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Questions and Answers
Which of these options are correct? (Select all that apply)
Which of these options are correct? (Select all that apply)
Which diuretic medication would most often be used for a patient with ascites?
Which diuretic medication would most often be used for a patient with ascites?
Hepatic encephalopathy is a neuropsychiatric manifestation of hepatic failure associated with portal hypertension and the shunting of blood from the portal venous system into the systemic circulation.
Hepatic encephalopathy is a neuropsychiatric manifestation of hepatic failure associated with portal hypertension and the shunting of blood from the portal venous system into the systemic circulation.
True
Which of the following is NOT a factor that precipitates hepatic encephalopathy?
Which of the following is NOT a factor that precipitates hepatic encephalopathy?
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Which of the following is a treatment for ascites?
Which of the following is a treatment for ascites?
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Which of the following is NOT a clinical manifestation of bleeding esophageal varices?
Which of the following is NOT a clinical manifestation of bleeding esophageal varices?
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Endoscopy can be used to identify the bleeding site in a patient with bleeding esophageal varices.
Endoscopy can be used to identify the bleeding site in a patient with bleeding esophageal varices.
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What is the name of the procedure that involves inserting a stent into the hepatic vein to relieve portal hypertension?
What is the name of the procedure that involves inserting a stent into the hepatic vein to relieve portal hypertension?
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Which of the following is a common cause of nonviral hepatitis?
Which of the following is a common cause of nonviral hepatitis?
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Hepatitis A is spread through blood, saliva, semen, and vaginal secretions.
Hepatitis A is spread through blood, saliva, semen, and vaginal secretions.
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There is a vaccine against Hepatitis A.
There is a vaccine against Hepatitis A.
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Hepatitis B is a major worldwide cause of cirrhosis and liver cancer.
Hepatitis B is a major worldwide cause of cirrhosis and liver cancer.
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There is a vaccine to prevent Hepatitis B.
There is a vaccine to prevent Hepatitis B.
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Hepatitis C is transmitted through which of the following?
Hepatitis C is transmitted through which of the following?
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Hepatitis C is a cause of one third of cases of liver cancer and the most common reason for liver transplant.
Hepatitis C is a cause of one third of cases of liver cancer and the most common reason for liver transplant.
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Cirrhosis is a chronic liver disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver.
Cirrhosis is a chronic liver disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver.
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Which of the following is NOT a type of cirrhosis?
Which of the following is NOT a type of cirrhosis?
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Mental deterioration is a common manifestation of hepatic cirrhosis.
Mental deterioration is a common manifestation of hepatic cirrhosis.
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Ascites is the build-up of fluid in the abdominal cavity, and it's a common complication of hepatic cirrhosis.
Ascites is the build-up of fluid in the abdominal cavity, and it's a common complication of hepatic cirrhosis.
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What is a nursing intervention directed toward promoting rest for a patient with hepatic cirrhosis?
What is a nursing intervention directed toward promoting rest for a patient with hepatic cirrhosis?
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Study Notes
Assessment and Management of Patients With Hepatic Disorders
- Learning Outcomes: Identify metabolic liver functions and alterations, explain liver function tests and clinical manifestations, relate jaundice, portal hypertension, and hepatic encephalopathy to pathophysiology, describe medical/surgical/nursing management of esophageal varices, compare hepatitis types, use the nursing process for cirrhosis, specify postoperative liver transplant care.
Key Terms
- Ascites: Albumin-rich fluid accumulation in the peritoneal cavity.
- Cirrhosis: Chronic liver disease with fibrotic changes, dense connective tissue, degenerative changes, and loss of functioning liver cells.
- Jaundice: Yellowish/greenish-yellow sclera and skin due to high bilirubin levels.
- Portal Hypertension: Elevated pressure in portal circulation caused by 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 is a highly vascular organ that receives blood from the gastrointestinal (GI) tract via the portal vein and from the hepatic artery.
Liver and Biliary System (Diagram)
- Shows the liver's lobes, inferior vena cava, gallbladder, falciform ligament, and round ligament.
Section of a Liver Lobule (Diagram)
- Illustrates the structure of a liver lobule, including portal vein, hepatic artery, hepatic cells, sinusoid, canaliculus, and central vein. It features Kupffer cells and bile ducts.
Metabolic Function of the Liver
- 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, ALT, GGT, GGTP, LDH), serum protein studies, direct/indirect serum bilirubin, urine bilirubin, urobilinogen, clotting factors, serum alkaline phosphatase, and serum ammonia. A table (49-1) is referenced.
Liver Function Tests (Specific Enzymes)
- Serum aminotransferases: Indicators of liver cell injury, useful in hepatitis detection.
- Alanine aminotransferase (ALT): Levels rise primarily in liver disorders, used to monitor treatment toxicity.
- Aspartate aminotransferase (AST): Not specific to liver disease, but elevated in cirrhosis, hepatitis, and liver cancer.
- Gamma-glutamyl transferase (GGT): Associated with cholestasis and alcoholic liver disease.
Additional Diagnostic Studies
- Liver biopsy, ultrasonography, CT, MRI, and other tests (refer to 49-3).
Hepatic Dysfunction
- Includes cirrhosis of the liver, liver failure associated with alcohol use, and infection.
- Fatty liver disease, nonalcoholic fatty liver disease(NAFLD), and nonalcoholic steatohepatitis(NASH) are subtypes.
Manifestations of Hepatic Dysfunction
- Jaundice: Yellow/greenish skin/sclera, serum bilirubin >2 mg/dL. Hemolytic, hepatocellular, obstructive, and hereditary hyperbilirubinemia are types.
- Portal Hypertension: Increased pressure in portal vein — leads to ascites and esophageal varices.
- Ascites & Varices: Fluid buildup in the abdominal cavity and enlarged blood vessels, respectively.
- Hepatic Encephalopathy/Coma: Neuropsychiatric manifestations of liver failure, including decreased mental status, and potential seizures or coma. (Refer to Table 49-3 for stages of encephalopathy.)
- Nutritional Deficiencies: Various nutrients may be deficient due to liver dysfunction.
Signs and Symptoms (Jaundice)
- Hepatocellular Jaundice: Mild/severe illness, loss of appetite, nausea, vomiting, weight loss, malaise, fatigue, weakness, headache, chills, fever, infection.
- Obstructive Jaundice: Dark orange-brown urine, clay-colored stools, dyspepsia, intolerance to fats, impaired digestion, and pruritus.
Portal Hypertension
- Increased pressure in the portal venous system from liver damage.
- Results in ascites and esophageal varices.
Fluid in Peritoneal Cavity (Ascites)
- Causes include portal hypertension, splanchnic vasodilation, changes in aldosterone metabolism, decreased albumin synthesis, and albumin movement into the peritoneal cavity. A diagram (49-5) is referenced.
Physiology/Pathophysiology (Ascites)
- A cycle of cirrhosis, portal hypertension, splanchnic arterial vasodilation, decreased circulating blood volume, activation of renin-angiotensin and sympathetic nervous systems, and kidney effects resulting in hypervolemia and ascites/edema formation.
Assessment of Ascites
- Daily monitoring of abdominal girth and weight is required.
- Assess for striae, distended veins, and umbilical hernias.
- Percuss for shifting dullness or employ fluid wave techniques to detect fluid buildup in the abdominal cavity.
- Monitor for potential fluid and electrolyte imbalances.
Treatment of Ascites
- Low-sodium diet, diuretics, bed rest, paracentesis, administration of salt-poor albumin, transjugular intrahepatic portosystemic shunt (TIPS), and other methods (e.g., peritoneovenous).
TIPS (Procedure)
- Includes catheter placement, stent placement in the liver, and creating a shunt between the hepatic and portal veins.
Nursing Management of Ascites
- Close monitoring of fluid intake/output (I&O), abdominal girth, daily weight to assess fluid balance.
- Monitor respiratory status carefully.
- Serum ammonia, creatinine, and electrolyte levels to track hepatic encephalopathy response to treatment.
Question #2 (Diuretic for Ascites)
- Option C, Furosemide (Lasix) is the appropriate diuretic.
Hepatic Encephalopathy
- A life-threatening complication that manifests as significant liver dysfunction.
- Neuropsychiatric manifestations associated with hepatic failure, portal hypertension, and shunting of blood into the systemic circulation
- Occurs with acute and chronic liver disease due to hepatic insufficiency (liver's inability to detoxify toxins) and portosystemic shunting (collateral vessels that allows portal blood into systemic circulation).
Clinical Manifestations (Hepatic Encephalopathy)
- Earliest symptoms include changes in mental status and motor disturbances (e.g., confusion).
- Mood and sleep patterns are altered.
- Progressive stages cause difficulty awakening and disorientation, followed by frank coma and potential seizures.
- Refer to Table 44-10 for factors precipitating hepatic encephalopathy including GI hemorrhage, constipation, hypokalemia, hypovolemia, infections, cerebral depressants, and others
Assessment (Hepatic Encephalopathy/Coma)
- EEG (electroencephalogram), changes in level of consciousness (LOC), potential seizures, fetor hepaticus, and monitoring of fluid, electrolyte, and ammonia levels are critical to assessing hepatic encephalopathy. (Table 49-3) is referenced.
Asterixis and Apraxia
- Asterixis ("liver flap"): Hand tremor, associated with late-stage hepatic encephalopathy. (Refer to diagram 49-13).
- Constructional apraxia: Difficulty with drawing, writing, or simple tasks—progresses with hepatic encephalopathy. (Refer to diagram 49-14).
Medical Management (Hepatic Encephalopathy)
- Eliminate the precipitating cause.
- Use lactulose to decrease serum ammonia levels.
- IV glucose to minimize protein catabolism.
- Restrict protein intake.
- GI tract ammonia reduction with (e.g., gastric suction, enemas, antibiotics).
- Discontinue sedatives, analgesics, and tranquilizers.
- Monitor/treat complications and infections.
Nursing Management (Hepatitis)
- Reference Table 49-3 for stages of hepatic encephalopathy and applicable nursing diagnoses
- Recognize potential nursing diagnoses for those with cirrhosis (e.g., activity intolerance, impaired nutrition, risk of injury, impaired skin integrity, excess fluid volume, confusion, risk for imbalanced temperature)
Promoting Rest
- Emphasize rest, supportive measures, positioning for respiratory efficiency, supplemental oxygen, planned mild exercises and rest periods, nutritional needs, and avoiding immobility hazards
Improving Nutritional Status
- Encourage small, frequent meals, high-calorie diet; sodium restriction; altered protein as needed for encephalopathy risk; supplemental vitamins/minerals (including B complex and fat-soluble vitamins such as vitamin K).
Other Interventions
- Frequent skin care with position changes.
- Gentle skin care to reduce scratching due to pruritus.
- Prevent falls/trauma to avoid potentially life-threatening bleeding.
Collaborative Problems/Complications (Cirrhosis)
- Bleeding and hemorrhage, hepatic encephalopathy, fluid volume excess.
Test Your Knowledge (Hepatitis A)
- Option A, Malaise, is the likely correct answer for possible hepatitis A detection.
Patient with Advanced Cirrhosis (Swelling)
- Option B, Portal Hypertension and Hypoalbuminemia, is the most likely cause of abdominal swelling.
Hepatitis (A, B, C)
- Viral Hepatitis: Systemic infection characterized by liver cell necrosis and inflammation with characteristic symptoms. Hepatitis A (fecal-oral), B (bloodborne – including sexual contact, needle sharing), and Hepatitis C (bloodborne) differ in mode of transmission.
- Hepatitis A: Spread by poor hand hygiene and contaminated food; incubation 2-6 weeks; illness 4-8 weeks; mild flu-like symptoms, low-grade fever, anorexia, later jaundice.
- Hepatitis B: Transmitted via blood, saliva, semen, and vaginal secretions; long incubation (1-6 months); similar HAV symptoms but often insidious onset.
- Hepatitis C: Transmitted via blood and sexual contact; generally mild symptoms, frequent chronic carrier state; significant cause of liver cancer and liver transplant
Management of Viral Hepatitis
- Hepatitis A: Prevention with hand hygiene, safe water, sewage disposal; vaccine; immunoglobulin for contacts; bed rest during acute stage; nutritional support.
- Hepatitis B: Medications (alpha interferon, entecavir, tenofovir) are available for chronic cases, bed rest and nutritional support; vaccinations routinely recommended, standard precautions, blood screening, and screening of blood products.
- Hepatitis C: Antiviral medications; avoid medications that affect the liver; prevention through public health programs to decrease needle sharing, blood supply screening, safety needles for workers.
Esophageal Varices
- Varicosities due to elevated pressure in veins draining into the portal system.
- Prone to rupture and cause massive hemorrhages.
- Occurs in about one-third of patients with cirrhosis
- Patients require screening endoscopy every 2-3 years.
- Varices lead to portal hypertension (increased portal system pressure). Venous collaterals (including hemorrhoidal plexus, esophageal plexus, and retroperitoneal veins) develop to compensate. These varicosities can rupture and lead to life-threatening hemorrhage.
Bleeding Esophageal Varices
- Physiology/Pathophysiology: Portal hypertension (caused by blockage of portal flow) leads to pressure gradient development, which, in turn, causes portal blood to shunt through created collaterals (e.g., esophageal varices), leading to rupture and potentially life-threatening hemorrhage.
- Clinical Manifestations: Hematemesis (vomiting blood), melena (black, tarry stools), general deterioration of mental/physical status, signs and symptoms of shock (cool clammy skin, hypotension, tachycardia).
Assessment & Diagnostic Findings (Esophageal Varices)
- Patient history of cirrhosis; physical examination; endoscopy to pinpoint the bleeding site; ultrasonography, CT scans & angiography; and use of endoscopic video capsules to identify esophageal varices.
Treatment of Bleeding Esophageal Varices
- IV fluids, electrolytes, volume expanders, blood products.
- Vasopressin, somatostatin, or octreotide to decrease bleeding.
- Nitroglycerin used with vasopressin to reduce coronary vasoconstriction.
- Propranolol or nadolol to lower portal pressure in conjunction with other treatment measures.
- Balloon tamponade, endoscopic sclerotherapy, endoscopic variceal ligation (banding), and surgical management (bypass procedures, devascularization, and transection).
- Diagram 49-14 and 49-15 illustrate endoscopic maneuvers.
Nursing Management (1)
- Monitor the patient's condition closely, especially physical and emotional responses, cognitive status, and vital signs.
- Assess the patient's nutritional and neurologic status.
- Maintain a safe environment to prevent injuries.
- Administer prescribed treatments and monitor for complications.
- Encourage deep breathing and position changes.
- Educate the patient and family.
Nursing Management (2)
- Maintain gastric emptying through suction to prevent straining/vomiting.
- Frequent oral hygiene and moist sponges for the lips (to relieve thirst).
- Closely monitor blood pressure.
- Administer vitamin K therapy and multiple blood transfusions as needed to compensate for blood loss.
- Refer to Table 49-2 for modalities & nursing care for patients with bleeding esophageal varices.
Hepatic Cirrhosis
- Definition: Chronic liver disease with replacement of normal tissues by fibrous tissue. Types include alcoholic, post-necrotic, and biliary.
- Pathophysiology: Refer to Table 49-5 for details.
- Manifestations: Include liver enlargement, portal obstruction, ascites, infection, GI varices, edema, vitamin deficiency, anemia, and mental deterioration (refer to Chart 49-10 for details).
Typical Symptoms (Cirrhosis)
- Skin pigmentation changes (e.g., xanthoma, spider angiomas, jaundice, paper-money skin); altered hormone metabolism (e.g., gynecomastia, loss of body hair, menstrual dysfunction, spider angiomas, and palmar erythema), hepatomegaly/hepatatrophia, caput medusae, ascites, complications involving the pancreas, impaired skin integrity from edema and jaundice, abdominal swelling (ascites), lower thigh edema, and hepatic encephalopathy.
Continuum of Liver Dysfunction
- Illustrated as a process of liver inflammation leading to necrosis, fibrosis, and scarring. Causes portal hypertension, complications including ascites, edema, and potentially life-threatening complications, and potentially leading to death.
Nursing Process (Cirrhosis)
- Nursing diagnoses address activity intolerance, imbalance nutrition, impaired skin integrity, risk for injury, disturbed body image, fluid volume excess, and confusion.
More about NCP (Cirrhosis)
- Nursing interventions focus on promoting rest, improving nutritional status, providing skin care, reducing injury risks, and monitoring/managing complications. (Refer to Chart 49-11 for additional details).
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