cirrhosis is associated with scarring that occurs in the liver around the bile ducts?
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What is the most common symptom of cirrhosis?
What is the most common symptom of cirrhosis?
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Which of the following is NOT a typical symptom of liver cirrhosis?
Which of the following is NOT a typical symptom of liver cirrhosis?
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The nursing process is a useful framework for providing patient care to individuals with cirrhosis of the liver.
The nursing process is a useful framework for providing patient care to individuals with cirrhosis of the liver.
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Study Notes
Assessment and Management of Patients With Hepatic Disorders
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Learning Outcomes:
- Identify metabolic liver functions and alterations in hepatic disorders (self-reading).
- Explain liver function tests and clinical manifestations of liver dysfunction in relation to pathophysiology (self-reading).
- Relate jaundice, portal hypertension, ascites, varices, nutritional deficiencies, and hepatic encephalopathy/coma to pathophysiological liver alterations.
- Describe medical, surgical, and nursing management of patients with esophageal varices.
- Compare different hepatitis types regarding causes, prevention, clinical manifestations, management, prognosis, and home health care needs.
- Utilize the nursing process as a framework for caring for cirrhosis of the liver patients.
- Specify postoperative nursing care for liver transplantation patients.
Key Terms
- Ascites: Albumin-rich fluid accumulation in the peritoneal cavity.
- Cirrhosis: Chronic liver disease with fibrotic changes, dense connective tissue formation, and loss of functioning cells.
- Jaundice: Yellowish/greenish-yellow sclerae and skin due to high bilirubin levels.
- Portal Hypertension: Elevated pressure in the portal circulation due to venous flow obstruction into and through the liver.
Review of Anatomy and Physiology
- The liver is the largest gland in the body, located in the upper right abdomen.
- It's a highly vascular organ receiving blood from the GI tract via the portal vein and from the hepatic artery.
Liver and Biliary System
- Diagram of liver lobes, gallbladder, falciform ligament, and round ligament, illustrating the liver's anatomical structure.
Section of a Liver Lobule
- Illustration displaying hepatic cells, portal vein, hepatic artery, bile duct and sinusoid components of a liver lobule. Highlights crucial structures and blood vessels.
- Indicates the central vein and Kupffer cells, important for liver function.
Metabolic Function of the Liver
- The liver has vital metabolic functions including glucose metabolism, ammonia conversion, protein metabolism, fat metabolism, vitamin and iron storage, bile formation, bilirubin excretion, and drug metabolism.
Liver Function Studies
- Serum aspartate aminotransferase (AST), alanine aminotransferase (ALT), gamma-glutamyl transferase (GGT), alkaline phosphatase, bilirubin, ammonia, and clotting factors: Measured to assess liver function and injury. Refer to Table 49-1 for specific details and ranges.
- Serum protein studies, direct and indirect serum bilirubin, urine bilirubin, and urine urobilinogen are also used
Liver Function Tests (Specific Enzymes)
- Serum aminotransferases (AST, ALT): Indicators of liver cell injury, useful in diagnosing hepatitis.
- Alanine aminotransferase (ALT): Primarily elevated in liver disorders, used to monitor treatment efficacy and toxicity.
- Aspartate aminotransferase (AST): Not specific to liver disease, but elevated levels may indicate issues like cirrhosis, hepatitis, and liver cancer.
- Gamma-glutamyl transferase (GGT): Associated with cholestasis and alcoholic liver disease.
Additional Diagnostic Studies
- Liver biopsy: Direct tissue examination, to determine the extent and type of liver damage.
- Ultrasonography: Uses sound waves to create images of the liver.
- CT (Computed Tomography) and MRI (Magnetic Resonance Imaging): Use advanced imaging techniques to produce detailed images for evaluation.
- Other imaging techniques, not described by the provided text.
Hepatic Dysfunction
- Cirrhosis of the liver: Chronic liver disease.
- Liver failure: Associated with alcohol use.
- Infection: A cause of hepatic dysfunction.
- Fatty liver disease: Nonalcoholic fatty liver disease (NAFLD) and nonalcoholic steatohepatitis (NASH) highlighted as common types.
Manifestations of Hepatic Dysfunction
- Jaundice: Yellow/greenish skin and sclera, caused by increased serum bilirubin.
- Portal Hypertension: Elevated pressure from obstructed blood flow into and through the damaged liver, accompanied by complications like ascites and esophageal varices.
- Ascites: Fluid accumulation in the abdominal cavity.
- Varices: Enlarged and dilated veins usually in the esophagus due to portal hypertension.
- Hepatic encephalopathy: Neuropsychiatric manifestation of liver failure with portal hypertension and blood shunting.
- Nutritional Deficiencies: Common issue due to liver dysfunction impacts nutrient processing and absorption.
Jaundice
- Serum bilirubin level of above 2 mg/dL.
- Hemolytic jaundice, Hepatocellular, Obstructive and Hereditary hyperbilirubinemia are types of jaundice
Signs and Symptoms of Hepatocellular and Obstructive Jaundice
- Obstructive jaundice: dark coloured urine, clay coloured stools, dyspepsia, intolerance to fats and pruritus.
- Hepatocellular jaundice: mild to severely ill, anorexia, nausea, vomiting, weight loss, malaise, fatigue, weakness, headache, chills, and infection
Fluid in Peritoneal Cavity
- Causes of Ascites: Portal hypertension, blood flow constriction, increased fluid content in abdominal organs, hormonal changes and decrease in osmotic pressure
Physiology/Pathophysiology (Ascites)
- Mechanisms linked to ascites formation as a result of cirrhosis with portal hypertension, through splanchnic arterial dilation, reduction in systemic blood volume, activation of renin-angiotensin and sympathetic-adrenal pathways, and resultant fluid retention due to sodium and water retention and continuous arterial underfilling.
Assessment of Ascites
- Daily monitoring of abdominal girth and weight.
- Assessment for striae, distended veins, and umbilical hernia.
- Percussion for shifting dullness and fluid wave.
- Monitoring of fluid and electrolyte imbalances.
Treatment of Ascites
- Low-sodium diet, diuretics, bed rest, paracentesis, administration of albumin, TIPS (Transjugular intrahepatic portosystemic shunt), and other procedures like peritoneovenous shunts.
TIPS
- Explanation of the procedure to create a shunt via catheter and stent placement in the liver to manage high blood pressure in the portal vein.
Nursing Management of Patients with Ascites
- Monitoring input and output (I&O).
- Measuring abdominal girth and daily weight.
- Respiratory status monitoring.
- Frequent assessment of ammonia, creatinine, and electrolyte levels.
- Responding to therapy and hepatic encephalopathy.
Question #2: Diuretic Medication for Ascites
- Furosemide (Lasix) is a common diuretic medication used for ascites management, not spironolactone.
Hepatic Encephalopathy
- Life-threatening condition associated with liver failure.
- Characterized by neuropsychiatric manifestation due to toxic by-product metabolism impairments, and portosystemic shunting (alternate blood flow pathways.)
Clinical Manifestations of Hepatic Encephalopathy
- Early symptoms: mental status changes, motor disturbances, confusion.
- Progressing symptoms: mood and sleep pattern alterations, difficulty awakening, disorientation, potentially frank coma, and possibly seizures.
Table 44-10: Factors Precipitating Hepatic Encephalopathy
- Various factors, such as GI bleeding, constipation, electrolyte abnormalities, infection, cerebral depressants, and metabolic disturbances, and their impact on ammonia levels in the body, in relation to hepatic encephalopathy. Includes relevant mechanisms.
Assessment (Hepatic Encephalopathy and Coma)
- EEG (Electroencephalogram) monitoring.
- Changes in level of consciousness (LOC).
- Identifying potential seizures.
- Assessing the characteristic hepatic breath odor, (fetor hepaticus).
- Monitoring fluid, electrolyte, and ammonia levels.
- Diagnosis of stages, using Table 49-3.
Asterixis and Apraxia
- Neurological signs associated with the disease and its progression. Details on how asterixis ("liver flap") and constructional apraxia (drawing impairment) manifest as indicators of hepatic encephalopathy severity. Refer to Figure 49-13 and 49-14 for illustrations.
Medical Management (Hepatic Encephalopathy)
- Eliminate precipitating factors (e.g., infections, bleeding).
- Reduce ammonia levels (e.g., lactulose).
- Minimize protein catabolism (e.g., IV glucose).
- Restrict protein intake when necessary.
- Correct existing abnormalities, like electrolyte imbalances.
- Discontinue sedatives, analgesics, and tranquilizers.
- Monitor and address complications/infections.
- Nutritional considerations.
Nutritional Management (Hepatic Encephalopathy)
- Nutritional management principles detailed as necessary interventions for the condition, including specific dietary concerns, and necessary chart references.
Nursing Management - Hepatic Encephalopathy
- Details on nursing assessment for hepatic encephalopathy, concerning patient condition and response to therapy. Includes complications that require specific management.
Esophageal Varices
- Varices, their development from portal pressure elevation, tendency to hemorrhage, and the necessity for screening in cirrhosis patients.
- Explanation of the pathophysiological mechanisms that lead to varicose vein formation in the esophagus as consequence of elevated portal pressure.
- Details on screening procedures and frequency.
Bleeding Esophageal Varices
- Portal hypertension, pressure gradients formation, collateral vein vascularity development, associated locations and rupture causes detailed in relation to hemorrhage.
Clinical Manifestations (Bleeding Esophageal Varices)
- Hematemesis, melena.
- Deterioration in mental/physical status.
- Shock (cool clammy skin, hypotension, tachycardia).
Assessment and Diagnostic Findings (Bleeding Esophageal Varices)
- Examination history, physical exam.
- Procedures such as endoscopy, ultrasonography, CT scanning, angiography, and endoscopic video capsule use to identify the bleeding source within the esophagus and varices.
Treatment of Bleeding Varices (Medical Management Approach)
- Aggressive medical interventions, mainly at the intensive care unit (ICU). Detailed treatment steps, including, and necessary fluids (electrolytes, volume expanders), blood and blood products, and vasoconstrictors like vasopressin, somatostatin, and octreotide to decrease bleeding and reduce coronary vasoconstriction. Included are treatments such as propranolol, nadolol, and balloon tamponade.
Balloon Tamponade
- Procedure description with diagram depicting the placement of gastric or esophageal balloons for controlling and reducing esophageal variceal bleeding.
Treatment of Bleeding Varices (Surgical and Endoscopic Approach)
- Details on different surgical and endoscopic procedures for managing bleeding esophageal varices, including endoscopic sclerotherapy, endoscopic variceal ligation (banding therapy,) and transjugular intrahepatic portosystemic shunts(TIPS). Also, surgical bypass and devascularization or transection are described
- Detailed explanations of endoscopic sclerotherapy and variceal banding procedures, accompanied by illustrated diagrams.
Portal System Shunts
- Illustrated diagrams (A through D.) detailing normal, and various types of shunts are used to manage complications from abnormal portal blood flow, including end-to-side portacaval shunts, splenorenal shunts, and H-graft mesocaval shunts, which are explained in the text.
Nursing Management (general)
- Nursing assessment (physical condition, emotional and cognition status, neurological status, vital signs and nutrition).
- Maintaining a safe environment to avoid injury
- Prescribed treatment monitoring for complications/care
- Encouraging deep breathing and positioning changes.
- Patient and family education/support.
Nursing Management (Specific to Ascites/Varices/Hepatic Encephalopathy)
- Nursing interventions focused on specific conditions, including details on interventions aimed at improving patient outcomes, such as encouraging rest, optimizing nutritional intake, managing skin care conditions, reducing injury risk, and monitoring/managing potential complications associated with treatment.
Hepatitis A
- Spread by poor hand hygiene and fecal-oral transmission.
- Incubation period: 2–6 weeks.
- Symptoms last 4–8 weeks, usually mild flu-like symptoms (low-grade fever, anorexia, later jaundice and dark urine, indigestion, epigastric distress, and liver and spleen enlargement).
- Prevention methods outlined (hand washing, sanitation).
- Management focuses on rest and nutritional support.
Hepatitis B
- Transmission through blood, saliva, semen, and vaginal fluids, frequently transmitted to infants during birth, and often a result of sexual contact.
- A major cause of cirrhosis and liver cancer.
- Incubation period 1 to 6 months
- Details on similar characteristics to HAV symptoms, and management.
- Medications and vaccine use for HBV as part of management strategies.
Hepatitis C
- Transmission by blood and sexual contact, including needle sharing.
- Common bloodborne infection, is a cause of one-third of liver cancers.
- Variable incubation period (15–160 days).
- Usually mild symptoms.
- Chronic carrier state is common.
- Management includes antiviral medications and public health preventive measures (needle sharing reduction.)
Hepatic Cirrhosis
- Chronic liver disease characterized by scar tissue formation.
- Various types, including alcoholic, postnecrotic, and biliary cirrhosis.
- Pathophysiology related to liver structure and function impairment details included.
Manifestations of Hepatic Cirrhosis
- Clinical manifestations of liver cirrhosis, including: liver enlargement, portal obstruction, ascites, infection and peritonitis, GI varices, edema, vitamin deficiency, anemia, and mental deterioration (refer to Chart 49-10).
Test Your Knowledge Questions
- Question about Hepatitis A patient assessment: Correct response to identifying a patient suspected of Hepatitis A is identified and explained.
- Question about advanced cirrhosis and abdominal swelling: Explain the best nurse response regarding the cause of swollen abdomen in a patient with advanced liver cirrhosis.
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Description
This quiz evaluates your understanding of hepatic disorders, focusing on liver functions and dysfunction. It explores liver function tests, manifestations of liver conditions, and management strategies for patients with various hepatic issues. From cirrhosis to esophageal varices, this quiz utilizes the nursing process to enhance patient care.
