Hepatic disorders_notes
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Transcript Hepatic disorders_notes
Alteration in Nutrition, less than
body requirements
Hepatitis/Cirrhosis
Liver: Largest internal organ
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Hepatic Artery
1/3 blood supply
Portal Vein
2/3 blood supply
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Organs of the Gastrointestinal Tract
Liver
(hepatitis, cirrhosis)
Gallbladder
(biliary diseases)
Pancreas
(pancreatitis, diabetes)
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Major Functions (pg 904/Table 39-4)
Review
Metabolic
CHO, Protein, and Fat metabolism
Albumin, clotting factors
Detoxification – Ammonia (NH3) to Urea
Bile/Bilirubin (Production/Excretion)
Liver cells destroyed – scar tissue forms – alters
blood flow in liver – BP in GI system elevates
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Inflammatory (Hepatitis)
Disorders of Liver
Inflammation of the liver caused by virus,
autoimmune, drugs
Liver cell damage results in hepatic cell
necrosis.
Viral hepatitis (A, B, C, D, E, G)
Toxic Hepatitis (most common –
Acetaminophen, ETOH)
Autoimmune (Wilson’s disease, PBC)
Non-Alcoholic Fatty Liver Disease (NAFLD)
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Table 44-1
Viral Hepatitis
Type A (HAV)
Fecal oral transmission
Onset Acute-Flu like symptoms
Hepatitis A vaccine
Type B (HBV)
Blood and body fluid transmission (not urine, feces, breast
milk, tears, sweat)
Onset slow-symptoms more severe
Hepatitis B vaccine
Type C (co-infection HIV)
Percutaneous transmission (needle thru skin)
Asymptomatic or mild symptoms
20% will progress to cirrhosis 20-30 years
Liver damage 15-20 years after infection
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Other causes of Hepatitis
(hepatoxicity)
Toxic & Drug induced
Table 39-6: Toxic agents causing liver
damage
Wilson’s disease
Neurological disease associated with
disorder of copper storage
DX by brownish/red rings around corneas
Also neuro changes such as drooling,
tremors, migraines
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Other causes of Hepatitis
Hemochromatosis
Iron
storage disorder
Autoimmune hepatitis – primary biliary
cirrhosis (PBC)
NAFLD and NASH
hepatic
steatosis, elevated ALT
Linked to obesity, certain drug
(steroids)
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Assessment
History
Exposure, foreign travel, Sexual practices,
etc
Medications/Toxic exposures
misuse of acetaminophen, illicit drugs,
chemical exposures
Physical Assessment Findings (table 44-2)
Depend on phase of infection
30% of patients with acute HBV and 80% of patients with acute HCV will be
asymptomatic.
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Phases of Infections
fulminant hepatic failure
Incubation/Prodromal
Asymptomatic to vague SX (anorexia, N/V,
malaise, fatigue, pruritis, arthralgia)
May be dx as a flu/virus gastro
Virus load can be detected
Icteric Phase
Classic presentation of jaundice, dark urine,
clay-colored stools, rt upper quad pain
Abnormal LFTs
Convalescent phase
Sx & jaundice resolve, LFTs return to normal
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Diagnostics - Lab values
Elevated liver enzymes
Serum/Urinary bilirubin
Coagulopathy – prolonged PT/PTT
Serum proteins (albumin) decreased
Hepatitis panel for high-risk exposures
(consider HIV co-infection)
Hep A – one dx test for active infection
Hep B – many DX tests for active infection
Genotyping Hep C important in TX
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Treatment of Hepatitis
Acute and Chronic
Well-balanced diet
Vitamin supplements
Rest (degree of strictness varies)
Avoidance of alcohol intake and drugs
detoxified by the liver
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Nursing Implementation
Acute interventions
Rest
Jaundice/ pruritus
Small, frequent meals
Ambulatory and home care
Dietary teaching (avoid ETOH) (low fat, high CHO)
Assessment for complications
Regular follow-up for 1 year after diagnosis
Medication teaching
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Collaborative Care: Drug therapy
No specific drug therapies (acute hepatitis)
Supportive therapy
Antiemetics
Watch for drugs metabolized by liver
Vitamins
Milk Thistle (Silymarin)
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Drug therapies: Chronic HBV & HCV
Anti-virals: Interferon
↓ viral load
↓ liver enzyme levels
↓ rate of disease progression
Side effects
Flu-like SX
Anemia, anorexia
Depression, insomnia
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Prevention/Health Promotion
Hepatitis A
Hepatitis B and C
Hand washing! Food
Screen donated blood
Washing
Use disposable needles
Proper personal hygiene
Hand washing
Immunization: HAV
Safe sex
vaccine (2 shots,
Avoid sharing
immunity in 30 days)
toothbrushes/razors
Immune Globulin
Immunization: HBV
1-2 weeks post exposure
Table 44-8: preventative
measures for Hepatitis
vaccine (3 doses, 1st @
birth/complete by 18m/o)
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Table 44-6
Plan of Care (see Moodle)
Imbalanced Nutrition: less than body requirements
r/t anorexia, N/V, metabolic problems
Goals: maintain weight, food/fluid intake to meet
nutritional needs
Activity Intolerance r/t fatigue, weakness
Goals: gradual increase in activity, able to
perform ADLs
Risk for impaired Liver Function r/t viral infection
Goal: maintain adequate liver FX throughout
infectious process
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Chronic HBV, HCV
Long-term goals
Prevention
of cirrhosis and
hepatocellular cancer
Not all patients respond to current
therapeutic regimens.
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Evaluation: Expected outcomes
Adequate nutritional intake
Increased tolerance for activity
Verbalization of understanding of
follow-up care
Able to explain to others methods of
transmission and methods of preventing
transmission
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Major Functions (pg 870/Table 39-4)
Review
Metabolic
CHO, Protein, and Fat metabolism
Albumin, clotting factors
Detoxification – Ammonia (NH3) to Urea
Management of Bilirubin (Production/Excretion)
Liver cells destroyed – scar tissue forms – alters
blood flow in liver – BP in GI system elevates
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Cirrhosis
Pg 1018
Acute liver failure
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Continuum of Liver dysfunction
Early S/SX of liver DX
Pain, Fever, Anorexia (N/V)
Fatigue
Physical exam may reveal hepatomegaly,
lymphadenopathy, and splenomegaly.
Complications:
Progressive S/SX
- Fulminant/acute hepatic
failure
Jaundice
- Chronic hepatitis
Ascites, anasarca
- Cirrhosis
Skin Lesions/bruising
- carcinomas
Patho Map – figure 44-5 pg 1018/Text
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Liver Dysfunction
Bleeding
Inability to make clotting factors
Development of collateral circulation r/t portal
hypertension
Increased serum Ammonia
Inability to convert NH3, from metabolism of
protein, to urea
Third spacing – ascites
Inability make plasma protein (albumin)
Other: altered drug metabolism, electrolyte
imbalances, etc
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Nursing Assessment (table 44-14)
Past health history
Chronic alcoholism
Viral hepatitis
Chronic biliary
disease
Medications
Physical examination
Weight loss
Jaundice
Abdominal distention
Nausea/vomiting
Altered
mentation/asterixis
RUQ pain
Abnormal laboratory
values
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Complications of liver failure
Portal hypertension
Esophageal and gastric varices
Peripheral edema and ascites (table 44-9)
Portal HTN, Hypoalbuminemia, hyperaldosteronism
Hepatic encephalopathy (table 44-10)
Protein metabolism dysfunction produces elevated
ammonia levels (conversion of ammonia to urea)
Hepatorenal syndrome
Kidney failure related poor circulating blood volume
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Esophageal Varices
No special assessment findings – obvious GI
bleed,
low H & H, occult
Sengstaken-Blakemore
Tubeblood
Goal: Avoid bleeding/hemorrhage
Avoid alcohol, aspirin, irritating foods, straining.
Supportive measures for acute bleeds
Next slide
Treatment Measures
Endoscopic sclerotherapy, Endoscopic ligation
Balloon tamponade (Blakemore tube) – old TX
Shunting procedures (TIPS) (portacaval shunt)
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Treatment for acute UGI bleed
Support ABCs, fluid resuscitation
Drug therapy may include
Octreotide (Sandostatin)
Vasopressin (VP, Terlipressin)
Fresh frozen plasma, Packed RBCs
Vitamin K
Histamine blockers, Proton pump inhibitors
Lactulose & Neomycin – prevents hepatic
encephalopathy from increased RBC
breakdown/ammonia
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Treatment of Ascites
High-carbohydrate, low-Na+ diet (2 g/day)
Diuretics, albumin infusion
Paracentesis
Peritoneovenous shunt
Continuous reinfusion of
ascitic fluid from abdomen to
vena cava
Complications : Thrombosis, infection,
fluid overload
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Paracentesis
Patient Positioning – sitting upright, HOB ↑
Empty bladder
Complications:
Persistent leak from the puncture site, bruising
Hypotension after a large-volume paracentesis
Perforation of bowel, infection, Major blood
vessel laceration
Post procedure
Position on right side to splint puncture site
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Hepatic encephalopathy
S/SX: altered mentation, asterixis (liver
flap), fetor hepaticus,
NH3 (ammonia)
Goal: Decrease ammonia formation
May reduce protein in diet
Sterilization of GI tract with antibiotics (e.g.,
neomycin)
Lactulose (Cephulac) traps NH3 in gut.
Cathartics/enemas
Treatment of precipitating cause
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Nursing Dx: Liver Failure
See Nursing Care Plan (44-2)
Imbalanced nutrition
Impaired skin integrity (jaundice /pruritis)
Ineffective breathing pattern
Excess fluid volume
Dysfunctional family processes: Alcoholism
Overall goals
Relief of discomfort
Minimal to no complications
Return to as normal a lifestyle as possible
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Generalized Collaborative Care
Rest, avoid further liver damage
Avoidance of alcohol, aspirin, acetaminophen,
and NSAIDs
Monitor LFTs, electrolytes
Management of ascites
Accurate I/O, Daily weights, Abdominal girth,
extremities measurement
Nursing care r/t paracentesis
Prevention and management of esophageal
variceal bleeding
Management of encephalopathy
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Nutritional Treatment
High in calories (3000 kcal/day)
↑ carbohydrate
Moderate to low fat
Protein restriction depends on degree of
hepatic encephalopathy
Low-sodium diet for patient with ascites and
edema
Between-meal nourishment, Explanation of
dietary restrictions
Administration of B-complex vitamins, vitamin K
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Nursing Evaluation
Maintenance of food/fluid intake to meet
needs
Maintenance of muscle tone and energy
Maintenance of skin integrity
Normalization of fluid balance
Maintenance of blood pressure and urinary
output
Reports increased ease of breathing
Experiences normal respiratory rate/rhythm
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