Chapter 43 Assessment and Management of Patients With Hepatic Disorders PDF

Chapter 43 Assessment and Management of Patients With Hepatic Disorders Learning outcomes Identify the metabolic functions of the liver and the alterations that occur with hepatic Identify disorders.(self reading) Explain liver function tests and the clinical manifesta...

Chapter 43 Assessment and Management of Patients With Hepatic Disorders Learning outcomes Identify the metabolic functions of the liver and the alterations that occur with hepatic Identify disorders.(self reading) Explain liver function tests and the clinical manifestations of liver dysfunction in relation to Explain pathophysiologic alterations of the liver..(self reading) Relate jaundice, portal hypertension, ascites, varices, nutritional deficiencies, and hepatic Relate encephalopathy and coma to pathophysiologic alterations of the liver. Describe Describe the medical, surgical, and nursing management of patients with esophageal varices. Compare the various types of hepatitis and their causes, prevention, clinical manifestations, Compare management, prognosis, and home health care needs. Use Use the nursing process as a framework for care of the patient with cirrhosis of the liver. Specify Specify the postoperative nursing care of the patient undergoing liver transplantation. Copyright © 2018 Wolters Kluwer · All Rights Reserved Key terms Ascites: an albumin-rich fluid accumulation in the peritoneal cavity. Cirrhosis: a chronic liver disease characterized by fibrotic changes, the formation of dense connective tissue within the liver, subsequent degenerative changes, and loss of functioning cells Jaundice: yellowish or greenish-yellow of the sclerae and skin due to high bilirubin levels Portal hypertension: elevated pressure in the portal circulation resulting from obstruction of venous flow into and through the liver Copyright © 2018 Wolters Kluwer · All Rights Reserved Review of Anatomy and Physiology ❖ Largest gland of the body ❖ Located in the upper right abdomen ❖ A very vascular organ that receives blood from GI tract via the portal vein and from the hepatic artery Copyright © 2018 Wolters Kluwer · All Rights Reserved Liver and Biliary System Copyright © 2018 Wolters Kluwer · All Rights Reserved Section of a Liver Lobule Copyright © 2018 Wolters Kluwer · All Rights Reserved Metabolic function of the liver ❖ Glucose metabolism ❖ Ammonia conversion ❖ Protein metabolism ❖ Fat metabolism ❖ Vitamin and iron storage ❖ Bile formation ❖ Bilirubin excretion ❖ Drug metabolism Copyright © 2018 Wolters Kluwer · All Rights Reserved  Liver Function Studies ❖ Serum aspartate aminotransferase: ❖ Clotting factors AST, ALT, GGT, GGTP, LDH ❖ Serum alkaline phosphatase ❖ Serum protein studies ❖ Serum ammonia ❖ Direct and indirect serum bilirubin, ❖ Lipids urine bilirubin, and urine bilirubin and urobilinogen ❖ Refer to Table 49-1 Copyright © 2018 Wolters Kluwer · All Rights Reserved  Liver Function Tests ❖ Serum aminotransferases: indicators of injury to the liver cells; useful in detecting hepatitis ❖ Alanine aminotransferase (ALT): levels increase primarily in liver disorders; used to monitor the course of hepatitis, cirrhosis, the effects of treatments that may be toxic to the liver ❖ Aspartate aminotransferase (AST): not specific to liver diseases however levels of AST may be increased in cirrhosis, hepatitis, and liver cancer ❖ Gamma-glutamyl transferase (GGT): levels are associated with cholestasis; alcoholic liver disease Copyright © 2018 Wolters Kluwer · All Rights Reserved Additional Diagnostic Studies ❖ Liver biopsy ❖ Ultrasonography ❖ CT ❖ MRI ❖ Other ❖ Refer to Chart 49-3 Copyright © 2018 Wolters Kluwer · All Rights Reserved ❖ Cirrhosis of the liver ❖ Liver failure associated with alcohol use ❖ Infection ❖ Fatty liver disease o Nonalcoholic fatty liver disease (NAFLD) o Nonalcoholic steatohepatitis (NASH) Copyright © 2018 Wolters Kluwer · All Rights Reserved  ❖Jaundice ❖Portal hypertension MANIFESTATIONS OF HEPATIC ❖Ascites and varices DYSFUNCTION ❖Hepatic encephalopathy or coma ❖Nutritional deficiencies Copyright © 2018 Wolters Kluwer · All Rights Reserved  Jaundice ❖ Yellow- or greenish-yellow of sclera and skin caused by increased serum bilirubin levels. ❖ Bilirubin level exceeds 2 mg/dL. ❖ Types of jaundice: o Hemolytic o Hepatocellular o Obstructive most associated with liver disease o Hereditary hyperbilirubinemia. Copyright © 2018 Wolters Kluwer · All Rights Reserved  Signs and Symptoms Associated With Hepatocellular and Obstructive Jaundice Hepatocellular Obstructive ❖Mild or severely ill ❖Dark orange-brown urine, clay-colored stools. ❖Lack of appetite, nausea or vomiting, weight loss. ❖Dyspepsia and intolerance of fats, impaired digestion ❖Malaise, fatigue, weakness ❖Pruritus ❖Headache, chills, fever, infection Jaundiced patient. Copyright © 2018 Wolters Kluwer · All Rights Reserved ❖ Portal hypertension is the increased pressure throughout the portal venous system that results from obstruction of blood flow into and through the damaged liver. ❖ Results in o Ascites o Esophageal varices` Portal Hypertension Copyright © 2018 Wolters Kluwer · All Rights Reserved Fluid in Peritoneal Cavity ❖ Causes; ▪ Portal hypertension resulting in increased capillary pressure and obstruction of venous blood flow ▪ Vasodilatation of splanchnic circulation (blood flow to the major abdominal organs) ▪ Changes in the ability to metabolize aldosterone, increasing fluid retention. ▪ Decreased synthesis of albumin, decreasing serum osmotic pressure ▪ Movement of albumin into the peritoneal cavity ▪ Figure 49-5 Ascites Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Assessment of Ascites ❖ Record abdominal girth and weight daily ❖ Patient may have striae, distended veins, and umbilical hernia ❖ Assess for fluid in abdominal cavity by percussion for shifting dullness or by fluid wave ❖ Monitor for potential fluid and electrolyte imbalances Copyright © 2018 Wolters Kluwer · All Rights Reserved Assessing for Abdominal Fluid Wave Copyright © 2018 Wolters Kluwer · All Rights Reserved  Treatment of Ascites ❖ Low-sodium diet ❖ Diuretics ❖ Bed rest ❖ Paracentesis ❖ Administration of salt-poor albumin ❖ Transjugular intrahepatic portosystemic shunt (TIPS) ❖ Other methods: peritoneovenous Copyright © 2018 Wolters Kluwer · All Rights Reserved TIPS Copyright © 2018 Wolters Kluwer · All Rights Reserved  Nursing measures include; ❖ Assessment and documentation of (I&O), ❖ Abdominal girth, and daily weight to assess fluid status. Nursing ❖ Close monitoring of Management of patient with ascites respiratory status. ❖ The nurse monitors serum ammonia, creatinine, and electrolyte levels, response to therapy, and indications of hepatic encephalopathy. Copyright © 2018 Wolters Kluwer · All Rights Reserved Question #2 Which diuretic medication would most often be used for a patient with ascites? A. Actazolamide (Diamox) B. Ammonium chloride C. Furosemide (Lasix) D. Spironolactone (Aldactone) Copyright © 2018 Wolters Kluwer · All Rights Reserved  Hepatic Encephalopathy ❖ Its a life threatening complication of liver disease that occurs with profound liver failure. ❖ Hepatic encephalopathy is the neuropsychiatric manifestation of hepatic failure associated with portal hypertension and the shunting of blood from the portal venous system into the systemic circulation. ❖ Two major alterations underlie its development in acute and chronic liver disease o Hepatic insufficiency: the inability of the liver to detoxify toxic by- products of metabolism o Portosystemic shunting: collateral vessels develop allowing elements of the portal blood to enter the systemic circulation Copyright © 2018 Wolters Kluwer · All Rights Reserved  ❖ The earliest symptoms of hepatic encephalopathy include mental status changes and motor disturbances. ❖ Confusion Clinical Manifestations ❖ Alterations in mood and sleep patterns. ❖ As hepatic encephalopathy progresses, the patient may become difficult to awaken and completely disoriented. ❖ With further progression, the patient lapses into frank coma and may have seizures. Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved  Hepatic Encephalopathy and Coma ❖ Assessment ❖ Life-threatening complications: accumulation of ammonia and other o EEG toxic metabolites in the blood o Changes in LOC ❖ Stages: refer to Table 49-3 o Potential seizures o Fetor hepaticus o Monitor fluid, electrolyte, and ammonia levels Copyright © 2018 Wolters Kluwer · All Rights Reserved Asterixis Apraxia ❖ Refer to Figure 49-13 Copyright © 2018 Wolters Kluwer · All Rights Reserved  Medical Management ❖ Eliminate precipitating cause ❖ Lactulose to reduce serum ammonia levels ❖ IV glucose to minimize protein catabolism ❖ Protein restriction ❖ Reduction of ammonia from GI tract by gastric suction, enemas, oral antibiotics ❖ Discontinue sedatives, analgesics, and tranquilizers ❖ Monitor or treat complications and infections ❖ Additional principles of management of hepatic encephalopathy (pp:3696). ❖ Nutritional Management; Chart 49-5 Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Management Copyright © 2018 Wolters Kluwer · All Rights Reserved  Esophageal Varices ❖ Varices are varicosities that develop from elevated pressure in the veins that drain into the portal system. ❖ They are prone to rupture and cause massive hemorrhages. ❖ Occurs in about one third of patients with cirrhosis. ❖ Patients with cirrhosis should undergo screening endoscopy every 2 to 3 years Copyright © 2018 Wolters Kluwer · All Rights Reserved Bleeding Esophageal Varices Copyright © 2018 Wolters Kluwer · All Rights Reserved Hematemesis, melena, General deterioration in mental or physical status Signs and symptoms of shock (cool clammy skin, hypotension, tachycardia) may be present. CLINICAL MANIFESTATIONS Copyright © 2018 Wolters Kluwer · All Rights Reserved History of cirrhosis Physical examination Endoscopy is used to identify the bleeding site. Ultrasonography, CT scanning, and angiography. Endoscopic video capsule, can detect esophageal varices. ASSESSMENT AND DIAGNOSTIC FINDINGS Copyright © 2018 Wolters Kluwer · All Rights Reserved  ❖ The patient is critically ill, requiring aggressive medical care and expert nursing care and is usually transferred to the ICU for close monitoring and management ❖ IV fluids, electrolytes, volume expanders, blood and blood products. Treatment of ❖ Vasopressin, somatostatin, Bleeding Varices #1 octreotide to decrease bleeding ❖ Nitroglycerin in combination with vasopressin to reduce coronary vasoconstriction ❖ Propranolol and nadolol to decrease portal pressure; used in combination with other treatment ❖ Balloon tamponade Copyright © 2018 Wolters Kluwer · All Rights Reserved Balloon tamponade Copyright © 2018 Wolters Kluwer · All Rights Reserved  Endoscopic sclerotherapy Endoscopic variceal ligation (esophageal banding therapy) Transjugular intrahepatic Treatment of portosystemic shunt Bleeding Varices #2 Surgical management Surgical bypass procedures Devascularization and transection Copyright © 2018 Wolters Kluwer · All Rights Reserved Endoscopic Sclerotherapy Copyright © 2018 Wolters Kluwer · All Rights Reserved Esophageal Banding Copyright © 2018 Wolters Kluwer · All Rights Reserved Portal Systemic Shunts Copyright © 2018 Wolters Kluwer · All Rights Reserved  Nursing assessment includes; ❖ Monitoring the patient’s physical condition ❖ Evaluating emotional responses and cognitive status. Nursing ❖ Monitors and records vital signs Management 1 ❖ Assesses the patient’s nutritional and neurologic status. ❖ Maintain safe environment; prevent injury ❖ Administer prescribed treatments and monitor for potential complications ❖ Encourages deep breathing and position changes. ❖ Education and support of patient and family Copyright © 2018 Wolters Kluwer · All Rights Reserved  ❖ Gastric suction usually is initiated to keep the stomach as empty as possible and to prevent straining and vomiting ❖ Frequent oral hygiene and moist sponges to the lips to Nursing relive severe thirst Management 2 ❖ The nurse closely monitors the blood pressure. ❖ Vitamin K therapy and multiple blood transfusions often are indicated because of blood loss. ❖ TABLE 49-2 Select Modalities and Nursing Care for the Patient With Bleeding Esophageal Varices Copyright © 2018 Wolters Kluwer · All Rights Reserved ❖ Viral hepatitis: a systemic viral infection that causes necrosis and inflammation of liver cells with characteristic symptoms and cellular and biochemical changes Hepatitis o A and E: fecal–oral route o B and C: blood borne o D: only people with hepatitis B are at risk o Hepatitis G and GB virus-C ❖ Nonviral hepatitis: toxic and drug induced ❖ Refer to Table 49-4 Copyright © 2018 Wolters Kluwer · All Rights Reserved  Hepatitis A ❖ Spread by poor hand hygiene; fecal–oral ❖ Incubation: between 2 and 6 weeks ❖ Illness may last 4 to 8 weeks ❖ Manifestations: o Mild flu-like symptoms, o Low-grade fever, o Anorexia, o Later jaundice and dark urine o Indigestion and epigastric distress, o Enlargement of liver and spleen Copyright © 2018 Wolters Kluwer · All Rights Reserved  ❖ Prevention o Good hand washing, safe water, and proper sewage disposal o Vaccine o Refer to Chart 49-7 o Immunoglobulin for Management of contacts to provide Hepatitis A passive immunity ❖ Bed rest during acute stage ❖ Nutritional support Copyright © 2018 Wolters Kluwer · All Rights Reserved  Transmitted through blood, saliva, semen, and vaginal secretions; sexually transmitted; transmitted to infant at the time of birth Hepatitis B A major worldwide cause of cirrhosis and liver cancer Risk factors: refer to Chart 49-8 Long incubation period: 1 to 6 months Copyright © 2018 Wolters Kluwer · All Rights Reserved Manifestations of HBV: insidious and variable; ❖ Similar to HAV, ❖ Loss of appetite, ❖ Dyspepsia, ❖ Abdominal pain, ❖ Generalized aching, malaise, and weakness ❖ Jaundice may or may not be evident Copyright © 2018 Wolters Kluwer · All Rights Reserved  Management of Hepatitis B ❖ Medications for chronic hepatitis B include o Alpha interferon o Antiviral agents: entecavir(ETV) and tenofovir (TDF). ❖ Bed rest and nutritional support ❖ Vaccine: for persons at high risk, routine vaccination of infants o Passive immunization for those exposed o Standard precautions and infection control measures o Screening of blood and blood products Copyright © 2018 Wolters Kluwer · All Rights Reserved  Hepatitis C ❖ Transmitted by blood and sexual contact, including needle sticks and sharing of needles ❖ The most common bloodborne infection ❖ A cause of one third of cases of liver cancer and the most common reason for liver transplant ❖ Risk factors: refer to Chart 49-9 ❖ Incubation period is variable: ranging from 15 to 160 days ❖ Symptoms are usually mild ❖ Chronic carrier state frequently occurs Copyright © 2018 Wolters Kluwer · All Rights Reserved Management of Hepatitis C ❖ Antiviral medications ❖ Medications that effect the liver should be avoided ❖ Prevention: public health programs to decrease needle sharing among drug users ❖ Screening of blood supply ❖ Safety needles for health care workers Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved  Hepatic Cirrhosis ❖ Cirrhosis is a chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver. ❖ Types o Alcoholic: in which the scar tissue characteristically surrounds the portal areas o Postnecrotic: in which there are broad bands of scar tissue o Biliary: in which scarring occurs in the liver around the bile ducts ❖ Pathophysiology: refer to Table 49-5 Copyright © 2018 Wolters Kluwer · All Rights Reserved  ❖ Liver enlargement, Manifestations ❖ Portal obstruction, ❖ Ascites, ❖ Infection and peritonitis, ❖ GI varices, ❖ Edema, ❖ Vitamin deficiency, ❖ Anemia, ❖ Mental deterioration; refer to Chart 49-10 Copyright © 2018 Wolters Kluwer · All Rights Reserved Copyright © 2018 Wolters Kluwer · All Rights Reserved Continuum of liver dysfunction in cirrhosis and resulting manifestations Copyright © 2018 Wolters Kluwer · All Rights Reserved Nursing Process: The Care of the Patient With Cirrhosis of the Liver ❖ Nursing diagnosis for patient with liver impairment 1. Activity intolerance R/T fatigue, lethargy and malaise 2. Imbalance nutrition ; less than body requirement R/T abdominal distension and discomfort and anorexia 3. Impaired skin integrity R/T pruritus from jaundice and edema 4. Risk for injury R/T altered clotting mechanism and LOC 5. Disturbed body image R/T change in appearance , sexual dysfunction and role function. 6. Excess fluid volume R/T ascites and edema formation. 7. Confusion R/T abnormal liver function and increase ammonia level 8. Risk for imbalanced body temperature: failure to maintain normal temperature due to inflammatory process of cirrhosis Copyright © 2018 Wolters Kluwer · All Rights Reserved ❖ More about NCP ; in Chart 49-11 ❖ Nursing interventions directed toward: o Promoting rest o Improving nutritional status o Providing skin care o Reducing risk of injury o Monitoring and managing potential complications Copyright © 2018 Wolters Kluwer · All Rights Reserved Promoting Rest ❖ Rest and supportive measures ❖ Positioning for respiratory efficiency ❖ Oxygen ❖ Planned mild exercise and rest periods ❖ Address nutritional status to improve strength ❖ Measures to prevent hazards of immobility Copyright © 2018 Wolters Kluwer · All Rights Reserved  Improving Nutritional Status ❖ I&O ❖ Supplemental vitamins, ❖ Encourage small frequent minerals, B complex, provide meals water-soluble forms of fat- soluble vitamins if patient has ❖ High-calorie diet, sodium steatorrhea restriction ❖ Consider patient preferences ❖ Protein modified or restricted if patient is at risk for encephalopathy Copyright © 2018 Wolters Kluwer · All Rights Reserved Other Interventions ❖ Providing skin care o Frequent position changes o Gentle skin care o Reduce scratching related to pruritus ❖ Reducing risk for injury o Prevent falls, trauma related to risk for bleeding Copyright © 2018 Wolters Kluwer · All Rights Reserved Collaborative Problems and Complications of Cirrhosis of the Liver ❖ Bleeding and hemorrhage ❖ Hepatic encephalopathy ❖ Fluid volume excess Copyright © 2018 Wolters Kluwer · All Rights Reserved Test your knowledge A patient has developed hepatitis A after eating contaminated sea food. The nurse assesses the patient for which of the following? A. Malaise B. Dark stools C. Weight gain D. Left upper quadrant discomfort Copyright © 2018 Wolters Kluwer · All Rights Reserved ❖ The patient with advanced cirrhosis asks why his abdomen is so swollen. The best nurse’s response is based on which of the following facts? A. A lack of clotting factors promotes the collection of blood in the abdominal cavity. B. Portal hypertension and hypoalbuminemia cause a fluid shift into the peritoneal space. C. Decreased peristalsis in the GI tract contributes to gas formation and distention of the bowel. D. Bile salts in the blood irritate the peritoneal membranes, causing edema and pocketing of fluid. Copyright © 2018 Wolters Kluwer · All Rights Reserved