Care of Patients with Liver Problems
Chapter 61
Mrs. Kreisel MSN, RN
NU130 Adult Health
Summer 2011
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.
Complications
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Portal hypertension
Ascites
Bleeding esophageal varices
Coagulation defects
Jaundice
Portal-systemic encephalopathy with hepatic
coma
• Hepatorenal syndrome
• Spontaneous bacterial peritonitis
Esophageal
Varices
Etiology
• Known causes of liver disease include:
• Alcohol
• Viral hepatitis
• Autoimmune hepatitis
• Steatohepatitis
• Drugs and toxins
• Biliary disease
• Metabolic/genetic causes
• Cardiovascular disease
Clinical Manifestations
• In early stages, signs of liver disease include:
• Fatigue
• Significant change in weight
• GI symptoms
• Abdominal pain and liver tenderness
• Pruritus
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
sacrum
Abdominal Assessment
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Massive ascites
Umbilicus protrusion
Caput medusae (dilated abdominal veins)
Hepatomegaly (liver enlargement)
Liver
Dysfunction
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)
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.
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.
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.
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.
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
• Electrolytes
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 open
Potential for Hemorrhage
• Interventions include:
• Identifying the source of bleeding and initiating
measures to halt it
• Massive esophageal bleeding
• Esophageal varices
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 balloon
Esophageal
Gastric
Tamponade
Management of Hemorrhage
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Blood transfusions
Esophagogastric balloon tamponade
Vasoactive therapy
Endoscopic procedures
Transjugular intrahepatic portal-systemic shunt
Surgical management
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
• Metronidazole
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
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.
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.
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.
Hepatitis D
• Transmitted primarily by parenteral routes
• Incubation period 14 to 56 days
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 days
Clinical Manifestations
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Abdominal pain
Changes in skin or eye color (Jaundice)
Arthralgia (joint pain)
Myalgia (muscle pain)
Diarrhea/constipation
Fever
Lethargy
Malaise
Nausea/vomiting
Pruritus (itching)
Nonsurgical Management
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Physical rest
Psychological rest
Diet therapy
Drug therapy includes:
• Antiemetics
• Antiviral medications
• Immunomodulators
• AVOID DRUGS METABOLISED BY THE
LIVER SUCH AS TYLENOL
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.
Hepatic Abscess
• Liver invaded by bacteria or protozoa causing
abscess
• Pyrogenic liver abscess; amebic hepatic abscess
• Treatment usually involves:
• Drainage with ultrasound guidance
• Antibiotic therapy
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.
Cancer of the Liver
• One of the most common tumors in the world
• Most common complaint—abdominal discomfort
• Treatment includes:
• Chemotherapy
• Hepatic artery embolization
• Hepatic arterial infusion (HAI)
• Surgery
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 hours
Complications
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Acute, chronic graft rejection
Infection
Hemorrhage
Hepatic artery thrombosis
Fluid and electrolyte imbalances
Pulmonary atelectasis
Acute renal failure
Psychological maladjustment
•NCLEX TIME
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
A.
B.
C.
D.
Intrahepatic
Hemolytic
Obstructive
Hepatocellular
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
A. Be a likely site for cancer growth in the future
B. Make the patient more likely to develop
obstructive jaundice in the future
C. Become re-infected with the hepatitis C virus
D. Make the patient more susceptible to develop
other forms of hepatitis
Question 3
Which assessment parameter requires
immediate
intervention in a patient with severe ascites?
A.
B.
C.
D.
Shallow respirations, rate 36 breaths/min
Low-grade fever
Confusion
Tachycardia, rate 110 beats/min
Question 4
A priority intervention in the management of a patient
with decompensated cirrhosis would be:
A.
B.
C.
D.
Limit protein intake.
Monitor fluid intake and output.
Manage nausea and vomiting
Elevate head of bed >30 degrees
Question 5
Which racial group is at the highest risk for
developing
liver cancer?
A.
B.
C.
D.
Caucasian
African American
Asian
Hispanic/Latino