Lisa Randall, RN, MSN, ACNS-BC
RNSG 2432
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• Compare and contrast risk factors associated with hepatitis and cirrhosis
• Analyze the etiology and pathophysiology of hepatitis and cirrhosis
• Integrate diagnostic tests with etiology, pathophysiology, and signs/symptoms of both disorders
• Formulate relevant prioritized nursing diagnoses that address physical, pyschosocial, and learning needs and evaluate nursing interventions
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• A Liver
• B Hepatic vein
• C Hepatic artery
• D Portal vein
• E Common bile duct
• F Stomach
• G Cystic duct
• H Gallbladder
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• Largest organ
• Metabolic functions
• Bile synthesis
▫ Hepatocytes
 Bile secretion
• Storage
• Mononuclear phagocyte system
▫ Kupffer cells
 Phagocytic activity
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• Metabolism of glucose
• Protein
• Fatty acids
• Cholesterol
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• Immunologic
• Blood storage
• Plasma protein synthesis
• Clotting
• Storage of vitamins and minerals
• Waste products of hemoglobin
• Bile formation and secretion
• Steroids and hormones
• Ammonia
• Drugs, ETOH, toxin metabolism
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• Inflammation
• Hepatic cell necrosis
• Proliferation/enlargement Kupffer cells
• Cholestasis
• Regeneration
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• Chronic
• Fulminant
• Toxic
• Hepatobillary
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• A
• B
• C
• D
• E
• G
*see handout
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Acute
• Anorexia
• N/V
• RUQ pain
• Bowel irregularity
• Malaise
• HA
• Fever
• Arthralgias
• Uticaria
• Weight loss
• Jaundice
• Hepatomegaly
• Splenomegaly
• Pruritus
• Dark urine
• Bilirubinuria
• Light stools
• Fatigue
Chronic
• Malaise
• Easy fatigability
• Hepatomegaly
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• Preicteric
▫ Prodromal
• Icteric
▫ Jaundice
• Posticteric
▫ Convalescent
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• Fecal/oral
• 15-50d
• S/S
▫ Light stools
▫ Dark urine
▫ Fatigue
▫ Fever
▫ Jaundice
• Labs
• Vaccine
• IgG
• Prevention
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• Percutaneous/permucosal
• Sexual contact
• Perinatal
• 45-180d
• S/S
▫ 30% asymptomatic
▫ Flu
▫ Light stools
▫ Dark urine
▫ Fatigue
▫ Fever
▫ Jaundice
• Labs
• Prevention
▫ Vaccine
▫ IgG
▫ Safe sex
▫ No sharing of razors, toothbrushes, needles
• Chronicity
▫ Antivirals
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• Percutnaeous/mucosal
• Sexual contact
• Perinatal
• 14-180d
• S/S
▫ 80% asymptomatic
▫ HBV
• http://youtu.be/y6osMO5xnag
• Labs
• Prevention
▫ Safe sex
▫ No sharing of razors, toothbrushes, needles
• Chronicity
▫ Interferon
▫ antivirals
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• HBV
• 2-26wk
• Labs
• Interferon
• HBV vaccine
• S/S
▫ HBV
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• Fecal/oral
• Contaminated water
• Poor sanitation
• 15-64d
• Labs
• S/S
▫ HBV
• No vaccine
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• LFT
• ALP
• Serum bilirubin
• Liver biopsy
• Antigen specific
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• Diet
▫ High cal/protein, low fat
▫ Vitamins (B, K)
▫ ETOH/Drugs
• Fluid management
• Bed rest
• Drug therapy
▫ Prevention of HAV and HBV
▫ Interferon
▫ Lamivudine
▫ Ribavirin
▫ Acetaminophen
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• Risk for infection (transmission)
• Imbalanced nutrition
• Disturbed body image
• Knowledge deficit
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• Caused by destruction of liver cells, fibrosis and nodule formation restricting blood and bile flow
• Normal hepatic blood pressure is near zero.
Restriction of blood flow in liver dysfunction causes hypertension, and blood will attempt to find other pathways, bypass liver
• Results in significant impairment of liver function
• 80% destroyed before signs and symptoms
• Liver can regenerate itself if good nutrition, rest, and no alcohol
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• Post necrotic
▫ Hepatitis
• Alcoholic Cirrhosis
▫ Laennec’s
▫ metabolic changes in liver, particularly fat
• Biliary
▫ obstructive
• Cardiac
▫ right side heart failure
• Drug induced
▫ INH, rifampin, Tylenol

• Liver enlarged
• Dull pain RUQ
• Weakness
• Anorexia
• Skin
• Sclera
• Portal hypertension
• Splenomegaly
• Ascites
• Esophageal varices
• Hepatic encephalopathy
• Hepatorenal Syndrome
• Liver failure
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• Excess bilirubin
• Heptocellular
▫ Cirrhosis
• Obstructive
• Hemolytic
▫ Excessive destruction of RBCs
 Transfusion reaction
 Autoimmune
 Faulty hemoglobin
 Sickle cell
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• LFT
• CBC
• Coags
• Bilirubin
• Albumin
• Ammonia
• Esophagascopy
• Liver biopsy
*See Table 44.15
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• 3 types
▫ Needle
▫ Laparoscopic
▫ Transvenous
 Catheter
 Blood clotting problems
 Excess fluid
• Complications
▫ Puncture of lung or gallbladder
▫ Infection
▫ Bleeding
▫ Pain
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• Adequacy of clotting- PT/ INR, Platelets (Vit. K?)
• Type and cross match for blood
• Stop aspirin, ibuprofen, and anticoagulants 1 wk. before
• Chest x-ray
• Consent form & NPO 4 to 8 hr.
• Vital signs & Empty bladder
• Supine position, R arm above head
• Hold breath after expiration when needle inserted
• Be very still during procedure – 20 minutes

• Pressure
• Right side
▫ minimum of 2 hrs
▫ flat 12-14 hrs
• Vital signs & check for bleeding
• NPO X 2 hr after
• Assess for peritonitis, shock, & pneumothorax
• Rt. shoulder pain common
▫ caused by irritation of the diaphragm muscle
▫ usually radiates to the shoulder a few hours or days.
• Soreness at the incision site
• Tylenol
▫ avoid aspirin or ibuprofen for the first week because they decrease blood clotting, which is crucial for healing.
• Avoid coughing, straining, lifting x 1-2 weeks

• LOC
• Reflexes
▫ Hyperreflexia
• Pupils
• Orientation
• Sensory/motor
▫ Asterexis
▫ http://www.youtube.com/watch?v=pAOWjYo-sX4
• Coordination
▫ Dysmetria
• Fluid/electrolytes
▫ Acid/base imbalances
See table 44.17
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• Safe environment
• Sustain life
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Hepatitis
• Risk for infection
(transmission)
• Imbalanced nutrition
• Disturbed body image
• Knowledge deficit
Cirrhosis
• Excess fluid volume
• Disturbed thought process
• Ineffective protection
• Impaired skin integrity
• Imbalanced nutrition
• Knowledge deficit
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• Diet
▫ Sodium restriction
▫ High carbs
▫ Mod fat
▫ 75-100gm protein
 60-80gm/d (hep encephalopathy)
• Fluid management
• Drug therapy
▫ Diuretics
▫ Laxatives
▫ Anti-infective agents
• Surgical/medical interventions
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Major Complications of
Cirrhosis
Portal hypertension
Variceal bleeding
Ascites
Spontaneous bacterial peritonitis
Splenomegaly
Hepatorenal syndrome
Hepatic encephalopathy

• Arteriovenous shunting
• Marked ascites
• Caput medusae
▫ Dilated abdominal veins
• Esophageal varices
• Hemorrhoids
• Hyperslenism
▫ Mod anemia
▫ Neuropenia
▫ Thrombocytopenia
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• Paracentesis
• Gastric lavage
• Balloon tamponade
• Schlerotherapy
• Banding
• TIPS (transjugular intrahepatic portosystemic shunt)
• Liver transplant
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• Sodium restriction
• Bedrest initially
• Diuretics
▫ Spironolactone
▫ Lasix
▫ HCTZ
• Fluid removal
▫ Paracentesis
▫ Peritoneovenous Shunt
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• Only used if respiratory distress
• Pt will loose 10-30 grams of protein
• Pt in sitting position
• Empty bladder first
• Post--watch for hypotension, bleeding, shock & infection
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• Collateral vessels
• Complex of swollen, enlarged veins
▫ Portal hypertension
• 2/3-3/4
• Bleeding
▫ LIFE-THREATENING
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Active bleeding
• Central line & pulmonary artery pressures
• Blood transfusions & fresh frozen plasma for clotting factors
• Somatostatin or Vasopressin – constrict gut vessels
• Airway/trach
Later prevention of re-bleeding
• Beta-blockers
• Long-acting nitrates
• Soft food, chew well, avoid intra-abdominal pressure
• Protonix
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Sclerotherapy sclerosant solution (ethanolamine oleate or sodium tetradecyl sulphate)
Complications fever, dysphagia and chest pain, ulceration, stricture, and (rarely) perforation.

Band ligation
Fewer treatment sessions and complications than sclerotherapy.

Balloon tube tamponade
Tube is inserted through the mouth
Correct placement within the stomach is checked by auscultation while injecting air through the gastric lumen
Gastric balloon is then inflated with 200 ml of air
Gastric balloon is pulled up against the esophagogastric junction, compressing the submucosal varices
Tension is maintained by strapping a split tennis ball to the tube at the patient's mouth
Complications gastric and esophageal ulceration aspiration pneumonia
esophageal perforation.

Sengstaken-
Blakemore
tube – has only 3 lumens
**Respiratory assessment**

• Neuropsychiatric manifestation
• Decreased liver detoxification>>>
▫ Increased ammonia
• Terminal complication
• Changes in LOC
• Asterixis
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• Reduce ammonia
▫ Lactulose
▫ Neomycin sulfate
▫ Cathartics
▫ Enemas
▫ Liver transplantation
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• Portal HTN + liver decompensation
▫ Systemic vasodilation
▫ Decreased arterial BF
▫ Renal vasoconstriction
• Functional renal failure
▫ Azotemia
▫ Oliguria
• Liver transplantation
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• Rejection
▫ 70%
▫ Medications
• Infection
▫ immunosuppression
• Cancer

• Therapeutic communication
• Diet*
• Exercise
• Lifestyle modifications
• Drugs
• Follow-up
• Resources
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• Advance directives
• Palliative care
• Organ donation
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• Live donor
• Liver regenerates
▫ 5 years
• Survival rates increase / shorter wait time
• Medical and psychological evaluations
• Potential donors evaluated for:
▫ liver disease, alcohol or drug abuse, cancer, or infection.
▫ hepatitis, AIDS, and other infections.
▫ matched according to blood type and body size.
▫ Age, race, and sex are not considered.
• Cadaver donor have to wait for brain dead donor
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1. Pathophysiology
1. Cirrhosis
2. Portal hyperetension
3. Liver failure
1. Encephalopathy
2. Hepato-renal syndrome
2. Signs & Symptoms
3. Treatment
4. Nsg. Care
5. Complications

• A client presenting with ascites s/t liver failure is being evaluated for fluid balance. Which of the following provides the best indicator of fluid status?
▫ a. I&O
▫ b. LFT
▫ c. caloric intake and serum protein levels
▫ d. daily weight
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• When providing DC teaching to the patient with cirrhosis, his wife asks the RN to explain why there is so much emphasis on bleeding precautions.
Which of the following provides the most appropriate response?
▫ a. “The liver affected by cirrhosis is unable to produce clotting factors.”
▫ b. “The low protein diet will result in reduced clotting factors.”
▫ c. “The increased production of bile decreases clotting factors.”
▫ d. “The required medications reduce clotting factors.”
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• When explaining the rationale for the use of lactulose syrup ot the patient with chronic cirrhosis, the nurse would choose which of the following statements?
▫ a. “lactulose reduces constipation, which is a frequent complaint with cirrhosis.”
▫ b. lactulose suppresses the metabolism of ammonia and aids in its elimination through feces.”
▫ c. lactulose helps to reverse cirrhosis of the liver.”
▫ d. lactulose can be taken intermittingly to reduce side effects.”
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• The patient has just had a liver biopsy. Which of the following nursing actions would be the priority after the biopsy?
▫ A. monitor pulse and BP every 30 minutes until stable and then hourly for up to 24 hours.
▫ B. ambulate every 4 hours for the first day, as long as the patient can tolerate it.
▫ C. measure urine specific gravity every 8 hours for the next 48 hours.
▫ D. maintain NPO status for 24 hours post-biopsy.
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• A male client is being treated for ruptured esophageal varices with a Sengstaken-Blakemore tube. His VS have been stable, and the suction port is draining scant amounts of drainage. He suddenly becomes acutely dyspneic, and oximetry reveals an
O2 sat of 74%. The nurse’s immediate action is to
▫ A. release the esophageal balloon
▫ B. release the gastric balloon
▫ C. increase the suction
▫ D. irrigate the gastric balloon
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• A newly admitted client with cirrhosis of the liver has a distended abdomen and the umbilicus is protruding. The nurse knows the pathological basis for this is
▫ A. increased fluid intake resulting from excessive use of alcohol causing overhydration
▫ B. increased size of the liver resulting in abdominal distention
▫ C. hypoalbuminemia causing fluid to leave the vascular system and enter the peritoneal cavity
▫ D. shunting of the blood to the collateral circulation in the esophagus resulting in decreased blood volume and accumulation of fluid
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