Liver Function - Liver Disorders PDF

**LIVER DISORDERS** **Liver Function** - The **liver produces and secretes bile** which helps break down fats and proteins. - It **produces most of the proteins** needed by the body. - The liver is responsible for **removing potentially toxic byproducts** of certain medications. -...

**LIVER DISORDERS** **Liver Function** - The **liver produces and secretes bile** which helps break down fats and proteins. - It **produces most of the proteins** needed by the body. - The liver is responsible for **removing potentially toxic byproducts** of certain medications. - It **metabolizes nutrients** from food to produce energy. - The liver helps fight infection by **removing bacteria from the blood**. - It **produces most of the substances that regulate blood clotting**. - The liver plays a role in **immunity against infection**. - Bile also **converts protein into ammonia, which then turns to urea**. - **Elevated ammonia levels are a key indicator of liver failure (hepatic encephalopathy)**. - **Hepatomegaly and jaundice** are manifestations of cirrhosis, which occurs as a result of altered metabolism of carbohydrates, fats, and proteins. - Jaundice results from red blood cells not being broken down. **Liver Disease Progression** 1. **Fatty liver**: Fat deposits in the cells cause the liver to enlarge. 2. **Fibrosis Liver**: Connective tissue begins to replace liver tissue. 3. **Cirrhosis Liver (thick scar tissue)**: Excessive connective tissue development restructures the liver and vascular system, and areas of necrosis form. 4. **Liver cancer**: Liver cancer forms as a result of the malignant transformation of hepatocytes. **Liver Cirrhosis** - Cirrhosis is the **final stage of liver disease** and is the end result of chronic liver diseases such as: - Hepatitis - Non-alcoholic fatty liver disease - Liver Cancer - Autoimmune hepatitis - Hepatobiliary obstruction - Right-sided heart failure - It **results from structural injury to the liver**. - Cirrhosis **leads to the following complications**: - Portal hypertension - Treated with beta-blockers. - Ascites - Caused by low albumin levels that result in fluid shift. - Hepatic encephalopathy - Esophageal varices - Splenomegaly **Manifestations of Cirrhosis** - Right upper quadrant dull pain - Weight loss - Weakness - Anorexia - Hepatomegaly - Jaundice - Splenomegaly - Bleeding tendencies - Hepatic encephalopathy - Confusion and tremors (asterixis). **Lab Results Indicating Cirrhosis** - Elevated liver enzymes: AST and ALT are specific to cirrhosis - Decreased albumin - Elevated INR and PT - Decreased Vitamin K - Decreased cholesterol - Elevated ammonia **Management of Cirrhosis** - Low protein and low sodium diet - Diuretics (potassium-sparing and potassium-wasting) - Lasix and Aldactone - Monitor weight to check for fluid retention **Ascites Management** - Sodium and water/fluid restriction - Dietary restrictions - Diuretics such as furosemide and spironolactone - Monitor for hypokalemia when administering diuretics. - Large volume paracentesis - Removal of 5L or more of fluid. - Indicated when diuretics are ineffective or the patient is symptomatic (e.g., respiratory distress). - Monitor for spontaneous bacterial peritonitis and hypovolemia. - Administering 25% albumin (5g per liter of ascetic fluid removed over 5L) decreases the risk of complications. - Monitor creatinine levels, as paracentesis can cause renal injury. - Monitor the patient\'s weight, vital signs, and the paracentesis site. - **Priority Assessment**: Circulation - Parotiditis is a complication of paracentesis. **Nursing Diagnosis for Cirrhosis** - **Priority Nursing Diagnosis**: Nutrition - Other possible nursing diagnoses: - Acute confusion - Death Anxiety - Interrupted Family Processes - Fear - Risk for shock - Social Isolation - **Imbalanced nutrition: less than body requirements related to alteration in liver function as evidenced by lack of interest in food, weight loss, and reported inadequate food intake**. **Nursing Interventions: Nutrition** - Monitor weight to evaluate nitrogen balance. - Provide oral care before meals to remove foul tastes and improve the taste of food. - Administer antiemetics as ordered to relieve nausea and prevent vomiting. - Provide small, frequent meals with nourishing content to prevent feeling full and to maintain nutritional status. - Determine the patient\'s food preferences to increase nutritional appeal. - A low-sodium diet may be unpalatable. - Restrict sodium intake. **Complications of Cirrhosis** - **Hemorrhage**: Risk of bleeding secondary to altered clotting factors and rupture of esophageal or gastric varices. - **Hepatic encephalopathy**: Related to the inability of the liver to detoxify toxins, evidenced by episodes of drowsiness, tremors, and confusion. **Nursing Interventions: Hemorrhage** - Monitor for hemorrhage by assessing for: - Epistaxis - Purpura - Petechiae - Easy bruising - Gingival bleeding - Hematuria - Melena - Provide gentle nursing care to minimize tissue trauma. - Use the smallest gauge needle possible when giving injections and apply gentle but prolonged pressure afterward to minimize the risk of bleeding into tissue. - Teach the patient to avoid straining at stool, vigorously blowing their nose, and coughing to reduce the risk of hemorrhage. - Observe for bruising on the skin. - Monitor laboratory results: - Hematocrit - Hemoglobin - Prothrombin time - Advise the use of a soft-bristled toothbrush and avoidance of irritating food to reduce trauma to the mucous membranes. **Hepatic Encephalopathy** - **Treatment**: Lactulose and beta-blockers - Teach the patient that they should have 2-5 bowel movements a day while taking lactulose. - **Focus of nursing care**: - Maintain a safe environment and assist with measures to reduce episodes of drowsiness. - Assess the patient's level of consciousness and sensory & motor abnormalities. - Assess fluid & electrolyte and acid-base imbalances. - Assess neurological status. - **Goal of care**: Reduce ammonia levels and the formation of ammonia using lactulose. - **Management**: - Lactulose - Antibiotics (usually neomycin or Flagyl) - Prevent constipation - Protein restriction - High calorie (3000kcal/day), high carbohydrate, moderate to low fat diet - Low sodium - Control GI bleed & remove blood from the GI tract - **Lactulose**: - Non-absorbable disaccharide - Hyperosmotic laxative that draws water into the colon to produce a laxative effect - Reduces ammonia by converting it to ammonium to prevent reabsorption - Lowers the pH of the intestine, affecting both the production and absorption of ammonia - Usual dose is 30 to 60 ml/dose, titrated in frequency to maintain 2 to 5 bowel movements per day - Onset of action: 24 hours - **Contraindications**: Patients on a low-galactose diet - **Side effects**: Excessive use can cause diarrhea, dehydration, and kidney impairment - **Nursing considerations**: - Abdominal assessment, vital signs, weights, intake & output, fluid & electrolyte levels, bowel habits - Assess abdominal pain, degree of peristalsis, history of recent abdominal surgery, nausea and vomiting, and weight loss **Understanding Pancreatitis** Pancreatitis is a condition characterized by inflammation of the pancreas. The pancreas plays a vital role in digestion and blood sugar regulation. It performs two main functions: - **Endocrine function**: Produces hormones like insulin that regulate blood sugar levels. - **Exocrine function**: Releases digestive enzymes that break down food after eating. **Causes of Pancreatitis** The sources identify several common causes of pancreatitis: - **Gallstones**: Migrating gallstones can temporarily obstruct the pancreatic duct, leading to inflammation. - **Alcohol abuse**: Prolonged and heavy alcohol consumption (4-5 drinks daily for over 5 years) is a significant risk factor. Alcohol can directly damage the pancreas or trigger immune responses that lead to inflammation. - **Certain Medications**: Drugs like azathioprine, 6-mercaptopurine, didanosine, valproic acid, angiotensin-converting enzyme inhibitors, and mesalamine are linked to pancreatitis. - **Genetic Mutations**: Inherited genetic mutations can predispose individuals to pancreatitis. **Blockage and Autodigestion** When the pancreatic duct is blocked (e.g., by gallstones), digestive enzymes build up within the pancreas, leading to **autodigestion**. This means the enzymes start breaking down the pancreas itself, causing inflammation, pain, and other symptoms. **Symptoms of Pancreatitis** Pancreatitis often presents with: - **Shortness of breath (SOB)** - **Upper abdominal pain radiating to the back** - **Vomiting** - **Dehydration** - **Fever** (due to inflammation) - **Rapid pulse** **Diagnosis of Acute Pancreatitis** To diagnose acute pancreatitis, at least two of the following three criteria must be met: - **Abdominal pain** consistent with acute pancreatitis. - **Significantly elevated serum lipase or amylase levels:** At least three times the upper limit of the normal range. These enzymes are released from the damaged pancreas. - **Imaging confirmation**: Abdominal ultrasound, CT scan, or MRI showing evidence of acute pancreatitis. These imaging tests help rule out other possible causes of abdominal pain. **Management of Pancreatitis** The management of pancreatitis involves: - **Accurate diagnosis and triage**: Determining the severity of pancreatitis is crucial for appropriate treatment. - **Supportive care**: This includes monitoring vital signs, managing pain, and addressing fluid and electrolyte imbalances. - **Monitoring and treating complications**: Pancreatitis can lead to complications such as fluid volume depletion, impaired gas exchange, infection, and malnutrition. - **Preventing relapse**: Lifestyle modifications and addressing underlying causes are essential to reduce the risk of future episodes. **Fluid Resuscitation** Aggressive fluid administration is crucial in the initial 24 hours of acute pancreatitis. It helps reduce morbidity and mortality. - **Intravenous fluids**: Typically, balanced crystalloid solutions are used to restore fluid volume. - **Monitoring**: Closely monitor fluid status, urine output, blood urea nitrogen (BUN), and hematocrit (Hct) to ensure adequate fluid therapy and avoid fluid overload. - **Risks of fluid overload**: Excessive fluid administration can lead to abdominal compartment syndrome, sepsis, respiratory distress, and even death. **Pain Management** The intense pain associated with pancreatitis necessitates effective pain relief measures. - **Intravenous opioids**: These are often required to manage severe pain. - **Addressing pain-related complications**: Severe abdominal pain can lead to shallow breathing, increasing the risk of atelectasis (collapsed lung) and pneumonia. Monitor oxygen saturation and respiratory rate for any signs of respiratory distress. **Other Management Strategies** - **Prophylactic antibiotics**: May be administered to prevent infection, especially in cases of severe pancreatitis. - **Endoscopic retrograde cholangiopancreatography (ERCP)**: This procedure is primarily used in patients with gallstone pancreatitis, particularly those with evidence of cholangitis (bile duct infection). It allows for the removal of gallstones blocking the pancreatic duct. **Nutritional Support** - **NPO status initially**: Keeping the patient nothing by mouth (NPO) rests the pancreas and reduces inflammation. Eating stimulates the release of digestive enzymes, which can worsen pain and inflammation. - **Enteral feeding**: Once the patient can tolerate feeding, enteral feeding via a nasogastric tube is preferred over parenteral nutrition (TPN). It helps maintain gut integrity, supports the immune system, and is generally less costly. - **Total parenteral nutrition (TPN)**: May be necessary for patients with acute necrotizing pancreatitis or those unable to tolerate enteral feeding. It is administered through a central venous line and carries a risk of infection. - **Dietary modifications**: - **Clear liquid diet**: May be initiated in mild cases, gradually advancing to solid foods as tolerated. - **Low-fat diet**: Essential to reduce pancreatic stimulation. - **High-carbohydrate diet**: Carbohydrates are the least stimulating to the pancreas. - **Limited fat and fiber**: Fats and fiber stimulate the pancreas and can worsen symptoms. **Long-Term Management** - **Risk factor modification**: Encourage abstinence from alcohol and smoking to reduce the risk of chronic pancreatitis. - **Cholecystectomy**: Surgical removal of the gallbladder can prevent recurrence in gallstone pancreatitis. - **Hyperlipidemia management**: Controlling high lipid levels can help prevent pancreatitis caused by hypertriglyceridemia. - **Emerging therapies**: These include temporary placement of pancreatic duct stents and prophylactic therapy with NSAIDs.