Nursing Care for Paracentesis and Cirrhosis

Liver Anatomy

• A diagram depicts the liver, gallbladder, and pancreas.
• The common hepatic duct, cystic duct, and common bile duct are also shown.
• The major duodenal papilla and pancreas are labeled.
• The diagram also shows the esophagus, stomach, and duodenum section of the small intestine.

Liver Functions

• The liver removes potentially toxic byproducts of certain medications.
• It prevents shortages of nutrients by storing vitamins, minerals, and sugar.
• The liver metabolizes nutrients from food to produce energy when needed.
• It produces most proteins needed by the body.
• It helps the body fight infection by removing bacteria from the blood.
• It produces most of the substances that regulate blood clotting.
• The liver produces bile, a compound needed to digest fat and absorb vitamins A, D, E, and K.

Progression of Liver Disease

• A healthy liver image is shown as a comparison to a fatty liver, fibrosis liver, cirrhosis liver, and liver cancer stages.
• Fatty liver: The liver is enlarged due to fatty deposits in the cells.
• Fibrosis liver: Liver tissue begins to be replaced by connective tissue.
• Cirrhosis liver: Excessive connective tissue develops, restructuring the liver and vascular system, with areas of necrosis forming.
• Liver cancer: Malignant transformation of hepatocytes, forming liver cancer.

Cirrhosis: The Final Stage of Liver Disease

• Cirrhosis results from structural liver damage; it's the end result of chronic liver diseases, including hepatitis, non-alcoholic fatty liver disease, liver cancer, autoimmune hepatitis, hepatobiliary obstruction, and right-sided heart failure.
• Cirrhosis leads to portal hypertension, ascites, hepatic encephalopathy, esophageal varices, and splenomegaly.

Goals of Cirrhosis

• The overall goals for patients with advanced cirrhosis are:
• Relief of discomfort
• Minimization of complications
• Maintenance of a normal lifestyle

Manifestations of Cirrhosis

• Manifestations of cirrhosis are variable.
• Symptoms worsen as liver failure advances.
• Symptoms include weight loss, muscle wasting, weakness, ammonia accumulation, acidosis, anorexia, and acidic and inflamed environments.
• Other symptoms include diarrhea, constipation, portal HTN, hepatomegaly, jaundice, splenomegaly, bleeding tendencies, low platelets, and immune issues.
• Endocrine and skin issues, hepatic encephalopathy, confusion, asterixis (tremor in the hand), and altered metabolic processes for CHO, fats, and proteins are additional symptoms.

Manifestations of Cirrhosis (Continued)

• Additional manifestations include jaundice, spider nevi (spider-like birthmarks), muscle wasting, fibrotic liver changes, ascites, hemorrhoids, edema, hepatic encephalopathy, facial telangiectasia, gynecomastia, splenomegaly, periumbilical caput medusae, palmar erythema, testicular atrophy, and purpura.

What is Ascites?

• Ascites is the accumulation of serous fluid in the peritoneal or abdominal cavity.
• Manifestations include abdominal discomfort, dyspnea, insomnia, and difficulty walking.

Management of Ascites

• Dietary restrictions include sodium and water intake.
• Diuretics are administered, with monitoring for side effects.
• Large-volume paracentesis (removing 5L or more fluid) is indicated when diuretics are ineffective or symptoms appear.
• Albumin supplements (25% solution) are used with large-volume paracentesis to address complications.

Paracentesis Responsibilities

• Patient monitoring and ensuring procedure execution are essential for a patient undergoing large-volume paracentesis.
• Key preparation includes having the patient empty their bladder prior to the procedure.

Paracentesis Complications

• Circulatory dysfunction
• Renal impairment
• Hypovolemia

Paracentesis - Patient Care

• Patient care requires a multifaceted approach, including medical and holistic care.
• Pain management, aseptic techniques, and post-procedural care (vital signs, monitoring the paracentesis site) are crucial.
• Additional medical/holistic supports are beneficial.

Paracentesis - Ways of Knowing

• Patterns of knowing impacting patient care include: empiricism (procedure specifics), aesthetics (aesthetic ways to provide pain management), ethical considerations (consent and post-procedure care), emancipatory (self-care to prevent ascites recurrence), and personal considerations (reflection).

Nursing Diagnoses for Liver Conditions

• Potential nursing diagnoses include acute confusion, death anxiety, interrupted family processes, risk for shock, social isolation, and imbalanced nutrition less than body requirements.

Imbalanced Nutrition: Less Than Body Requirements

• This nursing diagnosis stems from lack of interest in food, weight loss, and reported inadequate food intake.
• Maintaining adequate nutrient intake, and maintaining normal body weight are needed outcomes.

Nursing Interventions Regarding Liver Conditions

• Monitor weights to assess nitrogen balance.
• Provide oral care for enhanced taste and reduced nausea.
• Administer anti-nausea medication.
• Provide small, frequent meals with high nutritional content.
• Recognize patient food preferences for increased palatability (low-sodium diets).

Complications of Cirrhosis - Hemorrhage

• Hemorrhage is a risk due to altered clotting factors, leading to variceal rupture (esophageal or gastric).
• Preventing rupture involves using beta-blockers to reduce portal hypertension.
• Hepatic encephalopathy is related to the liver's inability to detoxify toxins, leading to symptoms like drowsiness, tremors, and confusion.
• Lactulose is used to manage the accumulating ammonia.

Nursing Interventions Regarding Hemorrhage

• Monitor for signs of hemorrhage (epistaxis, purpura, petechiae, easy bruising, gingival bleeding, hematuria, and melena).
• Implement gentle nursing care to minimize tissue trauma.
• Observe for bleeding episodes (hematuria, melena) to enable timely intervention.
• Use small-gauge needles for injections and apply prolonged pressure to lessen the risk of bleeding into tissues.

Nursing Interventions Regarding Hemorrhage (Continued)

• Advise patients to avoid straining, nose blowing, and coughing to reduce hemorrhage risk.
• Monitor lab results, including hematocrit, hemoglobin, and prothrombin time, to assess for anemia, active bleeding, or potential complications.
• Advise patients to use soft-bristled toothbrushes and avoid irritating foods, given increased risk of mucous membrane injury due to high vascularity.

Hepatic Encephalopathy

• A safe environment reduces drowsiness frequency.
• Assess LOC (level of consciousness), sensory, and motor functions.
• Monitor electrolyte and acid-base balance levels.
• Assess neurological function as needed.

Hepatic Encephalopathy - Lactulose Management

• Administer lactulose (40 ml q 2–4 hours) to reduce ammonia levels and its formation when symptoms manifest.
• Assess understanding of medication purpose.

Hepatic Encephalopathy - Management

• Ammonia reduction and formation prevention is cornerstone treatment.
• Lactulose, neomycin or flagyl antibiotics, constipation prevention, dietary restriction (high calorie/high carb, moderate-to-low fat, low sodium intake), and GI bleed control are key interventions.

Lactulose

• A non-absorbable disaccharide, a hyperosmotic laxative that draws water into the colon, contributing to a laxative effect.
• It reduces ammonia, converting it to ammonium to reduce reabsorption.
• Intestine pH lowering affects ammonia production and absorption.
• Administer 30-60ml doses, titrating to achieve 2-5 bowel movements per day.
• Onset of action is within 24 hours.

Lactulose Considerations

• Contraindicated for low-galactose diets due to potential for dehydration and kidney impairment.
• Assess for abdominal pain, vital signs, weight, I&O, electrolytes, bowel habits, history of recent abdominal surgery, nausea and vomiting, and weight loss.

Pancreatitis: Causes

• Alcohol-induced (prolonged alcohol use - 4–5 drinks daily, for 5+ years or more).
• Drug-induced: azathioprine, 6-mercaptopurine, didanosine, valproic acid, ACE inhibitors, and mesalamine.
• Genetic mutations.
• Obstruction (migrating gallstones blocking the pancreatic ducts).
• Alcohol toxicity or immunologic mechanisms.

Pancreatitis: Acute Symptoms

• Upper abdominal pain
• Radiating abdominal pain to the back
• Abdominal pain worsens post-eating
• Fever
• Rapid pulse
• Nausea and vomiting

Pancreatitis: Diagnostic Criteria

• Consistent abdominal pain indicative of pancreatitis.
• Serum lipase or amylase levels greater than three times the normal limits.
• Imaging (abdominal ultrasound, CT, or MRI) to rule out other abdominal conditions.

Pancreatitis: 2 Diagnostic Criteria

• Lipase 3x normal upper limit
• Abdominal pain consistent with pancreatitis
• Findings of pancreatitis on imaging

Pancreatitis: Potential Nursing Diagnoses

• Deficient fluid volume.
• Impaired gas exchange.
• Risk for infection.
• Imbalanced nutrition: less than body requirements.
• Acute pain

Pancreatitis: Nursing Goals

• Manage symptoms
• Assess complications
• Provide family-centered care.

Pancreatitis Management: Acute

• Accurate diagnosis, supportive care, monitoring for and treating complications, relapse prevention.
• Fluid resuscitation (aggressive fluid administration within 24 hours).
• Vigorous fluid therapy (12–24 hours after symptom onset).
• Balanced crystalloid solutions.
• Vital sign monitoring, I&O, BUN, and hematocrit to assess fluid requirements.
• Volume overload is a risk, potentially leading to abdominal compartment syndrome, sepsis, and death.
• Fluid therapy must be tailored to the patient's intravascular volume depletion and cardiopulmonary reserve.

Pancreatitis Management: Further Considerations

• Manage significant pain with appropriate IV opioids.
• Administer prophylactic antibiotics when indicated.
• ERCP (endoscopic retrograde cholangiopancreatography) frequently indicated, particularly for patients with gallstone pancreatitis or evidence of cholangitis

Pancreatitis: Nutritional Considerations

• NPO (nothing by mouth) status is often necessary to allow the pancreas to rest and heal given increased GI motility and enzyme secretion.
• Enteral feeding via nasogastric tube can be used to provide nutrition in patients unable to tolerate oral intake or those with NPO status.
• Appropriate nutrition is vital for stable patient outcomes.

Pancreatitis: Further Nutritional Considerations

• TPN (total parenteral nutrition) may be indicated for patients with severe necrotizing pancreatitis, ensuring appropriate venous access.
• Mild pancreatitis may have a diet progression starting with clear liquids and developing to low-fat/soft or solid foods.
• Fiber and lipids stimulate pancreatic function as well.

Pancreatitis: Long-Term Management

• Patients experiencing acute pancreatitis may develop chronic conditions, characterized by pancreatic exocrine and endocrine dysfunction.
• Preventing chronic issues involves assessing risk factors (alcohol, smoking) and using management strategies.
• Tight blood sugar control is important for patients with pancreatitis caused by hyperlipidemia or diabetes.
• Treatments such as cholecystectomy, temporary pancreatic stent placement, and pharmacologic prophylaxis using NSAIDs may be utilized.

This quiz assesses knowledge on nursing care protocols regarding large volume paracentesis and management strategies for cirrhosis and ascites. Test your understanding of important patient instructions, monitoring vital signs, and dietary restrictions essential for preventing complications.