Liver Disease: care and management of patients 6KNIN337 Level: 6 Credits: 15 Module leader: Tel: Email: Academic support: Tutorial times have been incorporated into the course timetable This handbook must be read in conjunction with module information provided on KEATS, the King’s ELearning And Teaching Service. You will be given access to KEATS on enrolment. Important information relating to assessment and related regulations can be found in the Postgraduate/Undergraduate (please delete as appropriate) Programme Handbook, available on KEATS and via the Student Services Centre. This handbook can also be provided in alternative formats (such as large print) upon request to asc@kcl.ac.uk. 1 Contents Module overview ................................................................................................................ 3 Module aims ................................................................................................................... 3 Learning outcomes ......................................................................................................... 3 Teaching arrangements.................................................................................................. 3 Timetable ....................................................................................................................... 4 Submitting coursework/exam information ......................................................................... 7 Assessment criteria ........................................................................................................ 7 Formative assessment .................................................................................................... 7 Summative assessment .................................................................................................. 7 Submission date for course work: ................................................................................... 7 Results and re-submissions for course work ................................................................... 8 Re- submission date: ...................................................................................................... 8 Learning resources ............................................................................................................. 9 Indicative reading ............................................................................................................... 16 Journals .............................................................................................................................. 16 Web sites ............................................................................................................................ 16 Module evaluation .............................................................................................................. 16 Action from previous evaluations ....................................................................................... 16 2 Module overview Module aims This module will enable practitioners to develop their knowledge base in caring for patients with liver diseases. The focus will predominately be on chronic liver disease, although the course will provide an overview of acute liver failure and transplantation. Learning outcomes The learning outcomes of this course meet some of the nine liver care competencies as set out by the Royal College of Nursing, NHS Liver Care and the Department of Health in the 'Caring for people with liver disease: a competence framework for nursing' (2013). 1. Analyse and apply the evidence base that underpins the medical and nursing management of patients with liver disorders, both in a Hepatology or general setting. 2. Appraise the knowledge and skills needed for assessment planning, delivery and evaluation of care for patients with liver disease 3. Appraise and evaluate the contribution of nursing and other professional groups in the management and delivery of effective care to patients with liver disease 4. Analyse the factors influencing health care promotion for patients with liver disease 5. Examine the factors which determine the provision of health care resources taking into account the importance of cost, efficiency, quality and resources available Teaching arrangements The educational approach is adult student centred, which builds on your experience as a qualified practitioner. You will experience a wide variety of teaching and learning strategies: Lecture and discussion Group work Tutorials Guided study Quiz Independent study Case study exploration E-learning 3 Timetable Please note the timetable is subject to change Day and Date Venue Time Topic Day One (All) FWB 5.132 11.00-11.30 Welcome and introduction to the liver course FWB 5.132 11.30-12.15 Quiz and introduction to the anatomy and physiology of the Liver FWB 5.132 12.15-13.00 Chronic liver disease: setting the scene JCMB B17 14.00-15.00 The effect of chronic liver disease on other body systems (Respiratory and cardiovascular) JCMB B17 15.00-16.00 Understanding and assessing a patient’s Liver Function and dispelling the myths about Hemostasis Self study 10.00-11.00 E-learning FWB 5.132 11.00-12.00 Causes of jaundice and care of the jaundiced patient FWB 5.132 12.00-13.00 Ascites and management in patients with Chronic Liver disease JCMB B17 14.00-15.00 Hepatorenal syndrome and renal complications Speaker 25/9/2015 Day Two (All) 2/10/15 4 Self study Day Three JCMB B17 15.00-16.00 Portal Hypertension and managing a patient with a variceal bleed Self study 10.00-11.00 E-learning FWB 1.70 11.00-12.00 Hepatitis B virus FWB 1.70 12.00-13.00 Hepatitis C virus FWB 4.63 14.00-15.00 Managing patients with Hepatic Encephalopathy in Chronic Liver disease FWB 4.63 15.00-16.00 Acute Pancreatitis FWB 4.63 16.00-17.00 Optional essay workshop Self study 10.00-11.00 E-learning and tutorials JCMB G14 11.00-12.00 Hepatocellular Carcinoma JCMB G14 12.00-13.00 Pancreatic, hepatobiliary and neuro-endocrine cancers FWB 1.17 14.00-15.00 Alcohol related liver disease FWB 1.17 15.00-15.30 Caring for a patient with Non Alcoholic Fatty Liver disease FWB 1.17 15.30-16.00 PBC/PSC Self study 10.00-11.00 E-learning and tutorials WEC Classroom 3 11.00.11.30 Small Bowel Transplantation WEC Classroom 3 11.30-12.15 Alpha 1 Antitrypsin Deficiency Self study (All) 9/10/15 Day Four (Adult nurses only) 16/10/15 Day 4Four (Paediatric nurses only) 23/10/15 5 Self study Self study Day Five WEC Classroom 3 12.15-13.15 Childhood liver cancers WEC Classroom 3 14.00-15.00 Nutrition in children with chronic liver disease WEC Classroom 3 15.00-16.30 Biliary Atresia and autoimmune diseases Self study 10.00-11.00 E-Learning and tutorials FWB 5.132 11.00-12.30 Acute Liver Failure and transplantation FWB 5.132 12.30-13.00 Immunosuppression for the post transplant patient WBW G552 14.00-16.00 Issues in Transplantation for patients with chronic liver disease (All) 30/10/15 6 Self study Submitting coursework/exam information Assessment criteria Essay 2000 words. This contributes to 100% of the overall grade You will demonstrate an achievement of the course learning outcomes by writing an assignment addressing either a liver disease or a complication of liver disease as identified in a patient-based case study. Formative assessment Students are advised to seek tutorial support from the course lecturer. This should be a student led discussion focusing on the students’ essay. The student should provide a plan in which the key themes are identified along with relevant literature using the bullet points below. o Which patient case study have you chosen? o What disease/complication aspect will you focus on? o Identify the key references which you will use to support the pathophysiology/management of the chosen aspects o Is the evidence clear? Are there any opposing views? How does it relate to your practice? Summative assessment Your assignment must be in a structured essay format, but sub heading may be used. It should include an introduction, main body and conclusion Critically appraise the management of either the chosen liver disease or complication of liver disease which may be carried out to address the patients’ health care needs, this must include a critical appraisal of the nurses’ role and nursing practice in relation to the identified management Critically analyse the evidence-based literature in relation to both the patients problem, interventions and nursing management Make recommendations for future nursing practice in relation to your analysis of the interventions and nursing management of your identified complication Your assignment needs to be appropriately referenced using the Harvard referencing system (please see post registration handbook for guidance) Course work submission/exam instructions are provided on the KEATS module page. It is essential that you use your candidate number on all assignments/examinations. Your candidate number, will be available via Student Records on the King’s Intranet approximately one month after you enrol. Submission date for course work: 5th January 2016 Late Submissions Late submissions will be accepted for 24 hours following the submission date. All work submitted late will be marked as normal but will be capped at the pass mark for the module. If your assignment is submitted electronically through TurnItIn, information about how to submit late will be provided on KEATS module sites under assessment information. 7 Results and re-submissions for course work Students will receive a provisional (unratified) mark for their coursework 4 weeks following submission. According to the method of submission as detailed on your KEATS site, if your work was submitted online you will be able to download marked coursework from KEATS; alternatively, if you completed a hard-copy submission you can collect your coursework and feedback from the Student Services Centre. To collect a hard copy assignment, you must provide your candidate number. Alternatively, you may send a stamped addressed envelope to the Student Services Centre ensuring that this is large enough to accommodate your assignments and that you have applied sufficient postage. Hard copy assignments will be retained for four weeks; if you have not collected your assignment by then, it will be destroyed. Feedback will include the award of a numerical grade which remains provisional until ratified by the examination boards. The dates for the examination boards are available on KEATS. Ratified marks can be viewed via Student Records on the King’s Intranet, the Monday following the relevant examination board. If you are unsuccessful, it is recommended that you contact the module leader before submitting your second attempt. This will enable the module lead to provide you with an appropriate level of support as you prepare to re-submit your work. Re- submission date: 12th April 2016 8 Learning resources Day 1: 25th September 2015 Session One: Course introduction, ice breaker and Quiz By the end of this session the students will be able to: Demonstrate familiarity with the course structure and content Demonstrate familiarity with other course students Understand the principles of e-learning and self directed learning To understand how to access KEATS liver disease module 6KNIN 337 Differentiate between acute and chronic liver disease Acknowledge the common aetiologies of liver failure Understand the anatomy of the Liver and the main functions Indicative reading Module Handbook Post Qualification Handbook Hill C (2009) Anatomy and Physiology. Chapter 1. In Sargent S (2009) Liver Diseases; an essential guide for nurses and health care professionals. Wiley-Blackwell. Session Two: Chronic liver disease; setting the scene By the end of the session students will Understand the UK prevalence of chronic liver disease Understand the most common aetiologies Recognise stigmata of chronic liver disease and reasons for these Indicative reading NHS Liver care website http://www.liver.nhs.uk/ Liver matters on-line newsletter accessed through http://www.livermatters.nhs.uk/ Session Three: The effect of chronic liver disease on other body systems (Respiratory and cardiovascular) By the end of the session the student will be able to To analyse the respiratory and cardiovascular complications of chronic and acute liver failure To revise the relevant pathophysiology of occurrence To examine current treatments and evaluate effectiveness Explore the current nursing management of respiratory and cardiovascular complications in patients with liver diseases Indicative reading Møller S & Bernardi M (2013) Interactions of the heart and the liver. European Heart Journal 34; 28042811 Yang YY & Lin HC (2012) The heart: Pathophysiology and clinical implications of cirrhotic cardiomyopathy. Journal of the Chinese Medical Association 75; 619-623 9 Session Four: Understanding and assessing a patient’s Liver Function and dispelling the myths about Hemostasis By the end of the session the students will be able to: Differentiate between liver enzymes and liver function tests To analyse normal and abnormal values and the relation to liver disease To understand how Hemostasis changes in Liver disease To debate appropriate interventions and precautions in managing coagulopathy in liver disease Indicative reading Greenslade L (2009) Assessment of liver function and diagnostic studies in Sargent S (ed) (2009) Liver Diseases; An Essential Guide for Nurses and Health Care Professional Oxford; Wiley-Blackwell Patch D & Dhillon AP (2011) Chapter 3 Biopsy of the Liver in Dooley JS, Lok ASF, Burroughs AK & Heathcote EJ (2011) Sherlock’s Diseases of the Liver and Biliary System. 12th Edition. Wiley-Blackwell Northu PG & Caldwell SH (2013) Coagulation in Liver Disease; a guide for the clinician. Clinical Gastroenterology and Hepatology 11; 1064-1074 Tripodi A & Mannuccio Mannucci P(2010) Abnormalities of haemostasis in chronic liver disease: Reappraisal of their clinical significance and need for clinical and laboratory research. Journal of Hepatology 46; 727-733 Day 2: 2nd October 2015 Session One: The Jaundiced patient By the end of the session the student will be able to To revise the anatomy and physiology of liver cells and biliary system to understand the flow of bile To examine the differences between conjugated and unconjugated bilirubin To examine the pre hepatic, hepatic and post hepatic causes of jaundice To analyse current treatments and nursing management To analyse and evaluate the psychological impact of altered body image Indicative reading Clayton M (2009) Jaundice in Sargent S (Ed.) (2009) Liver Disease; An Essential Guide for Nurses and Health Care Professionals Oxford; Wiley-Blackwell Elias E (2011) Chapter 11 Jaundice and Cholestasis in Dooley JS, Lok ASF, Burroughs AK & Heathcote EJ (2011) Sherlock’s Diseases of the Liver and Biliary System. 12th Edition. Wiley-Blackwell Session Two: Ascites and management By the end of the session the student will be able to To examine the pathophysiology of ascites and diagnostic criteria To analyse the dietary, medical and surgical approaches to the management of patients with ascites To analyse and evaluate the nursing management of patients with ascites Indicative reading 10 EASL (2010) Clinical Practice Guidelines on the management of ascites, spontaneous bacterial peritonitis and hepatorenal syndrome in cirrhosis. Journal of Hepatology 53; 397-417 Fullwood D & Purushothaman (2014) Managing ascites in patients with chronic liver disease. Nursing Standard 28(23)51-58 Session Three: Acute Kidney Injury and Hepatorenal Syndrome in chronic liver disease By the end of the session the student will be able to To identify causes of acute kidney injury in patients with chronic liver disease and some of the management strategies To demonstrate increased understanding of the pathophysiological factors underpinning hepatorenal syndrome and the international ascites club diagnostic criteria To examine the current medical and nursing strategies for patients with hepatorenal syndromes Indicative reading Tsien CD, Rabie R & Wong F (2013) Acute kidney injury in decompensated cirrhosis. GUT 62; 131-137 Wadai HM (2012) Hepatorenal syndrome; a critical update. Seminars in Respiratory and Critical Care Medicine 33(1) 55-69 Session Four: Portal Hypertension and the Management of a patient with a variceal haemorrhage By the end of the session the student will be able to To revise the pathophysiology of portal hypertension and formation of varices To demonstrate knowledge of the SIGN guidelines for management of variceal bleeding To examine the emergency and long-term treatment strategies for portal hypertension Indicative reading Fullwood D (2012) Portal hypertension and varices in patients with liver cirrhosis. Nursing Standard 26 (48) 52-57 National Institute for Clinical Excellence (2012) Acute upper gastrointestinal bleeding management. Guideline 141 http://www.nice.org.uk/nicemedia/live/13762/59549/59549.pdf accessed 13/6/14 Day 3: 9th October 2015 Session One: Overview of Viral hepatitis B By the end of the session the student will be able to Understand the current modes of viral transmission of hepatitis B Explore current epidemiology both world wide and UK Analyse serological tests for the diagnosis and treatment of Hepatitis B Understand current treatment options for patients with Hepatitis B Indicative reading Oakes K (2014) Management of chronic hepatitis B virus. Nursing Times. 110(8) 20-24 EASL (2012) Revised Clinical Practice Guidelines on the Management of Chronic Hepatitis B http://www.easl.eu/assets/application/files/ef520780b91cf4f_file.pdf accessed 13/6/14 11 Sarri G, Westby M, Bermingham S, Hill-Cawthorne G, Thomas H (2013) Diagnosis and management of chronic hepatitis B virus in children, young people and adults: summary of NICE guidance. British Medical Journal 346(7915) f3893 Session Two: Overview of Viral hepatitis C By the end of the session the student will be able to Understand the current modes of viral transmission of hepatitis C Explore current epidemiology both worldwide and UK Analyse serological tests for the diagnosis and treatment of Hepatitis C Understand current treatment options for patients with Hepatitis C Indicative reading EASL (2014) Recommendation on treatment of hepatitis C infection. http://files.easl.eu/easlrecommendations-on-treatment-of-hepatitis-C/index.html accessed 13/6/14 Session Three: Hepatic Encephalopathy and management in chronic liver disease By the end of the session the student will be able to To revise the pathophysiology and underlying theories of hepatic encephalopathy To review current treatment therapies and effects Have an understanding of future therapies To analyse and review current nursing management Indicative reading Houlston C, O’Neil H (2009) Hepatic Encephalopathy in Sargent S (Ed.) (2009) Liver Disease; An Essential Guide for Nursed and Health Care Professionals Oxford; Wiley-Blackwell Prakesh R & Mullen KD (2010) Mechanisms, diagnosis and management of hepatic encephalopathy. Nature Reviews Gastroenterology and Hepatology 7; 515-525 Session Four; Acute Pancreatitis By the end of the session the student will be able to To understand the difference between acute and chronic pancreatitis Interpret clinical and biochemical findings and link them with the pathogenesis of the disease To analyse the current management strategies for severe acute and chronic pancreatitis Indicative reading Andris A (2010) Pancreatitis; understanding the disease and implications for care. AACN Advanced Critical Care 21 (2) 195-204 Brenner Z & Krenzer M (2010) Understanding acute pancreatitis. Nursing 40 (1) 32-37 12 Day 4: 16th October 2015 (Adult nurses only) Session One and Two: Hepatocellular, hepatobiliary and pancreatic carcinomas By the end of the sessions the student will be able to To examine the incidence of Liver related cancers in the United Kingdom To review both medical and surgical treatment strategies Demonstrate increased understanding of the postoperative complication of hepatobiliary surgery and procedures To examine current nursing management strategies for patients with liver related cancers Indicative reading EASL (2012) Management of hepatocellular carcinoma http://www.easl.eu/assets/application/files/d38c7689f123edf_file.pdf accessed 13/6/14 Jervis N (2009) in Sargent S (Ed.) (2009) Liver Disease; An Essential Guide for Nursed and Health Care Professionals Oxford; Wiley-Blackwell Session Three: Overview and Management of Alcoholic Related Liver Disease By the end of the session the student will be able to To analyse current incidence and impact on the health service To examine the pathophysiology of alcoholic liver disease, including fatty liver, alcoholic hepatitis and cirrhosis To appraise current management for both ALD and alcoholic hepatitis Indicative reading Webb K (2009) Alcohol Related Liver Disease in Sargent S (Ed.) (2009) Liver Disease; An Essential Guide for Nursed and Health Care Professionals Oxford; Wiley-Blackwell Government alcohol strategy March 2012 http://www.homeoffice.gov.uk/publications/alcoholdrugs/alcohol/alcohol-strategy?view=Binary Session Four: Non Alcoholic Fatty Liver Disease By the end of the session the student will be able to To understand the increasing incidence of NAFLD To examine the underlying pathophysiology, disease presentation and associated complications To review the current evidence base management strategies Indicative reading Nikolopoulos A and Oben JA Non Alcoholic Fatty Liver Disease in Sargent S (Ed.) (2009) Liver Disease; An Essential Guide for Nursed and Health Care Professionals Oxford; Wiley-Blackwell Sullivan S (2010) Implications of diet on non alcoholic fatty liver disease. Current opinions in Gastroenterology 26 92) 160-164 Session Five: Primary Biliary Cirrhosis and Primary Sclerosing Cholangitis By the end of the session the student will be able to To review the basic pathophysiology of cholestatic liver diseases To examine diagnostic testing and signs and symptoms To examine disease related complications Appraise the effectiveness of current medical, surgical and nursing management. 13 Indicative reading Fullwood D (2009) Primary Biliary Cirrhosis and Primary Biliary Cholangitis in Sargent S (Ed.) (2009) Liver Disease; An Essential Guide for Nursed and Health Care Professionals Oxford; Wiley-Blackwell Fullwood D (2009) The Diagnosis and Treatment of patient with Primary Sclerosing Cholangitis; Gastrointestinal Nursing 7(5) 38-42 Sargent S, Fullwood D (2008) Diagnosing and treating a patient with primary biliary cirrhosis. British Journal of Nursing, 17 (9) 566 – 570. Day 5: 23rd October 2015 (Paediatric nurses only) Session One: Small Bowel Transplantation By the end of the session the student will be able to Understand the need for small bowel transplantation Explore the nursing care for a patient pre and post small bowel transplant Indicative reading Bodeur C, Aucion J, Johnson R et al (2014) Clinical practice guidelines-Nursing management for paediatric patients with small bowel or multivisceral transplant. Journal for Specialists in Paediatric Nursing 19(1) 90-100 Session Two: Alpha 1 Antitrypsin Deficiency By the end of the session the student will be able to To review the basic pathophysiology of alpha 1 antitrypsin deficiency To examine diagnostic testing and signs and symptoms To examine disease related complications Appraise the effectiveness of current medical, surgical and nursing management. Indicative reading Konvalinka P (2010) Alpha-1 antitrypsin deficiency panniculitis. Dermatology Nursing 22(6) 23-25 Young V (2010) Living with alha-1 antitrypsin deficiency panniculitis. Dermatology Nursing 22(6) 26 Session Three: Childhood Liver Cancers By the end of the session the student will be able to Demonstrate and understanding of both benign and malignant liver tumours Critically review the surgical management of liver tumours including transplantation Critically analyse the medical management of liver tumours Session Four: Nutrition in chronic and metabolic liver disease By the end of the session the student will be able to Review the pathophysiology of malnutrition in children with chronic liver disease To evaluate the methods of assessing nutritional status To examine formulations used in chronic, acute and metabolic liver disease Indicative reading Sadlier C (2008) Intestinal failure and long term parenteral nutrition in children. Paediatric Nursing 20(10) 37043 14 Session Five: Biliary Atresia and Autoimmune diseases By the end of the session the student will be able to Revise the different causes of jaundice in infants Understand the use of the ‘Yellow Alert’ early identification algorithm for infant jaundice Demonstrate an increased understanding of the epidemiology and pathophysiology of biliary atresia Currently review medical and, surgical and nursing treatments for biliary atresia Indicative reading Manns MP, Czaja AJ, Gorham JD, Krwitt EL, Mieli-Vergani G, Vergani D, Vierling JM (2010) Diagnosis and management of Autoimmune Hepatitis; AASLD practice guidelines. Hepatology 51(6) 2193-2213 Day 6: 30th October 2015 Session One: Acute Liver Failure By the end of the session the student will be able to To examine the clinical presentations of hyperacute, acute and sub acute liver failure. To recognise the main aetiologies of acute liver failure To examine clinical presentation and nursing management of encephalopathy and cerebral oedema, renal failure, coagulopathy, metabolic, cardiovascular and respiratory complications in acute liver failure Consider the indications for referral and transplantation criteria Evaluate the current and future research of acute liver failure management Indicative reading Bernal W, Hyyrylainen A, Gera A, Audimoolam VK, McPhail MJW et al (2013) Lessons from lookback in acute liver failure ? A single centre experience of 3300 patients. Journal of Hepatology 59; 7480 Lee WM, Larson AM and Stravitz T (2011) AASLD position paper: Management of Acute Liver Failure: Update 2011. http://www.aasld.org/practiceguidelines/Documents/AcuteLiverFailureUpdate2011.pdf accessed 11 July 2014 Session Two: Introduction to Immunosuppression for the post transplant patient By the end of the session the student will be able to To examine current Immunosuppression therapies in Transplantation To look at Immunosuppression for the treatment of specific diseases of the Liver Indicative reading Geissler EK & Schlitt HJ (2008) Immunosuppression for Liver transplantation. Gut 58;452-463 Session Three: Liver Transplant assessment for patients with chronic liver disease By the end of the session the student will be able to Appraise the current transplant assessment and listing criteria for chronic transplant recipients Indicative reading Fullwood D, Jones F, Lau-Walker M (2011) Care of patients following liver transplantation. Nursing Standard 25(49) 50-56 Littlejohn W, Routledge J ( 2009) in Sargent S (Ed.) (2009) Liver Disease; An Essential Guide for Nursed and Health Care Professionals Oxford; Wiley-Blackwell 15 Indicative reading Dooley JS, Lok ASF, Burroughs AK & Heathcote EJ (2011) Sherlock’s Diseases of the Liver and Biliary System. 12th Edition. Wiley-Blackwell Sargent S (2009) Liver Diseases, An Essential Guide for Nurses and Health Care Professionals Oxford, Wiley-Blackwell Journals British Journal of Nursing Hepatology British Medical Journal Journal of Advanced Nursing Critical Care Medicine Journal of Gastroenterology Gut Journal of Hepatology Gastrointestinal Nursing Lancet Liver Transplant Proceedings Nursing Standard New England Journal of Medicine Transplantation Web sites American Association for the study of liver disease (AASLD) http://www.aasld.org. British Liver Trust http://britishlivertrust.org.uk British Society of Gastroenterology http://www.bsg.org.uk Department of Health http://www.doh.gov.uk European Association for the Study of the Liver (EASL) http://www.easl.eu National Institute For Clinical Excellence (NICE) http://www.nice.org.uk United Kingdom Transplant services http://www.uktransplant.org.uk/ukt/default.jsp Module evaluation At the end of the module you are requested to complete the short online evaluation which will be available on your module KEATS site. Student evaluations are very important to us and are required by Health Education England and the regional London Local Education and Training Boards. Action from previous evaluations 1. Four study days with 6 hours teaching evaluated as too long and too much information on each day. Course lengthened to 5 study days of 4-5 hours. 2. Assignment changed to avoid unintended plagiarism 16