Liver, Esophageal Varices, and Pancreatitis Module 12 PDF

NUPD701 Acute and Chronic Illness Theory Liver Cirrhosis, Esophagea l Varices and Pancreatiti s Function s of the Liver  Cirrhosis The Final Stage of Liver Disease Cirrhosis results from structural injury to the liver End result of chronic liver diseases such as:...

NUPD701 Acute and Chronic Illness Theory Liver Cirrhosis, Esophagea l Varices and Pancreatiti s Function s of the Liver  Cirrhosis The Final Stage of Liver Disease Cirrhosis results from structural injury to the liver End result of chronic liver diseases such as: Non-alcoholic Autoimmune Hepatobiliary Right sided Hepatitis fatty liver Liver Cancer hepatitis obstruction heart failure disease Leads to portal hypertension, ascites, hepatic encephalopathy, esophageal varices, splenomegaly  Goals: Cirrhosis The overall goals for the patient with advanced cirrhosis: relief of discomfort minimize or limit complications (ascites, esophageal varices, hepatic encephalopathy) maintain as normal a lifestyle as possible.  Manifestations of Cirrhosis Weight loss (at times masked by ascites) Diarrhea or constipation, Muscle wasting – malnutrition Hepatomegaly, jaundice Weakness Portal HTN accumulation of ammonia Splenomegaly, bleeding tendencies Acidosis low platelet and immunity Anorexia Endocrine & skin disorders Acidic and inflamed environment ( cytonkines) Hepatic encephalopathy N & V ( same as anorexia) Confusion, asterixis's (tremoring) Abdominal pain (dull, aching, RUQ pain) – key in the hand Symptoms → result from altered metabolism of CHO, fats, proteins Manifestatio ns of Cirrhosis (Source: Porth, 2017). WHAT IS ASCITES? Accumulation of serous fluid in peritoneal or abdominal cavity Manifestations that accompany ascites: Abdominal discomfort Dyspnea Insomnia Difficulty walking *** only used for symptom management - based on weight and symptoms Management of Ascites Your client who is living with cirrhosis of the liver has developed Ascites. What is the management for this complication? Management of Ascites Dietary restrictions: Na+ H2O /fluid restriction Administer diuretics – what should you monitor for? Furosemide Spironolactone Large volume paracentesis: Removal of 5L or more of fluid Indicated when diuretics ineffective or when symptomatic (respiratory distress) Monitor for spontaneous bacterial peritonitis & hypovolemia Albumin 25%: Supplementing 5 g of albumin per each liter over 5 L of ascetic fluid removed decreases complications of paracentesis  What are Your patient is going your for a large volume Paracentesis, what do responsibilitie you need to consider s? as you care for the patient?  Instruct patient to empty bladder prior to procedure to prevent puncture of the bladder Complications of large volume paracentesis: Circulatory dysfunction Renal impairment Paracente Hypovolemia sis Intra and post procedure, the nurse should monitor vital signs for hypovolemia and check the dressing for bleeding and leakage from the puncture site. * Priority Nursing Assessment? * Priority Nursing Diagnosis? Paracentesis – patient care Think about the medical and holistic care that your patient will require. Pain management Aseptic/sterile techniques in preparation for the procedure Post procedural care: vital signs, monitoring paracentesis site What other medical/holistic care can you include?  Paracentesis – Ways of Knowing What patterns of Knowing influence your care and decision- making ? Empirics: procedure, pain management, post procedural care & complications Aesthetics: preparation for procedure, the aesthetic way of providing non-pharma pain management, body image Ethical: consent for paracentesis treatment, care of wound post procedure Emancipatory: self-care to prevent recurrence of ascites Personal: reflection, biases, body image, non judgemental Nursing Diagnosis Some other possible nursing diagnosis: Acute confusion Death Anxiety Interrupted Family Processes Fear Risk for shock Social Isolation Imbalanced nutrition: less than body requirements Nursing Diagnosis: Nutrition Imbalanced nutrition: less than body requirements related to alteration in liver function AEB: lack of interest in food, weight loss, reported inadequate food intake Expected Outcomes Maintains adequate intake of nutrients Maintains normal body weight  Monitor weight to evaluate nitrogen balance. Provide oral care before meals to remove foul tastes and improve taste of food. Administer antiemetic's as ordered to relieve nausea and prevent vomiting. Provide small, frequent meals with Nursing nourishing content to prevent feeling of Interventio fullness and to maintain nutritional status. ns: Determine patient's food preferences to increase nutritional appeal because a low- Nutrition sodium diet may be unpalatable. Complications: Cirrhosis Hemorrhage: Risk of bleeding secondary to altered clotting factors and rupture of esophageal or gastric varices Collateral circulation can rupture Decrease risk of rupture = use beta blockers ( decrease portal HTN Hepatic encephalopathy: related to inability of liver to detoxify toxins as evidenced by episodes of drowsiness, tremors, confusion Accumulation of Ammonia liver cannot detoxify Give lactulose to remove toxins There are more…….  Monitor for hemorrhage by assessing for epistaxis, purpura, petechiae, easy bruising, gingival bleeding, hematuria, and melena to provide early intervention if any of these are present. Provide gentle nursing care to minimize the risk of tissue trauma. Nursing Watch for bleeding episodes, including Interventio hematuria and melena, to enable prompt intervention. ns: Hemorrhag Use smallest-gauge needle possible when e giving injections and apply gentle but prolonged pressure after injection to minimize risk of bleeding into tissue.  Nursing Interventions: Hemorrhage Teach patient to avoid straining at stool, vigorous blowing of nose, and coughing to reduce risk of hemorrhage. Observe for bruising on the skin to detect bleeding early and enable prompt intervention or modification of care protocol. Monitor laboratory results (hematocrit, hemoglobin, and prothrombin time) as indicators of anemia, active bleeding, or impending complications. Advise use of soft-bristle toothbrush and avoidance of irritating food to reduce trauma because mucous membranes have increased risk of injury as a result of high vascularity Hepatic Encephalopathy Focus of nursing care: Maintain safe environment and assist with measures to reduce episodes of drowsiness Assess patient’s LOC, sensory & motor abnormalities Assess fluid & electrolyte; acid-base imbalances Assess neurological status  Patient with Cirrhosis has developed Hepatic Encephalopathy: Doctor orders: Administer Lactulose Hepatic 40 mls. q 2-4 hrs Encephalopa thy Using Empirical knowing-what are your initial thoughts on this medication and dose? What is the purpose of giving this medication? Hepatic Encephalopathy Goal of care: reduce ammonia levels & formation of ammonia using lactulose Management: Lactulose: Antibiotics (usually neomycin or flagyl) Prevent constipation Protein restriction ( due to muscle wasting), high calorie (3000kcal/d), high carb, mod to low fat, Low sodium Control GI bleed & remove blood from GI tract Lactulose Non absorbable disaccharide, hyperosmotic laxative - draws water into colon & produce laxative effect Reduces ammonia, converts to ammonium to prevent reabsorption pH of the intestine is lowered, affecting both the production & absorption of ammonia Sugars cause a laxative effect Usual dose is 30 to 60mls/dose, titrated in frequency to maintain 2 to 5 bowel movements per day Onset of action: 24h See Fowler, 2013 article. Lactulose Contraindication: pts on low-galactose diet Excessive use can cause diarrhea, dehydration & kidney impairment Nursing considerations: Abdominal assessment, vital signs, weights, intake & output, fluid & electrolyte levels, bowel habits Assess abdominal pain, degree of peristalsis, hx of recent abdominal surgery, N&V, weight loss  Pancreatitis Most common causes: Gallstones Alcohol – prolonged alcohol use (4-5 drinks daily over a period of >5yrs) Drugs: azathioprine, 6-mercaptopurine, didanosine, valproic acid, angiotensin-converting–enzyme inhibitors, and mesalamine Genetic mutations Migrating gallstones cause transient obstruction of the pancreatic duct, a mechanism shared by other recognized causes (endoscopic retrograde cholangiopancreatography [ERCP]. Alcohol use can cause acute or chronic pancreatitis due to direct toxicity or immunologic mechanisms. Symptoms Pancreatitis: Diagnosis Acute pancreatitis – requires at least 2 of the following 3 diagnostic features: Abdominal pain consistent with acute pancreatitis **Serum lipase or amylase levels that are at least 3 times the upper limit of the normal range** Findings of acute pancreatitis in abdominal ultrasound, CT or MRI to rule out other abdominal etiologies.  Pancreatitis Potential nursing diagnosis include (problems and complications related to pancreatitis): Deficient fluid volume Impaired gas exchange Risk for infection Imbalanced nutrition: less than body requirements Acute pain Nursing goals:  Managing symptoms  Assess complications  Provide family-centered care Pancreatitis: Management Accurate diagnosis, appropriate triage, supportive care, monitoring for and treatment of complications, and prevention of relapse. Fluid resuscitation – aggressive fluid administration during the first 24hrs reduces morbidity and mortality.  Vigorous fluid therapy for 12-24hrs after the onset of symptoms  Administer balanced crystalloid solution Clinical cardiopulmonary monitor fluid status, hourly measurement u/o, and monitor BUN & hct are practical ways to gauge adequacy of fluid therapy. Risk re: fluid therapy: volume overload – excess fluid administration results in increased risk of abdominal compartment syndrome, sepsis, need for intubation, and death. Fluid therapy needs to be tailored to the degree of intravascular volume depletion & cardiopulmonary reserve. Pancreatitis: Management Monitor hemodynamic status: hypovolemic shock and vasodilation Manage acute pain Intense pain of acute pancreatitis causes an increase in pancreatic enzymes, requiring absolute treatment Provide IV opioids as necessary and appropriate to manage pain Acute, severe abdominal pain results in shallow breathing, atelectasis, and possible pneumonia which will be reflected in oxygen saturations and increased respiratory rate or signs of respiratory distress. Administer prophylactic antibiotics as indicated ERCP  Used primarily in patients with gallstone pancreatitis  Indicated for those who have evidence of cholangitis superimposed on gallstone pancreatitis  Due to increased metabolic needs and NPO status, maintenance of adequate nutrition is necessary NPO status: eating stimulates GI motility, & digestive enzymes secretion from the Pancreatiti pancreas which increases inflammation and pain. Pancreas requires rest in order s: to heal. Nutrition In patients who cannot tolerate oral feeding or have NPO status, tube feeding can be initiated. Enteral feeding via nasogastric tube: preferred as it is less costly (compared to TPN), maintains function and integrity of the gut, enhances immune system functioning  Total parenteral nutrition (as indicated for those who have acute necrotizing pancreatitis) it needs to be administered through central venous line; there is also a risk for sepsis or infection. Mild acute pancreatitis (those who do not have Pancreatiti organ failure): clear liquid diet with slow advancement to solid foods; low fat, soft or s: solid diet. Nutrition Low fat-diet in the absence of severe pain, nausea, vomiting, and ileus (all of which are unusual in mild cases of acute pancreatitis) Once oral intake is permitted, person with pancreatitis require a diet higher in CHOs  Carbohydrates are least stimulating to the pancreas  Lipids are most stimulating to the pancreas (lipase & amylase produced by the pancreas digest fats and proteins)  Fiber increases increases peristalsis, which stimulates pancreatic function. Pancreatitis: After acute pancreatitis, pancreatic Long-term exocrine and endocrine dysfunction develops in approximately 20 to 30% of patients Management Chronic pancreatitis develops in ½ of those patients Prevention: Modify risk factors: smoking, heavy alcohol increases risk of transition to chronic pancreatitis, encourage abstinence Cholecystectomy prevents recurrence of gallstone pancreatitis Tight control of hyperlipidemia prevents relapse of pancreatitis caused by hypertriglyceridemia New therapies: Temporary placement of pancreatic duct stents Pharmacologic prophylaxis therapy with NSAIDs