Transcript Hepatic Disorders: Hepatitis/Cirrhosis

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Hepatic Disorders:
Hepatitis/Cirrhosis
Lisa Randall, RN, MSN, ACNS-BC
RNSG 2432
Fall 2011
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Objectives
• 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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Anatomy & Physiology
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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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Pathophysiology
• Largest organ
• Metabolic functions
• Bile synthesis
▫ Hepatocytes
 Bile secretion
• Storage
• Mononuclear phagocyte system
▫ Kupffer cells
 Phagocytic activity
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Metabolic functions
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Metabolism of glucose
Protein
Fatty acids
Cholesterol
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Other Functions
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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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HEPATITIS
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Pathophysiology
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Inflammation
Hepatic cell necrosis
Proliferation/enlargement Kupffer cells
Cholestasis
Regeneration
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Types
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Chronic
Fulminant
Toxic
Hepatobillary
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Hepatitis Types (Viral)
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A
B
C
D
E
G
*see handout
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Clinical Manifestations
Acute
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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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Phases
• Preicteric
▫ Prodromal
• Icteric
▫ Jaundice
• Posticteric
▫ Convalescent
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Hepatitis A
• Fecal/oral
• 15-50d
• S/S
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Light stools
Dark urine
Fatigue
Fever
Jaundice
Labs
Vaccine
IgG
Prevention
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Hepatitis B
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Percutaneous/permucosal
Sexual contact
Perinatal
45-180d
S/S
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30% asymptomatic
Flu
Light stools
Dark urine
Fatigue
Fever
Jaundice
• Labs
• Prevention
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Vaccine
IgG
Safe sex
No sharing of razors,
toothbrushes, needles
• Chronicity
▫ Antivirals
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Hepatitis C
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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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Hepatitis D
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HBV
2-26wk
Labs
Interferon
HBV vaccine
S/S
▫ HBV
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Hepatitis E
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Fecal/oral
Contaminated water
Poor sanitation
15-64d
Labs
S/S
▫ HBV
• No vaccine
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Diagnostics
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LFT
ALP
Serum bilirubin
Liver biopsy
Antigen specific
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Treatment
• Diet
▫ High cal/protein, low fat
▫ Vitamins (B, K)
▫ ETOH/Drugs
• Fluid management
• Bed rest
• Drug therapy
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Prevention of HAV and HBV
Interferon
Lamivudine
Ribavirin
Acetaminophen
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Nursing Diagnoses
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Risk for infection (transmission)
Imbalanced nutrition
Disturbed body image
Knowledge deficit
Cirrhosis
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Pathophysiology
• 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
Types of Cirrhosis
Classified by risk factors
• 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
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Signs & Symptoms
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Liver enlarged
Dull pain RUQ
Weakness
Anorexia
Skin
Sclera
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Portal hypertension
Splenomegaly
Ascites
Esophageal varices
Hepatic encephalopathy
Hepatorenal Syndrome
Liver failure
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Signs & Symptoms
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Jaundice
• Excess bilirubin
• Heptocellular
▫ Cirrhosis
• Obstructive
• Hemolytic
▫ Excessive destruction of RBCs
 Transfusion reaction
 Autoimmune
 Faulty hemoglobin
 Sickle cell
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Diagnostics
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LFT
CBC
Coags
Bilirubin
Albumin
Ammonia
Esophagascopy
Liver biopsy
*See Table 44.15
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Liver Biopsy
• 3 types
▫ Needle
▫ Laparoscopic
▫ Transvenous
 Catheter
 Blood clotting problems
 Excess fluid
• Complications
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Puncture of lung or gallbladder
Infection
Bleeding
Pain
Liver Biopsy
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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
After Needle Liver Biopsy
• Pressure
• Right side
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▫ 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
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Nursing Assessment
• 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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Nursing care
• Safe environment
• Sustain life
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Nursing Diagnoses
Hepatitis
Cirrhosis
• Risk for infection
(transmission)
• Imbalanced nutrition
• Disturbed body image
• Knowledge deficit
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Excess fluid volume
Disturbed thought process
Ineffective protection
Impaired skin integrity
Imbalanced nutrition
Knowledge deficit
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Treatment
• Diet
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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
Major Complications of
Cirrhosis
Portal hypertension
Variceal bleeding
Ascites
Spontaneous bacterial peritonitis
Splenomegaly
Hepatorenal syndrome
Hepatic encephalopathy
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Portal Hypertension
• Arteriovenous shunting
• Marked ascites
• Caput medusae
▫ Dilated abdominal veins
• Esophageal varices
• Hemorrhoids
• Hyperslenism
▫ Mod anemia
▫ Neuropenia
▫ Thrombocytopenia
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Surgical/Medical Interventions
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Paracentesis
Gastric lavage
Balloon tamponade
Schlerotherapy
Banding
TIPS (transjugular intrahepatic portosystemic
shunt)
• Liver transplant
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Ascites
• Sodium restriction
• Bedrest initially
• Diuretics
▫ Spironolactone
▫ Lasix
▫ HCTZ
• Fluid removal
▫ Paracentesis
▫ Peritoneovenous Shunt
Ascites
Caput medusae
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Paracentesis
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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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Esophageal varices
• Collateral vessels
• Complex of swollen, enlarged veins
▫ Portal hypertension
• 2/3-3/4
• Bleeding
▫ LIFE-THREATENING
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Esophageal varices treatment
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
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.
Minnesota
Tube
SengstakenBlakemore
tube – has only 3
lumens
**Respiratory
assessment**
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Hepatic encephalopathy
• Neuropsychiatric manifestation
• Decreased liver detoxification>>>
▫ Increased ammonia
• Terminal complication
• Changes in LOC
• Asterixis
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Treatment HE
• Reduce ammonia
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Lactulose
Neomycin sulfate
Cathartics
Enemas
Liver transplantation
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Hepatorenal syndrome
• Portal HTN + liver decompensation
▫ Systemic vasodilation
▫ Decreased arterial BF
▫ Renal vasoconstriction
• Functional renal failure
▫ Azotemia
▫ Oliguria
• Liver transplantation
Liver Transplant
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Liver Transplant
Liver transplant complications
• Rejection
▫ 70%
▫ Medications
• Infection
▫ immunosuppression
• Cancer
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Patient Teaching
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Therapeutic communication
Diet*
Exercise
Lifestyle modifications
Drugs
Follow-up
Resources
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Legal/Ethical Considerations
• Advance directives
• Palliative care
• Organ donation
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Donors
• Live donor
• Liver regenerates
▫ 5 years
• Survival rates increase / shorter wait time
• Medical and psychological evaluations
• Potential donors evaluated for:
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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
Review
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
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Question
• 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?
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a. I&O
b. LFT
c. caloric intake and serum protein levels
d. daily weight
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Question
• 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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Question
• 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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Question
• 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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Question
• 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
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A. release the esophageal balloon
B. release the gastric balloon
C. increase the suction
D. irrigate the gastric balloon
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Question
• 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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Case Study