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Hepatic Disorders: Hepatitis/Cirrhosis. Lisa Randall, RN, MSN, ACNS-BC RNSG 2432. Objectives. C ompare and contrast risk factors associated with hepatitis and cirrhosis Analyze the etiology and pathophysiology of hepatitis and cirrhosis

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Hepatic disorders hepatitis cirrhosis

Hepatic Disorders:Hepatitis/Cirrhosis

Lisa Randall, RN, MSN, ACNS-BC

RNSG 2432


Objectives
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



A Liver

B Hepatic vein

C Hepatic artery

D Portal vein

E Common bile duct

F Stomach

G Cystic duct

H Gallbladder


Pathophysiology
Pathophysiology

  • Largest organ

  • Metabolic functions

  • Bile synthesis

    • Hepatocytes

      • Bile secretion

  • Storage

  • Mononuclear phagocyte system

    • Kupffer cells

      • Phagocytic activity


Metabolic functions
Metabolic functions

  • Metabolism of glucose

  • Protein

  • Fatty acids

  • Cholesterol


Other functions
Other Functions

  • 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



Pathophysiology1
Pathophysiology

  • Inflammation

  • Hepatic cell necrosis

  • Proliferation/enlargement Kupffer cells

  • Cholestasis

  • Regeneration


Types
Types

  • Chronic

  • Fulminant

  • Toxic

  • Hepatobillary


Hepatitis types viral
Hepatitis Types (Viral)

  • A

  • B

  • C

  • D

  • E

  • G

*see handout


Clinical manifestations
Clinical Manifestations

Acute

Chronic

  • Anorexia

  • N/V

  • RUQ pain

  • Bowel irregularity

  • Malaise

  • HA

  • Fever

  • Arthralgias

  • Uticaria

  • Weight loss

  • Jaundice

  • Hepatomegaly

  • Splenomegaly

  • Pruritus

  • Dark urine

  • Bilirubinuria

  • Light stools

  • Fatigue

  • Malaise

  • Easy fatigability

  • Hepatomegaly


Phases
Phases

  • Preicteric

    • Prodromal

  • Icteric

    • Jaundice

  • Posticteric

    • Convalescent


Hepatitis a
Hepatitis A

  • Fecal/oral

  • 15-50d

  • S/S

    • Light stools

    • Dark urine

    • Fatigue

    • Fever

    • Jaundice

  • Labs

  • Vaccine

  • IgG

  • Prevention


Hepatitis b
Hepatitis B

  • Percutaneous/permucosal

  • Sexual contact

  • Perinatal

  • 45-180d

  • S/S

    • 30% asymptomatic

    • Flu

    • Light stools

    • Dark urine

    • Fatigue

    • Fever

    • Jaundice

  • Labs

  • Prevention

    • Vaccine

    • IgG

    • Safe sex

    • No sharing of razors, toothbrushes, needles

  • Chronicity

    • Antivirals


Hepatitis c
Hepatitis C

  • 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


Hepatitis d
Hepatitis D

  • HBV

  • 2-26wk

  • Labs

  • Interferon

  • HBV vaccine

  • S/S

    • HBV


Hepatitis e
Hepatitis E

  • Fecal/oral

  • Contaminated water

  • Poor sanitation

  • 15-64d

  • Labs

  • S/S

    • HBV

  • No vaccine


Diagnostics
Diagnostics

  • LFT

  • ALP

  • Serum bilirubin

  • Liver biopsy

  • Antigen specific


Treatment
Treatment

  • Diet

    • High cal/protein, low fat

    • Vitamins (B, K)

    • ETOH/Drugs

  • Fluid management

  • Bed rest

  • Drug therapy

    • Prevention of HAV and HBV

    • Interferon

    • Lamivudine

    • Ribavirin

    • Acetaminophen


Nursing diagnoses
Nursing Diagnoses

  • Risk for infection (transmission)

  • Imbalanced nutrition

  • Disturbed body image

  • Knowledge deficit



Pathophysiology2
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
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


Signs symptoms
Signs & Symptoms

  • Liver enlarged

  • Dull pain RUQ

  • Weakness

  • Anorexia

  • Skin

  • Sclera

  • Portal hypertension

  • Splenomegaly

  • Ascites

  • Esophageal varices

  • Hepatic encephalopathy

  • Hepatorenal Syndrome

  • Liver failure



Jaundice
Jaundice

  • Excess bilirubin

  • Heptocellular

    • Cirrhosis

  • Obstructive

  • Hemolytic

    • Excessive destruction of RBCs

      • Transfusion reaction

      • Autoimmune

      • Faulty hemoglobin

        • Sickle cell


Diagnostics1
Diagnostics

  • LFT

  • CBC

  • Coags

  • Bilirubin

  • Albumin

  • Ammonia

  • Esophagascopy

  • Liver biopsy

*See Table 44.15


Liver biopsy
Liver Biopsy

  • 3 types

    • Needle

    • Laparoscopic

    • Transvenous

      • Catheter

      • Blood clotting problems

      • Excess fluid

  • Complications

    • Puncture of lung or gallbladder

    • Infection

    • Bleeding

    • Pain


Liver biopsy1
Liver Biopsy

  • 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
After Needle Liver Biopsy

  • Pressure

  • Right side

    • 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


Nursing assessment
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


Nursing care
Nursing care

  • Safe environment

  • Sustain life


Nursing diagnoses1
Nursing Diagnoses

Hepatitis

Cirrhosis

  • Risk for infection (transmission)

  • Imbalanced nutrition

  • Disturbed body image

  • Knowledge deficit

  • Excess fluid volume

  • Disturbed thought process

  • Ineffective protection

  • Impaired skin integrity

  • Imbalanced nutrition

  • Knowledge deficit


Treatment1
Treatment

  • Diet

    • 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


Portal hypertension
Portal Hypertension

  • Arteriovenous shunting

  • Marked ascites

  • Caput medusae

    • Dilated abdominal veins

  • Esophageal varices

  • Hemorrhoids

  • Hyperslenism

    • Mod anemia

    • Neutropenia

    • Thrombocytopenia


Surgical medical interventions
Surgical/Medical Interventions

  • Paracentesis

  • Gastric lavage

  • Balloon tamponade

  • Schlerotherapy

  • Banding

  • TIPS (transjugular intrahepatic portosystemic shunt)

  • Liver transplant


Ascites
Ascites

  • Sodium restriction

  • Bedrest initially

  • Diuretics

    • Spironolactone

    • Lasix

    • HCTZ

  • Fluid removal

    • Paracentesis

    • Peritoneovenous Shunt


Ascites

Caput medusae


Paracentesis
Paracentesis

  • 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


Esophageal varices
Esophageal varices

  • Collateral vessels

  • Complex of swollen, enlarged veins

    • Portal hypertension

  • 2/3-3/4

  • Bleeding

    • LIFE-THREATENING


Esophageal varices treatment
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 tetradecylsulphate)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 submucosalvarices

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

Sengstaken-Blakemore tube – has only 3 lumens

**Respiratory assessment**


Hepatic encephalopathy
Hepatic encephalopathy

  • Neuropsychiatric manifestation

  • Decreased liver detoxification>>>

    • Increased ammonia

  • Terminal complication

  • Changes in LOC

  • Asterixis


Treatment he
Treatment HE

  • Reduce ammonia

    • Lactulose

    • Neomycin sulfate

    • Cathartics

    • Enemas

    • Liver transplantation


Hepatorenal syndrome
Hepatorenal syndrome

  • Portal HTN + liver decompensation

    • Systemic vasodilation

    • Decreased arterial BF

    • Renal vasoconstriction

  • Functional renal failure

    • Azotemia

    • Oliguria

  • Liver transplantation



Liver transplant1
Liver Transplant

  • http://youtu.be/ZD_Tlu1JUoI


Liver transplant complications
Liver transplant complications

  • Rejection

    • 70%

    • Medications

  • Infection

    • immunosuppression

  • Cancer


Patient teaching
Patient Teaching

  • Therapeutic communication

  • Diet*

  • Exercise

  • Lifestyle modifications

  • Drugs

  • Follow-up

  • Resources


Legal ethical considerations
Legal/Ethical Considerations

  • Advance directives

  • Palliative care

  • Organ donation


Donors
Donors

  • Live donor

  • Liver regenerates

    • 5 years

  • Survival rates increase / shorter wait time

  • Medical and psychological evaluations

  • Potential donors evaluated for:

    • 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

  • Pathophysiology

    • Cirrhosis

    • Portal hyperetension

    • Liver failure

      • Encephalopathy

      • Hepato-renal syndrome

  • Signs & Symptoms

  • Treatment

  • Nsg. Care

  • Complications


Question
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?

    • a. I&O

    • b. LFT

    • c. caloric intake and serum protein levels

    • d. daily weight


Question1
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.”


Question2
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.”


Question3
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.


Question4
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

    • A. release the esophageal balloon

    • B. release the gastric balloon

    • C. increase the suction

    • D. irrigate the gastric balloon


Question5
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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