Nursing Diagnoses in End-Stage Liver Disease

Nursing Management of Adults with Disorders of the Liver and Biliary Tract

• The presentation covers nursing management for adults with liver and biliary tract disorders, using specific examples.
• Key objectives include interpreting assessment data, creating comprehensive nursing care plans (including discharge plans), analyzing patient impact (physiologically, psychologically, and socially), summarizing common drugs and their effects, understanding nursing research, ethical considerations, advocacy, and economic factors.

Anatomy Review

• Diagrams illustrate the liver, gallbladder, common bile duct, pancreas, and related structures.
• Key anatomical features are presented.

The Gallbladder

• The gallbladder is described as a distensible, sac-like organ.
• Its primary function is storing, concentrating, and expelling bile.
• Hormones stimulate gallbladder contraction to release bile.
• Gallstones are made up of cholesterol, bilirubin, calcium salts, and unconjugated bilirubin.
• Definitions for cholecystitis, cholelithiasis, and choledocholithiasis are given (inflammation of the gallbladder, gallstones in the gallbladder, and gallstones in the common bile duct).
• Additional details on Cholangitis (inflammation in the common bile duct) are also mentioned.

Acute Cholecystitis

• Acute cholecystitis is a diffuse inflammation of the gallbladder.
• Obstruction (often gallstones) is a common cause.
• Inflammation develops behind the cystic duct obstruction.
• Treatment involves removing the obstruction; it may resolve on its own, or may recur.

Chronic Cholecystitis

• Repeated episodes of acute cholecystitis typically lead to chronic cholecystitis.
• Symptoms can vary.
• Treatment often involves cholecystectomy (removal of the gallbladder).

Cholecystitis Risk Factors & Assessment

• Women are more frequently affected than men.
• Age, pregnancy, and obesity are also risk factors.
• Underlying causes include gallstones.
• Symptoms include pain (right upper quadrant or radiating to the back, worsening with deep breathing), fever, leukocytosis, jaundice, nausea, vomiting, anorexia, abdominal distention, feeling of fullness, and fat intolerance.

Cholecystitis Diagnostics

• X-rays may not clearly show gallstones; these are used initially to rule out other causes.
• Ultrasonography is helpful to visualize abdominal organs and identify gallstones in relation to presence or absence of masses.
• Magnetic resonance cholangiopancreatography (MRCP) visualizes biliary structures and can detect biliary tract obstructions.
• Endoscopic retrograde cholangiopancreatography (ERCP) visualizes biliary structures and pancreas via endoscopy.
• Cholecystography and cholangiography visualize the gallbladder and bile duct.
• Laparoscopy provides direct visualization of the gallbladder, liver, and mesentery through a trocar.

Cholecystitis Medical Management

• Surgery (cholecystectomy): Standard treatment.
• Collaboration with the patient is essential (Rest, IV fluids, NG suction).
• Diet: Generally low-fat, liquid diet initially; then advance diet as tolerated.
• Medications: Analgesics, antibiotics, and drugs to reduce stone size or dissolve small stones (e.g., ursodeoxycholic acid (UDCA) & chenodeoxycholic acid (CDCA)) can be used.
• Extracorporeal shock wave lithotripsy (ESWL) - shock waves are used to break up stones.

The Pancreas

• The pancreas has two primary functions: Exocrine and Endocrine functions.
• Exocrine pancreas produces digestive enzymes and secretes them into the small intestine
• Endocrine pancreas releases hormones (like insulin and glucagon) into the bloodstream to regulate blood sugar.

Pancreatitis Patho

• Pancreatic enzymes are activated (typically trypsin, amylase, and lipase) within the pancreas itself.
• Autodigestion of pancreatic cells results from the accidental release of these enzymes, causing inflammation, damage, scarring, dysfunction, and pain.

Acute Pancreatitis

• Risk factors include gallstones, alcohol abuse, biliary tract disease, bacterial or viral infections, trauma, drug toxicities, and smoking.
• Clinical manifestations includes abdominal pain (often severe), nausea and vomiting, fever, hypotension, tachycardia, jaundice, abdominal tenderness with muscle guarding, decreased or absent bowel sounds, Cullen's sign (bluish periumbilical discoloration).

Acute Pancreatitis Diagnostics

• X-rays, including abdominal and chest X-rays
• CT scans
• Endoscopic retrograde cholangiopancreatography (ERCP)
• Ultrasound
• Laboratory testing: serum amylase, serum lipase, blood glucose, WBC, serum bilirubin, serum calcium.

Acute Pancreatitis Medical Management

• Pain management
• IV fluids and electrolyte correction
• Prevention/alleviation of shock
• Reduction of pancreatic secretions
• Monitor infected/necrotic drainage
• Antibiotics
• Removal of precipitating cause/obstruction
• Diet: Initially NPO; advance to tolerated diet

Chronic Pancreatitis Patho

• Continuous, long-term inflammation and fibrosis of the pancreas.
• Pancreatitis may cause progressive tissue destruction with the development of strictures and calcifications.
• Common symptoms overlap with acute pancreatitis.
• Digestive issues, problems with glucose control, and biliary symptoms are also likely.

Chronic Pancreatitis Medical Management

• Medications (e.g., non-opioid analgesics, insulin).
• Replacement of pancreatic enzymes.
• Nutritional therapy: small, frequent, bland meals, low-fat diet.
• Lifestyle changes (no alcohol, no smoking).
• Surgery may be necessary.

Pancreatic Surgery

• ERCP with Sphincterotomy, and surgical procedures such as Choledochojejunostomy, or Roux-en-Y Pancreatojejunostomy, can be used.

The Liver

• The presentation covers the liver's functions, including metabolism of drugs, bile salts, steroid hormones, and its role in carbohydrate, fat, and protein metabolism.
• The liver plays various biological roles including storage of vitamins (such as A, D, and K).

Portal Circulation

• The liver receives blood from the digestive tract, pancreas, and spleen via the portal vein.
• Blood leaves the liver via the hepatic veins, entering the inferior vena cava.
• The blood flow rate is approximately 1.5 liters per minute.

Liver Functions

• The liver processes and removes toxins, drugs, and bacteria from the bloodstream.
• It metabolizes various substances, such as drugs and hormones.
• It produces bile for fat digestion and removes bilirubin.

Fate of Bilirubin

• Old red blood cells (RBCs) are broken down, releasing hemoglobin.
• The liver processes this bilirubin, converting the unconjugated type to conjugated bilirubin.
• Conjugated bilirubin is eliminated through the bile.

Jaundice

• Jaundice arises from impaired bilirubin excretion (due to liver dysfunction).
• This results in an abnormally high level of bilirubin in the blood.
• The skin and whites of the eyes take on a yellow tint.

Hepatitis

• Hepatitis is inflammation of the liver, often caused by toxins, bacteria, or viruses (Hepatitis A, B, C, D, and E).

Hepatitis Diagnostic Tests

• Lab tests can indicate liver inflammation and dysfunction.
• Ultrasound, X-rays, and EGD (esophagogastroduodenoscopy) are diagnostic tests.

Hepatitis Medical Management

• Treatment focuses on rest, adequate calorie intake, and limiting drugs that affect liver metabolism.
• Specific antiviral drugs are required.

Cirrhosis

• Extensive, irreversible scarring of the liver.
• Factors such as alcohol, hepatitis C & B, drugs/toxins, and autoimmune or metabolic diseases are risk factors for cirrhosis.

Portal Hypertension

• Increased pressure in the portal system, leading to the development of collateral channels and varices.
• Clinical manifestations include Ascites (fluid in the peritoneum), esophageal varices (dilated veins in the esophagus), hemorrhoids, encephalopathy (neurological complications).

Cirrhosis Clinical Manifestations

• Jaundice, spider angiomas, skin changes, anemia, coagulation disorders, superficial veins on the abdominal wall, palmar erythema, sexual and neurological changes, and edema can be manifestations of cirrhosis.

Portal Hypertension

• Increased pressure in the portal system, leading to the development of collateral channels.
• Collateral channels form, and varices develop to shunt blood away from the liver.

Liver Failure

• End stage liver disease- liver is unable to perform its metabolic or excretory functions properly or at all..
• Symptoms overlap clinical manifestations of Cirrhosis
• Common causes of liver failure include hepatitis B and C, cirrhosis, toxins, and alcohol use disorder.

Liver Transplant

• Procedure for replacing a diseased liver with a healthy one.
• Key motivations are advanced liver disease/liver failure, and some malignancies.
• Immunosuppressants are often used to prevent the body from rejecting the new liver.

Issues Related to Liver Transplantation

Selection process is rigorous, involves determining risk factors and patient compatibility. Issues related to allocation of organs and ethics come into play.

Nursing Process

Nursing management for liver and biliary tract disorders, focusing on patients' needs and overall care.

Nursing Interventions

• Nursing interventions addressing rest, nutrition, skin care, fluid balance, and other care activities.