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Medsurg II - Liver

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olanjones's version from 2017-04-20 15:17

Cirrhosis

Question Answer
Descriptionchronic progressive liver disease characterized by extensive degeneration, disorganized regeneration, & destruction of liver cells resulting in irregular size and impeded blood flow
StatsApprox 20% of ps w/ chronic hepatitis C & 10-20% of those with chronic hepatitis B will develop cirrhosis
Biliary cirrhosiscauses include primary biliary cirrhosis (d/t inflammation & obstruction) & primary sclerosing cholangitis
Primary sclerosing cholangitischronic inflammatory condition of liver & bile ducts (frequently in men)
Cardiac cirrhosisresults from long-standing, severe right-sided heart failure (spectrum of changes)
Early symptomsFatigue; many pts have no symptoms until late
Later symptomsJaundice, Peripheral edema, Ascites, Skin lesions, Hematologic & Endocrine problems, Neurologic disorders
Advanced stageLiver becomes small & nodular
Skinlesions d/t ↑in circulating estrogen (liver unable to metabolize steroid hormones); Spider angiomas (on nose, cheeks, ↑trunk, neck, shoulders); Palmer erythema (blanches w/ pressure)
Hematologic↓ (thrombocytopenia, leukopenia, anemia - prob d/t splenomegaly); portal HTN results in ↑removal of blood cells from circulation by the spleen; Coagulation problems d/t liver’s inability to produce factors
EndocrineGynecomastia, Loss of axillary/pubic hair, Testicular atrophy, Impotence, Loss of libido (men), Amenorrhea/bleeding, Hyperaldosteronism (both sexes)
NeuroNeuropathy & sensory symptms (dietary ↓of thiamine, folic acid, cobalamin)
Compensatedno complications of cirrhosis
UncompensatedOne or more complications (portal HTN, varices, edema/3rd spacing, encephalopathy, hepatorenal syndrome)
Portal HTN →splenomegaly, collateral veins, ascites, varices
Varicesvery fragile, bleed easily (can be life-threatening), most in esophagus but can be throughout GI
Edema & Third spacing↓colloidal oncotic pressure (↓albumin) & ↑ portacaval pressure; serous fluid in peritoneal/abd cavity
Encephalopathy ↑ammonia (crosses BBB), abn neurotransmission, astrocyte swelling, inflammatory cytokines
Hepatorenal syndromeazotemia, oliguria, & intractable ascites (no structural kidney abn); Portal hypertension → vasodilation → renal vasoconstriction (tx w/ liver transplant)
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Cirrhosis Dx & Tx

Question Answer
LabsLiver enzymes initially ↑because of release from damaged cell but may be nl in end-stage
↓cholesterol (d/t fat metabolism), ↓protein & albumin, ↑serum bilirubin & globulin, prolonged PT
Other dx testsLiver u/s or biopsy, Analysis of ascetic fluid
CCRest, B-complex vitamins, No ETOH, NSAIDs, Tylenol
CC of complicationsDiuretic tx, Sodium restriction, Paracentesis, Transjuglar intrahepatic portosystem shunt (TIPS), β-blockers, Band/ligation of varices, ↓ammonia formation (lactulose, rifaximin, prevent constipation)
If bleeding occursStabilize airway; Admin blood products; Drug tx: vasoconstrictors (octreotide/vasopressin), nitroglycerin, Vit K, Lactulose, PPIs, Abx; Endoscopic repair (banding, sclerotherapy)
*If bleeding can’t be controlled may use balloon tamponade (mechanical compression)
Balloon tamponade tubes-Sengstaken-Blakemore: 2 balloon, 3 lumens; 1 gastric, 1 esophageal, 1 gastric aspiration
-Minnesota: modified Sengstaken w/ esophageal suction port above esophageal balloon
-Linton-Nachlas: larger capacity than Sengstaken, no esophageal balloon
Balloon insertionInserted through nose or mouth by physician; Inflated w/ approx 250 mL air, & retracted until resistance (lower esophageal sphincter) is felt; Secured by placement of a piece of sponge or foam rubber at the nostrils (nasal cuff). Esophageal balloon is inflated (usu to 20-40 mmHg); Position is verified by x-ray
Balloon safetyLabel each lumen, Deflate balloons for 5 mins q 8-12 hrs to prevent necrosis
TIPSNonsurgical procedure in which a shunt btwn systemic & portal venous system is created to redirect portal blood flow; does not interfere w/ future transplant
Contraindicated in severe hepatic encephalopathy, hepatocellular carcinoma, severe hepatorenal syndrome, & portal vein thrombosis
Surgical shuntsPoratcaval or distal splenorenal – used to decrease portal HTN by diverting some portal blood flow while allowing adequate liver perfusion
NutritionPt’s w/ no complications: ↑calorie (3000/day), ↑carbs, mod-↓ fat, may need protein supplementation
* If severe flare of symptoms protein may be temporarily restricted but malnutrition is us a more serious prob than encephalopathy; In ascites/edema may be on low-sodium diet
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Cirrhosis Nursing

Question Answer
Subjective- Past HHPrevious viral/toxic/idiopathic hepatitis; NASH, chronic biliary obstruction, & infection; severe right-sided heart failure
Subjective- MedsAdverse reaction to any medication; use of anticoagulants, aspirin, NSAIDs, acetaminophen
Subjective- Health Patternschronic ETOH; weakness/fatigue; anorexia, ↓wt, dyspepsia, N&V; gingival bleeding; dark urine, ↓UO; light or black stools, flatulence, change in bowel habits; dry, yellow skin; bruising; RUQ pain, numbness/tingling of extremities; pruritus; impotence, amenorrhea
Objectivefever, cachexia, wasting of extremities; icterus, petechiae/ecchymosis; spider angiomas, palmer erythema; hair loss; edema; shallow/rapid breathing, epistaxis; abd distention, palpable liver/spleen, hematemesis, hemorrhoids; AMS, endocrine changes (gynecomastia, amenorrhea, etc)
DxAnemia, thrombocytopenia; leukopenia; ↓ serum albumin level, ↓ potassium level; abnormal LFTs; ↑ INR, ↑ ammonia level, ↑ bilirubin levels; abnormal abdominal u/s or MRI
Health promoReduce or eliminate risk factors, Treat alcoholism, Maintain adequate nutrition, Identify & treat acute hepatitis, Bariatric surgery for morbidly obese
Acute NI-Rest: prevent complications, modify sched
-Nutrition: oral hygiene, snacks, food preferences, explain dietary restrictions
-Dyspnea: semi or high Fowler’s; cough/deep breathing for prevention
-Skin care: special mattress (alt-air pressure), turn q 2 hrs; ROM exercises; Elevate extremities, scrotal support
-Monitor for F&E, bleeding; Assess body image
NI for jaundice, pruritusRx (cholestyramine, hydroxyzine), baking soda/Alpha Keri baths, antihistamines, temp control, short nails, rub w/ knuckles
I&Os, daily wt, measurements of extremities/abdominal girth
NI for paracentesisPt to void before procedure, Position in high Fowler’s or sitting on side of bed, Monitor F&E & for bleeding/leakage
NI for bleedingAssess for hemorrhage, Call physician, Be ready to assist w/ tx used to control bleeding
NI balloon tamponade-Explain use of tube & how it will be inserted, Check balloon for patency
-Monitor for complications (rupture, erosion, aspiration, occlusion), Keep scissors at bedside
-Position in semi-Fowler’s (pt unable to swallow saliva b/c inflated esophageal balloon occludes the esophagus)
-Encourage pt to expectorate, provide an emesis basin & tissues, Frequent oral & nasal care (↓taste of blood & irritation from mouth breathing)
NI hepatic encephalopathyMaintain safe environment, Assess pt’s level of responsiveness, sensory/motor abnormalities, F&E/acid-base imbalances, Effect of treatment measures; Neuro exam q 2 hrs, prevention of constipation
NI ambulatory & homeCaring attitude ALWAYS, Proper diet, Rest, Avoid hepatotoxic drugs, Abstain ETOH, Community support programs, S/S complications (when to seek medical attention), Written instructions w/ adequate explanations for patient/family, Referral to community or home health nurse
NI expected outcomesPt will: Maintain food & fluid intake adequate to meet nutritional needs; Maintain skin integrity w/ relief of edema & pruritus; Experience normalization of fluid balance as a result of medical & nursing interventions; Acknowledge & get treatment for a substance abuse problem
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