Chapter 61 - PowerPoint Presentation

Slide1

Chapter 61

Care of Patients with Liver Problems

Mrs. Kreisel MSN, RN

NU130 Adult Health

Summer 2011Slide2

Cirrhosis

Cirrhosis is extensive scarring of the liver, usually caused by a chronic reaction to hepatic inflammation and necrosis.

Complications depend on the amount of damage sustained by the liver.

In compensated cirrhosis, the liver has significant scarring but performs essential functions without causing significant symptoms.Slide3

Complications

Portal hypertension

Ascites

Bleeding esophageal varices

Coagulation defects

Jaundice

Portal-systemic encephalopathy with hepatic coma

Hepatorenal syndrome

Spontaneous bacterial peritonitisSlide4

Esophageal

VaricesSlide5

Etiology

Known causes of liver disease include:

Alcohol

Viral hepatitis

Autoimmune hepatitis

Steatohepatitis

Drugs and toxins

Biliary

disease

Metabolic/genetic causes

Cardiovascular diseaseSlide6

Clinical Manifestations

In early stages, signs of liver disease include:

Fatigue

Significant change in weight

GI symptoms

Abdominal pain and liver tenderness

Pruritus Slide7

Clinical Manifestations (Cont’d)

In late stages, the signs vary:

Jaundice and

icterus

(pigmentation of tissue, membranes and

secreations

with bile pigments)

Dry skin

Rashes

Petechiae

, or

ecchymoses

(lesions)

Warm, bright red palms of the hands

Spider

angiomas

: associated with cirrhosis of the liver, branched growth of dilated capillaries on the skin looking like a spider

Peripheral dependent edema of the extremities and sacrumSlide8

Abdominal Assessment

Massive ascitesUmbilicus protrusion

Caput medusae (dilated abdominal veins)

Hepatomegaly (liver enlargement)Slide9

Liver

DysfunctionSlide10

Other Physical Assessments

Assess

nasogastric

drainage,

vomitus

, and stool for presence of blood

Fetor

hepaticus

(breath odor)

Amenorrhea

Gynecomastia

, testicular atrophy, impotence

Bruising,

petechiae

, enlarged spleen

Neurologic changes

Asterixis

( also known as liver flap or liver tremors: abnormal involuntary jerking muscles)Slide11

Laboratory Assessment

Aminotransferase serum levels and lactate dehydrogenase may be elevated.

Alkaline phosphatase levels may increase.

Total serum bilirubin and urobilinogen levels may rise.

Total serum protein and albumin levels decrease.Slide12

Laboratory Assessment (Cont’d)

Prothrombin time is prolonged; platelet count is low.

Hemoglobin and hematocrit values and white blood cell count are decreased.

Ammonia levels are elevated.

Serum creatinine level is possibly elevated.Slide13

Excess Fluid Volume

Interventions:

Nutrition therapy consists of low sodium diet, limited fluid intake, vitamin supplements.

Drug therapy includes a

diuretic like

Lasix

,

electrolyte replacement.

Paracentesis

is the insertion of a

trocar

catheter into the abdomen to remove and drain

ascitic

fluid from the peritoneal cavity.

Observe for possibility of impending shock.Slide14

Comfort Measures

For dyspnea, elevate the head of the bed at least 30 degrees, or as high as the patient wishes to help minimize shortness of breath.

Patient is encouraged to sit in a chair.

Weigh patient in standing position, because supine position can aggravate dyspnea.Slide15

Fluid and Electrolyte Management

Interventions:

Fluid and electrolyte imbalances are common as a result of the disease or treatment; test for:

Blood urea nitrogen level

Serum protein

level, if low may order albumin (protein)

Hematocrit

level

ElectrolytesSlide16

Surgical Interventions

Peritoneovenous

shunt &

Portocaval

shunt are rarely done today because of serious complications. They are shunts that divert fluid away from the diseased liver into the venous system.

Transjugular

intrahepatic

portosystemic

shunt is a nonsurgical procedure done in interventional radiology. Thread a balloon through the jugular to the liver into the portal vein. Enlarge it with a balloon and insert a stent to keep it openSlide17

Potential for Hemorrhage

Interventions include:Identifying the source of bleeding and initiating measures to halt it

Massive esophageal bleeding

Esophageal varicesSlide18

Potential for Hemorrhage (Cont’d)

Nonsurgical management includes:

Drug therapy

—

possibly nonselective beta blocker

Gastric intubation

Esophagogastric

balloon

tamponade

: catheter surround3d by a balloon used in the esophagus to arrest bleeding from

varices

. 3 lumens, one for fluids, one balloon, control of the balloonSlide19

Esophageal Gastric

TamponadeSlide20

Management of Hemorrhage

Blood transfusions

Esophagogastric balloon tamponade

Vasoactive therapy

Endoscopic procedures

Transjugular intrahepatic portal-systemic shunt

Surgical management Slide21

Potential for Portal-Systemic Encephalopathy

Interventions include:

Role of

ammonia: it is converted into urea in the liver and along with CO2 it becomes the final product of protein metabolism

Reduction of ammonia

levels High levels indicate Liver Failure

Nutrition therapy using simple and brief guidelines

Drug therapy:

Lactulose

: Empty the bowel of ammonia

Neomycin sulfate

MetronidazoleSlide22

Hepatitis

Widespread viral inflammation of liver cells can lead to Hepatic Encephalopathy (brain dysfunction due to high ammonia levels or

orther

liver problems. Can lead to a coma.

Hepatitis A

Hepatitis B

Hepatitis C

Hepatitis D

Hepatitis E

Slide23

Hepatitis A

Similar to that of a typical viral syndrome; often goes unrecognized

Spread via the fecal-oral route by oral ingestion of fecal contaminants

Contaminated water, shellfish from contaminated water, food contaminated by handlers infected with hepatitis A

Also spread by oral-anal sexual

activity

Incubation period for hepatitis A is 15 to 50 days.

Disease is usually not life threatening.

Disease may be more severe in individuals older than 40 years.

Many people who have hepatitis A do not know it; symptoms are similar to a GI illness.Slide24

Hepatitis B

Spread is via unprotected sexual intercourse with an infected partner, sharing needles, accidental needle sticks, blood transfusions,

hemodialysis

, maternal-fetal route.

Symptoms occur in 25 to 180 days after exposure; symptoms include anorexia, nausea and vomiting, fever, fatigue, right upper quadrant pain, dark urine, light stool, joint pain, and jaundice

.

Hepatitis carriers can infect others, even if they are without symptoms.Slide25

Hepatitis C

Spread is by sharing needles, blood, blood products, or organ transplants (before 1992), needle stick injury, tattoos, intranasal cocaine use.

Incubation period is 21 to 140 days.

Most individuals are asymptomatic; damage occurs over decades.

Hepatitis C is the leading indication for liver transplantation in the United States.Slide26

Hepatitis D

Transmitted primarily by parenteral routesIncubation period 14 to 56 daysSlide27

Hepatitis E

Present in endemic areas where waterborne epidemics occur and in travelers to those areas

Transmitted via fecal-oral route

Resembles hepatitis A

Incubation period 15 to 64 daysSlide28

Clinical Manifestations

Abdominal pain

Changes in skin or eye

color (Jaundice)

Arthralgia

(joint pain)

Myalgia

(muscle pain)

Diarrhea/constipation

Fever

Lethargy

Malaise

Nausea/vomiting

Pruritus

(itching)Slide29

Nonsurgical Management

Physical restPsychological rest

Diet therapy

Drug therapy includes:

Antiemetics

Antiviral medications

Immunomodulators

AVOID DRUGS METABOLISED BY THE LIVER SUCH AS TYLENOLSlide30

Fatty Liver (Steatohepatitis)

Fatty liver is caused by the accumulation of fats in and around the hepatic cells.

Causes include:

Diabetes mellitus

Obesity

Elevated lipid profile

Alcohol abuse

Many patients are asymptomatic.Slide31

Hepatic Abscess

Liver invaded by bacteria or protozoa causing abscess

Pyrogenic liver abscess; amebic hepatic abscess

Treatment usually involves:

Drainage with ultrasound guidance

Antibiotic therapySlide32

Liver Trauma

The liver is one of the most common organs to be injured in patients with abdominal trauma.

Clinical manifestations include abdominal tenderness, distention, guarding, rigidity.

Treatment involves surgery, multiple blood products.Slide33

Cancer of the Liver

One of the most common tumors in the worldMost common complaint

—

abdominal discomfort

Treatment includes:

Chemotherapy

Hepatic artery embolization

Hepatic arterial infusion (HAI)

SurgerySlide34

Liver Transplantation

Used in the treatment of end-stage liver disease, primary malignant neoplasm of the liver

Donor livers obtained primarily from trauma victims who have not had liver damage

Donor liver transported to the surgery center in a cooled saline solution that preserves the organ for up to 8 hoursSlide35

Complications

Acute, chronic graft rejection

Infection

Hemorrhage

Hepatic artery thrombosis

Fluid and electrolyte imbalances

Pulmonary atelectasis

Acute renal failure

Psychological maladjustmentSlide36

NCLEX TIMESlide37

Question 1

These laboratory results are expected with which type

of jaundice?

Indirect serum bilirubin: Increased

Direct serum bilirubin: Normal

Stool urobilinogen: Increased

Urine urobilinogen: Increased

Intrahepatic

Hemolytic

Obstructive

Hepatocellular

Slide38

Question 2

A possible outcome for the patient receiving a liver

transplant because of hepatitis C–induced cirrhosis

is that the newly transplanted liver may

Be a likely site for cancer growth in the future

Make the patient more likely to develop obstructive jaundice in the future

Become re-infected with the hepatitis C virus

Make the patient more susceptible to develop other forms of hepatitisSlide39

Question 3

Which assessment parameter requires immediate

intervention in a patient with severe ascites?

Shallow respirations, rate 36 breaths/min

Low-grade fever

Confusion

Tachycardia, rate 110 beats/minSlide40

Question 4

A priority intervention in the management of a patient

with decompensated cirrhosis would be:

Limit protein intake.

Monitor fluid intake and output

.

Manage nausea and vomiting

Elevate head of bed >30 degrees

Slide41

Question 5

Which racial group is at the highest risk for developing

liver cancer?

Caucasian

African American

Asian

Hispanic/Latino