Transcript 24. Interventions for Clients with Liver Problems

Interventions for
Clients with Liver
Problems
Cirrhosis
• Cirrhosis is extensive scarring of the
liver, usually caused by a chronic
irreversible reaction to hepatic
inflammation and necrosis.
• Complications depend on the amount
of damage sustained by the liver.
• In compensated cirrhosis, 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
Etiology
• Known causes of liver disease include:
– Alcohol
– Viral hepatitis
– Autoimmune hepatitis
– Steatohepatitis
– Drugs and toxins
– Biliary disease
(Continued)
Etiology (Continued)
– Metabolic/genetic causes
– Cardiovascular disease
Clinical Manifestations
• In early stages, signs of liver disease
include:
– Fatigue
– Significant change in weight
– Gastrointestinal symptoms
– Abdominal pain and liver tenderness
– Pruritus
Clinical Manifestations
• In late stages, the signs vary:
– Jaundice and icterus
– Dry skin
– Rashes
– Petechiae, or ecchymoses (lesions)
– Warm, bright red palms of the hands
– Spider angiomas
– Peripheral dependent edema of the
extremities and sacrum
Abdominal Assessment
• Massive ascites
• Umbilicus protrusion
• Caput medusae (dilated abdominal
veins)
• Hepatomegaly (liver enlargement)
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
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.
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Laboratory Assessment
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• Prothrombin time prolonged; platelet
count low
• Decreased hemoglobin and hematocrit
values and white blood cell count
• Elevated ammonia levels
• Serum creatinine level possibly
elevated
Surgical Interventions
• Peritoneovenous shunt
• Portocaval shunt
• Transjugular intrahepatic
portosystemic shunt
Potential for Hemorrhage
• Interventions include:
– Identifying the source of bleeding and
initiating measures to halt it
– Massive esophageal bleeding
– Esophageal varices
– Nonsurgical management includes:
• Drug therapy: possibly nonselective beta
blocker
• Gastric intubation
• Esophagogastric balloon tamponade
Management of Hemorrhage
• Blood transfusions
• Endoscopic procedures
• Transjugular intrahepatic portalsystemic shunt
• Surgical management
Potential for Portal-Systemic
Encephalopathy
• Interventions include:
– Role of ammonia
– Reduction of ammonia levels
– Diet therapy using simple and brief
guidelines
– Drug therapy:
• Lactulose
• Neomycin sulfate
• Metronidazole
Hepatitis
• Widespread viral inflammation of liver
cells
• Hepatitis A
• Hepatitis B
• Hepatitis C
• Hepatitis D
• Hepatitis E
• Hepatitis F and G are uncommon
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
(Continued)
Hepatitis A (Continued)
• 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 of age.
• Many people who have hepatitis A don’t
know it; symptoms are similar to a
gastrointestinal 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 B (Continued)
• Hepatitis carriers can infect others,
even if they are without symptoms.
Hepatitis C
• Spread is by sharing needles,
blood, blood products, or organ
transplants (prior to 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 U.S.
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
Arthralgia (joint pain)
Myalgia (muscle pain)
Diarrhea/constipation
Fever
Lethargy
Malaise
Nausea/vomiting
Pruritus
Nonsurgical Management
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Physical rest
Psychological rest
Diet therapy
Drug therapy includes:
– Antiemetics
– Antiviral medications
– Immunomodulators
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
• Many clients 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
Cancer of the Liver
• One of the most common tumors in the
world
• Most common complaint: abdominal
discomfort
• Treatment includes:
– Chemotherapy
– 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