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Cirrhosis Chapter 58

Terms in this set (60)

cirrhosis
-extensive, irreversible scarring of the liver, usually caused by a chronic reaction to hepatic inflammation and necrosis.
-typically slowly develops and ends in end stage liver disease
-most common causes are:
alcoholism, viral hepatitis, nonalcoholic steatohepatitis, bile duct disease, genetic diseases
cirrhosis pathophysiology
-widespread fibrotic (scarred) bands of connective tissue change the liver's normal makeup and function
-tissues become nodular and these nodules can block bile ducts and normal blood flow throughout the liver
-in early disease:
liver is enlarged, firm and hard
-with continuation of disease: liver shrinks in size
-cirrhosis can be without symptoms until severe
COMMON CAUSES OF CIRRHOSIS
-alcohol
-viral hepatitis
-autoimmune hepatitis
-steatohepatitis (from fatty liver)
-drugs and chemical toxins
-gallbladder disease
-metabolic / genetic causes
-cardiovascular disease
types of cirrhosis
-postnecrotic cirrhosis (caused by hepatitis, drugs)
-laennec's or alcoholic cirrhosis (chronic drinking)
-biliary cirrhosis (caused by biliary obstruction)
complications of cirrhosis
-depends on the amount of damage done
-compensated cirrhosis = the liver is scarred but essential functions are fine and no major symptoms
-decompensated cirrhosis= liver function is impaired
complications of cirrhosis listed:
portal hypertension
ascites / esophageal varices
coagulation issues
jaundice
portal systemic encephalopathy (PSE) with hepatic coma
hepatorenal syndrome
spontaneous bacterial peritonitis
portal hypertension (1)
-persistent increase in pressure of the portal vein greater than 5mm Hg, a major complication of cirrhosis
-increased resistance or obstruction of flow through the portal vein and branches
-splenomegaly can occur
-can result is ascites, esophageal varices, hemorrhoids
ascites and gastroesphageal varices (2)
-ascites is the collection of free fluid within the peritoneal cavity caused by increased hydrostatic pressure from portal hypertension
-patient can have hypovolemia (decreased plasma volume) and edema at the same time (fluid shifts)
-esophageal varices is the distention of veins from the increased pressure caused by portal hypertension. there is so much pressure building up in the liver the veins are becoming distended and risk for rupture
-distal esophagus, stomach, rectum
-severe blood loss can occur from this
-do not heavy lift or strain
what is the first clinical sign of liver dysfunction
-thrombocytopenia caused by an enlarged spleen destroying platelets
biliary obstruction (3)
-the production of bile in the liver is decreased
-this prevents the absorption of vitamin K
-predisposition caused by gallbladder disease or autoimmune form of the disease called primary biliary cirrhosis
jaundice (4)
-yellowish coloration of the skin of patients with cirrhosis is caused by one of two mechanisms:
hepatocellular jaundice: liver cells not effectively excrete bilirubin: excessive circulation of bilirubin levels
intrahepatic obstructive jaundice: edema, fibrosis, scarring of the hepatic bile channels and bile ducts while interferes with normal excretion.
-patients with jaundice often report pruritus
hepatic encephalopathy (5)
is a complex cognitive syndrome caused from liver failure and cirrhosis
-sleep disturbance, mood disturbance, mental changes, speech problems early at this complication begins
-may be reversible with early intervention
-late neuro changes include altered LOC, impaired thinking, neuromuscular problems
stages of hepatic encephalopathy
STAGE 1:
subtle, may not be recognized, personality changes, behavior changes, emotional lability, impaired thinking,
STAGE 2:
continue of mental changes, arousable with force confusion progresses, disorientation of time, place, person, hand flapping (asterixis)
STAGE 3:
progressive deterioration, marked mental confusion, stuporous, drowsy, muscle twitching, hyperreflexia
STAGE 4:
unresponsive, leads to death, unarousable, doesn't respond to stimuli, no asterixis, muscle rigidity
encephalopathy continued
-probably is the result from shunting of portal venous blood into central circulation so the liver is bypassed, as a result substances absorbed by the intestine are not broken down properly, elevated ammonia and GABA occurs
-elevated serum ammonia results from inability of liver to detoxify protein
factors influencing hepatic encephalopathy with cirrhosis:
high protein diet
infection
hypovolemia
hypokalemia
constipation
GI bleeding (large protein load in intestines)
drugs (hypnotics, opoids, sedatives)
hepatorenal syndrome (6)
often a cause of death. manifested by:
-sudden decrease in urinary flow (less than 500ml in 24hrs)
-elevated BUN and creatinine
-increased urine osmolarity
acute spontaneous bacterial peritonitis (7)
-usually with very advanced disease
-bacteria usually from the bowel and reach ascitic fluid
clinical manifestations:
fever, chills, abd pain, tenderness, manifestations can also be minimal
diagnosis: sample of ascitic fluid is obtained by paracentesis for counts and culture
etiology and genetic risk
-hepatitis C is the second leading cause of cirrhosis and liver failure in the U.S
-B and D most common causes worldwide
-can occur as a result of nonalcoholic fatty liver disease
-NAFLD is associated with:
obesity, dm2, metabolic syndrome
-most common cause of liver disease in the world
-can progress to liver cancer, cirrhosis, or failure
assessment: history
-alcohol or liver disease in the family
-amount of alcohol consumed
-history of drug abuse and tattoos
-military or prison?
-alcohol damage can be reversible if intervened early
clinical manifestations of cirrhosis
early manifestations are often fatigue:
fatigue, change in weight, GI symptoms (n/anorexia), abd pain and liver tenderness (both easily ignored)
late signs of cirrhosis
GI bleeding
jaundice
ascites
spontaneous bruising (poor liver function)
assess for:
yellowing of the skin
dry skin
rashes
purpuric lesions (petechiae)
warm and red palms of the hands (palmar erythema)
spider angiomas
ascites (abd fluid)
peripheral edema of the extremities
-fat soluable vitamin deficiencies (A,D,E,K)
abdominal assessment
massive ascites can be detected
-orthopnea and dyspnea from increased distention can interfere with your lungs
-measure abdominal girth for any changes
-take daily weights
other physical assessment
-vomit and stool for blood
-fetor hepaticus (breath odor of liver disease, fruity, musty)
-amenorrhea
-testicular atrophy, gynecomastia (enlarged breast) in men
-asterix (coarse tremor)
psychosocial assessment
-personality, cognitive, behavior changes can occur
-sleep pattern disturbances can occur, emotional lability, euphoria, depression
-repeated hospital visits
someone has liver cirrhosis and is visiting the medical center. what would you expect to fine?
ecchymosis
ankle edema
jaundice
NOT soft abd NOT fever
laboratory assessment
-AST, ALT, LDH will all be elevated because these enzymes are released into the blood during hepatic inflammation
-ALT is specific to liver
-AST can be found in muscle, kidney, brain, heart
-increased alkaline phosphatase and GGT
-serum bilirubin will be high due to inability of liver to excrete bilirubin
-serum protein and albumin decreases from decreased synthesis of the liver
-PT time decreased (altered coagulability)
imagining and diagnostic assessment
-ultrasound is often the first assessment with a suspected liver disease because is shows ascites, hepatomegaly, splenomegaly
-biopsy for extent of disease is possible
-EGD to visualize upper GI to detect signs of liver failure
-ERCP inject contrast material into sphincter of oddi to view biliary tract and allow for stone removal, biopsies, stent placement
nutrition therapy and cirrhosis
-ascites = low sodium diet to control fluid
drug therapy
-diuretic to reduce fluid accumulation
-norfloxacin for spontaneous bacterial peritonitis
paracentesis
-performed at the bedside
-catheter or drain into the abdomen to remove ascitic fluid -uses an ultrasound for safety
-empty bladder prior to procedure
-SBP suspected = send sample to lab
respiratory support
-ascites can cause respiratory issues from the buildup of fluid hurting lung expansion
-hepatopulmonary syndrome = dyspnea, increased abdominal pressure, auscultate lungs q4-8 hours
varices
all patients with cirrhosis should be screened by endoscopy before an issue arises
-if they do have it, preventive therapy
endoscopic therapies for varices
-endoscopic variceal ligation (banding) decrease blood supply to the varices, no discomfort, unaware of them
-endoscopic sclerotherapy = injection sclerotherapy may be done to stop the bleeding.
rescue therapy for varices
balloon tamponade and esophageal stents
-can cause aspiration, asphyxia, esophageal perforation
-tube is placed through the nose into the stomach
-attached balloon inflated to apply pressure to the bleeding variceal area
interventions for encephalopathy
liver cannot convert ammonia and other products to a less toxic form
-this is where the altered cerebral function is thought to occur
-decrease ammonia production with diet and drugs
nutrition therapy and encephalopathy
-high carbs, moderate fat, high protein diets
-watch protein? contradicted with what she said book says protein is ok to help with healing
drug therapy and encephalopathy
-used sparingly because they are difficult for a failing liver to metabolize
-avoid opioid, analgesics, sedatives, barbiturates
-lactulose (evalose, heptalac)
-promotes the excretion of ammonia in stool
-viscous, sticky, sweet tasted liquid with orally or by NG
-patient may report intestinal bloating and cramping with lactulose
-neomycin sulfate nonabsorable antibiotics
evaluation: outcomes
-remain free of ascites
-electrolytes are normal
-remain free of hemorrhage
-encephalopathy will be managed
-sustain from the use of alcohol and drugs
Which statement by a client with cirrhosis indicates that further instruction is needed about the disease?
"My liver is scarred, but the cells can regenerate themselves and repair the damage."
Although cells and tissues will attempt to regenerate, this will result in permanent scarring and irreparable damage. Cirrhosis is a chronic condition that leaves scars on the liver. Permanent scars form in response to attempts by the cells to regenerate and create problems in blood circulation moving through the liver. Liver scarring will create problems with blood clotting, cholesterol levels, and blood pressure, as well as with the metabolism of drugs and toxins.
A client who has liver disease with ascites asks about any necessary dietary changes. What instruction does the nurse include when teaching this client
Avoid using table salt.
Because of the fluid accumulation associated with ascites, this client should be on a sodium-restricted diet and should be taught to avoid table salt. High-protein or high-calcium diets are not recommended. Potassium supplements may be prescribed for clients taking certain diuretics, but are not routinely recommended.
A client who has liver disease has undergone a percutaneous needle biopsy. Which is the priority nursing assessment for the client after this procedure?
Assessing for bleeding.
Clients with liver disease are often at risk for bleeding, so the nurse should watch for this after a percutaneous biopsy. Determining pain level, evaluating urine output, and monitoring for hepatomegaly are part of the ongoing monitoring of the client, but are not the priority.
When caring for a client with Laennec's cirrhosis and portal hypertension, which point is essential for the nurse to emphasize to the client and family?
Do not consume any alcohol.
Laennec's cirrhosis is otherwise known as alcoholic cirrhosis; it is caused by chronic alcohol use. Avoiding alcohol is essential to prevent further organ damage. Sodium restriction is recommended for ascites. Fat intolerance may occur with liver disease; however, reduction of alcohol is essential, especially with Laennec's cirrhosis. Anticoagulants are not used to manage cirrhosis as there is a risk of bleeding related to prolonged International Normalized Ratio and prothrombin time.
A client with refractory ascites has a tunneled ascites drain (PleurX catheter). The community health nurse teaches the client and family which most important aspect of care while this device is in place?
Keeping hands and the area clean
Clients with an indwelling device are prone to infection. Clients with ascites may also develop spontaneous bacterial peritonitis. Therefore, hands should always be cleansed before touching the area or using the device. Bedrest is necessary after a procedure such as paracentesis, but is not necessary while the drainage device is in place. Diminished urine output and a lower blood pressure are typically present with hepatic failure and ascites because fluid is third-spaced. Blood pressure may also drop with bleeding varices; however, daily monitoring is not needed with the ascites drainage device.
A client who has early signs of hepatic encephalopathy may be asked to make which changes in the diet?
Reduce protein
Clients with hepatic encephalopathy should reduce protein intake since a high-protein diet increases serum ammonia, which can increase the risk. Clients who have hepatic encephalopathy are often hypovolemic and hypokalemic, so neither fluids nor potassium should be restricted. Increasing calcium is not indicated with hepatic encephalopathy.
When caring for a client with hepatic encephalopathy, in which situation does the nurse question the use of neomycin (Mycifradin)?
Kidney failure
The aminoglycoside drugs, which include neomycin, are nephrotoxic and ototoxic, and should not be taken by the client with hepatic encephalopathy. Cirrhosis and hepatic failure cause both ascites and encephalopathy; no contraindication for neomycin is known. Fetor hepaticus causes an ammonia smell to the breath when serum ammonia levels are elevated; neomycin is used to decrease serum ammonia levels. The client may be NPO for a few hours before paracentesis, but may take neomycin when the procedure is complete, or with less than 30 mL of water, depending on hospital policy.
Which problem for a client with cirrhosis takes priority?
Potential for injury related to hemorrhage
Potential for injury related to hemorrhage is the priority client problem because this complication could be life-threatening. Insufficient knowledge, discomfort, and inadequate nutrition are not priorities because these issues are not immediately life-threatening.
Which activity by the nurse will best relieve symptoms associated with ascites?
Elevating the head of the bed
The enlarged abdomen of ascites limits respiratory excursion; Fowler's position will increase excursion and reduce shortness of breath. The client may need oxygen, but first the nurse should raise the head of the bed to improve respiratory excursion and oxygenation. Monitoring will detect anticipated decreased serum albumin levels associated with cirrhosis and hepatic failure but does not relieve the symptoms of ascites. Administering IV fluids will contribute to fluid volume excess and fluid shifts into the peritoneal cavity, worsening ascites.
A client with liver disease has portal hypertension. Which clinical finding prompts the nurse to notify the provider immediately?
Blood-tinged emesis
Clients with portal hypertension are at risk for hemorrhage and should be monitored closely; blood-tinged emesis may indicate bleeding esophageal varices and should be reported immediately. A moderate elevation in blood pressure and liver distention are common, nonemergent findings in clients with liver disease. A urine output of 200 mL/hr does not need to be reported because normal urine output is 1500-2000 mL per day.
How does the home care nurse best modify the client's home environment to manage side effects of lactulose (Evalose)?
Requests a bedside commode for the client
Lactulose therapy increases the frequency of stools, so a bedside commode should be made available to the client, especially if he or she has difficulty reaching the toilet. Small frequent meals and elevating the head of the bed will not have any effect on the side effects of lactulose. Although lactulose produces excessive stools and could potentially result in loss of potassium, it is inappropriate for the nurse to suggest that the client take potassium supplements.
The nurse administers lactulose (Evalose) to a client with cirrhosis for which purpose?
Promotes gastrointestinal excretion of ammonia
Lactulose reduces serum ammonia levels by excreting ammonia through the GI tract. Lactase is the enzyme that digests dairy. The mechanism of action of lactulose is not to reduce portal pressure. Lactulose does not affect bleeding.
The nurse is administering spironolactone (Aldactone) to a client with portal hypertension and portal systemic encephalopathy. Which additional medication order does the nurse question?
Potassium chloride
Spironolactone is a potassium-sparing diuretic; additional potassium may result in potassium intoxication. Cephulac and neomycin are used to control hepatic encephalopathy, which is part of the expected treatment plan. Propranolol is used to prevent gastrointestinal hemorrhage secondary to portal hypertension and gastroesophageal varices, which is an expected treatment for portal hypertension.
---------------CHAPTER ON CHIRROSIS ENDS-------------
--------------------------ATI BEGINS------------------------
cirrhosis
-extensive scarring of the liver caused by injury on chronic inflammation over a longer period of time
-over time bile ducts and normal blood flow in impaired and overgrowth of tissue and enlargement occurs. jaundice is often a result as well from bilirubin the the blood
3 types of cirrhosis
postnecrotic: caused by hepatitis, medications and toxins
laennec's: caused by alcohol use
biliary: chronic biliary obsturction or autoimmune disease
RISK FACTORS for cirrhosis
alcohol use
hepatitis
steatohepatits (fatty liver disease caused by inflammation)
medications, substance, toxins, infections
chronic biliary cirrhosis (bile duct obstruction, stasis
-cardiac cirrhosis from right heart failure
EXPECTED FINDINGS for cirrhosis
-faitufe, weight loss, abd pain, distention
-pruritus (itching from jaundice)
-confusion or difficulty thinking (encephalapathy) from buildup of waste product)
-personality and mental changes, emotional lability, euphoria, depression
physical assessment findings
-cognitive changes
-altered sleep pattern
-gastroesophageal bleeding (varices) can burst, causing vomiting and passing of blood in stool
-splennomegaly caused by backup of blood into spleen
-ascites (fluid buildup in abdomen)
-jaundice
-petechiae (decreased clotting function because liver)
-palmar erythema( redness of the palms)
-spider angiomas (red lesions, on nose, cheeks, thorax)
-edema of the extremities and sacrum
-asterixis (liver flapping tremor of the hands and fingers)
-fetor hepaticus (liver breath) fruity or musty odor
LAB VALUES for cirrhosis
-ALT, AST, ALP all elevated at first until the destruction is so bad they are unable to be produced by liver from damage except for ALP, which increases from biliary obstruction
-serum bilirubin: elevated: inability to be excreted
-serum protein, albumin: decreased: lack of synthesis
NURSING CARE for cirrhosis
-respiratory status
-skin integrity (wash for cool water, lotion)
-fluid balance
-vital signs and pain level
-neuro status (encephalopathy)
-nutritional status watch proteins
-GI status (abdominal girth)
-pain status
THIS SET IS OFTEN IN FOLDERS WITH...