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Case Study, Chapter 43, Assessment and Management of
Patients with Hepatic Disorders
1. John Adams, 55 years of age, is admitted to the intensive care unit with
the diagnosis of acute esophageal varices bleed. The patient has a longstanding history of alcoholism and cirrhosis of the liver. Six months ago, the
patient received an EGD, which diagnosed the esophageal varices. The
patient has quit drinking alcohol for the past 6 months and has been active in
Alcoholics Anonymous. The patient has a history of coronary artery disease
and angina. The patient has been taking nadolol and isosorbide. The
admission vital signs include: BP, 88/50; P, 110; R, 26; and T, 99°F. The
supplemental oxygen is on room air and the patient is placed on 2 L/min of
oxygen per nasal cannula with supplemental oxygen. The patient’s
hemoglobin is 6 g/dL, the hematocrit is 12%, and the platelets are 75,000.
The patient has a prolonged PT and PTT. The liver profile shows a mild
elevation of the aspartate aminotransferase (AST) and the alanine
aminotransferase (ALT). The BUN and serum creatinine are also elevated.
The patient has in place from the emergency department a nasogastric tube
to low wall suction. The emergency department primary provider placed a
right subclavian triple lumen catheter and there is NS infusing at 100 mL/h.
The emergency department nurse administered vitamin K. Additional orders
on the chart from the gastroenterologist include the following: octreotide 5mcg bolus followed with continuous infusion 500 mcg in 250 mL D5NS at 25
mcg/h. Administer six units of PRBCs STAT and administer furosemide 20 mg
IVP in between each unit. Repeat CBC 1 hour after the transfusion is
completed. (Learning Outcome 4)
a. In what order should the nurse institute the provider orders that are
listed above? Perform dosage calculations and state how to administer
the medications.
As the nurse I would follow the hospital policy and procedure and
obtain a signed written consent for transfusion of blood products. I
would also obtain a type and cross match for PRBCs. Provide the 5mcg bolus of octreotide, which is 2.5 mL administered IVP over 3
minutes. I would monitor intake and output and also electrolytes
closely.
b. The nurse observes the nasogastric secretions and, upon admission to
the ICU, there was 200 mL of dark red-colored drainage. The nurse
continues to monitor the drainage and, as the nurse hangs the first
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unit of PRBCs, 200 mL of bright red bloody drainage is dumped into
the collection canister. What should the nurse do?
The nurse should reassess the patient’s vital signs, mental status, and
oxygenation status, and call the gastroenterologist immediately and
report the change in the drainage and the large amount of drainage
and receive further orders.
c. The gastroenterologist orders for the nurse to increase the octreotide
to 50 mcg/h, and the endoscopy nurse and the primary provider will
be up shortly to perform an endoscopic variceal ligation (EVL). What
does the nurse need to do in preparation for this procedure?
The nurse needs to increase the octreotide to 25 mL/hr and explain
the vertical band ligation procedure to the patient. Pull the bed away
from the wall and remove the headboard so the physician can access
the patient easily. Make sure that ample suction, an Ambu bag, and
oral and tracheal suctioning materials are available. The nurse would
also need to have a defibrillator and emergency medical supplies on
hand.
2. Carl Vinson, a 65-year-old Caucasian man, was admitted today with
increased shortness of breath, fatigue, and decreased level of consciousness.
Mr. Vinson has a history of liver disease, most likely related to a long history
of alcohol use. Upon arrival to the unit, he is somnolent and responds only to
shouting and shaking. Upon arousal, he is only able to state his first name.
His wife accompanies him to the unit, and describes that he has become
increasingly restless over the last 3 days, and she is concerned for his safety.
Additionally, he has not eaten or taken in any fluids in 24 hours. (Learning
Outcomes 1, 3, and 6)
a. Correlate the patients presenting clinical manifestations to hepatic
encephalopathy.
The earliest symptoms of hepatic encephalopathy include minor
mental changes and motor disturbances. Mr. Vinson has a decreased
level of consciousness, and is somnolent. The restlessness may also be
an indication of hepatic encephalopathy
b. The primary provider orders a STAT ammonia level, along with a CBC
and complete chemistry panel. The ammonia result is elevated. What
is your interpretation?
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The largest source of ammonia is the enzymatic and bacterial digestion
of dietary and blood proteins in the GI tract. Ammonia from these
sources increases as a result of GI bleeding, such as, bleeding
esophageal varices, chronic GI bleeding. A high-protein diet, bacterial
infection, or uremia.
c. The primary provider orders Mr. Vinson to receive lactulose orally.
What is the rationale for this medication?
Lactulose is given to lower serum ammonia levels by increasing
ammonia excretion in the stool. It acts this way because ammonia is
maintained in an ionized state, resulting in a decrease in colon pH,
reversing the normal passage of ammonia from the colon to the blood.
Evacuation of the bowel decreases the ammonia absorbed from the
colon. The fecal flora are changed to organisms that do not produce
ammonia from urea.
d. Mrs. Vinson asks why her husband must decrease intake of protein.
How will you respond to her question?
The largest source of ammonia for the body is digestion, which is in
what you eat. Decreasing his intake of protein is intended to decrease
serum ammonia levels.