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What is cirrhosis? What can it be caused by and how does it effect the liver?
Extensive, irreversible scarring of the liver as a reaction to hepatic inflammation and necrosisUsually caused by Hep C, alcohol, substance abuseUsually develops slowly, has stages and ends in end stage liver diseaseEarly stages the liver is firm and hard and then it shrinks over time with disease progression
What is portal hypertension? What is it caused by? what are the clinical manifestations?
- major complication of renal disease
- Increase in pressure of the portal vein due to liver inflammation and increased obstruction of blood flow through portal vein
- Surrounding veins become dilated and engorged
- Blood backs up into the spleen, causing splenomegaly and subsequent hemolysis causing thrombocytopenia
- Leads to ascites, esophageal varices, abdominal vein engorgement and hemorroids
Describe ascites and the possible complications
- Collection of fluid in the abd cavity due to fluid third spacing
- Pt may become dehydrated
- Edema and hypovolemia at the same time
What are esophageal varices? What are the s/s? What nursing care can be done?
- Esophageal veins becomes engorged from portal hypertension
- Bleeding esophageal are a LIFE THREATENING event and a medical emergency! Results in hypovolemia
- S/S include hematemesis, melena, decreased LOC, decreased BP and increased HR,
- Nursing Care includes serial H&H, call blood bank, 2 large bore IVs, sit pt up. NG Tube and Balloon Tamponade
How does liver disease cause jaundice?
- Biliruin is formed when hemoglobin is broken down as a normal part of blood cell replacement
- Bilirubin is filtered by the liver, dumped into the bloodstream and eliminated in stool
- Cirrhotic liver cells cannot excrete bilirubin and it builds up in the skin, leaving the patient yellow
- Icterus is the sclera turning yellow
- Jaundice increases the risk of pressure ulcers and is often accompanied by puritis
What is hepatic encephalopathy? What are the clinical manifestations and what lab changes may you see? What are the four stages?
- Also called Porta-Systemic Encephalopathy (PSE)
- Results from cirrhotic liver and the emitted toxins
- Causes mental status changes, mood changes, sleep distubrances, slurred speech, tremors
- Ammonia levels often rise
- 1. Prodromal
- 2. Impending
- 3. Stuporous
- 4. Comatose
What are the stages of liver disease?
- Healthy liver: filters blood and drugs/alcohol, breaks dow fat to produce cholesterol. can regenerate, clotting factors produced
- Inflammation: becomes tender and enlarged, may be palpated
- Fibrosis: scarring begins and replaces healthy tissue. Can still heal at this stage
- Fatty liver: can be reversed, may be asymptomatic
- Cirrhosis: pt bleeds or bruises easily, ascites and peripheral edema, jaundice, pruritis, loss of muscle mass, kidney failure, poor metabolism of medications, encephalopathy develops, stenorrheic stools due to lack of bile, liver is bumpy instead of smooth and transplant is necessary
- Liver failure: life-threatening comatomse
How is liver disease diagnosed?
- Advanced physical examination
- Liver may be hard and bumpy when palpated
- Liver function tests (labs) AST, ALT
- Ultrasound (usually first assessment) and CT scan
- Diagnostic laparoscopy
What is NAFLD? What are the clinical manifestations? What is the treatment?
- Non-Alcoholic Fatty liver Disease
- Also called Steatosis
- Build up of fat around liver that is not caused by alcohol, occurs most often in obese, DM and may be asymptomatic
- S/S include:
- -fatigue and weakness
- -abd pain
- -jaundice and pruritis
- -peripheral edema and ascites
- -increased liver enzymes
- -increased lipid profile
- -prolonged prothrombin time
- -diet, exercise, limit alcohol and meds
What s/s may a nurse find upon assessment of someone with liver disease? What nursing care can be done?
- Fetor hepaticus: fruity or musty breath
- Asterixis: tremors
- Amenorrhea, testicular atrophy, gynecomastia
- Mental status changes and personality changes
- Sleep pattern disturbances
- Increased abd girth can be measured at the end oh exhalation. Mark position of tape measurer so next shift can measure at same spot.
- Ascites may sound tympanic with fluid like waves
- Daily wts, I/O, E/F, assessment for edema
- Assist with paracentesis for removal of ascites from the peritoneal cavity
What nursing actions should be taken during a paracentesis for ascites?
- Explain what to expect and answer any questions
- Obtain pre-procedure VS, including wt
- Have the pt empty bladder to reduce risk of bladder trauma
- Monitor VS during according to policy or physician
- Measure and describe fluid and document
- Label and send fluid for analysis, document
- Apply pressure dressings, assess for leakage
- Maintain bedrest as per protocol
- Weigh pt after paracentesis, document and balance I/O
What is serum AST? Whats the normal range? What do abnormal labs indicate?
- Aspatate Aminotransferase
- 0-35 units/L
- Liver cells lyse and AST is released, higher the results the worse the disease
- hepatitis, cirrhosis, drug-induced injury, cancer
- For acute disease, levels rise and fall
- For chronic disease, levels remain elevated
What is serum ALT? Whats the normal range? What do abnormal labs indicate?
- Alanine Aminotransferase
- Viral Hepatitis: ALT/AST ratio >1
- Hepatocellular Disease: ALT/AST <1
- Damaged liver enzymes enter the blood stream and aids in a hepatitis diagnosis
- Many drugs can increased ALT levels
What is serum ALP? Whats the normal range? What do abnormal labs indicate?
- Alkaline Phosphatase
- 30-120 units/L
- Excreted by the liver into the bile
- Increase with obstructive biliary disease, cirrhosis, liver tumors, etc
- Many medications can cause increases and decreases in ALP
What is serum bilirubin? Whats the normal range? What do abnormal labs indicate?
- 0.3-1.0 mg/dL (critical is >12)
- RBCs break down and spill into bowel
- Usually caused by hep, cirrhosis, gall stones
- Protect blood sample from sunlight
- Many medications can increase or decrease bilirubin
What is serum Prothrombin time? Whats the normal range? What do abnormal labs indicate?
- 11-12 sec (critical >20)
- Full anticoag therapy 1.5-2x normal (16.5-25)
- Clotting factors are produced in the liver
- Decreased clotting factors occur with hepatocellular dysfunction, bile duct obstruction, and gall stones
What is an upper GI series?
- Also called a barium swallow, replaced by EGD
- Fluoroscope study of the esophagus, stomach and duodenum
- NPO 8hr prior, then pt drinks barium at beginning of test
- Rotating table moves the barium by gravity to visualize structures
- Teach patient to drink plenty of fluids to flush out barium and prevent constipation
What is a lower GI series?
- Also called barium enema
- A lubricated enema tip inserted into the rectum and colon is filled with barium. Balloon is filled so that the barium doesn't come out too son
- Xrays are taken with barium in place
- Pt may have cramping during this time
- Tube is removed along with most of the barium
- Teach pt to drink plenty of water to expel barium
What is an EGD? What nursing care considerations should be taken?
- visualization of esophagus, stomach and duodenum through a fiberoptic endoscope
- Avoid anticoags, aspirin and NSAIDs for 2 days prior
- NPO 8hrs prior
- Monitored Anesthesia Care (MAC) for moderate sedation (versedm fentanyl, sublimaze, propofol)
- Put client into the left lying position with bite block
- Local anesthetic sprayed in mouth to prevent gagging
- VS q 15, then q30 post procedure
- NPO until gag reflex returns
Describe a colonoscopy. What nursing care considerations should be taken?
- Direct visualization of large bowel by endoscopy
- Should have one every 5-10 years after 50, more often if colon or prostate cancer runs in family
- Provider can take tissue for biopsy, snare polyps, rinse tissue, locate bleeders
- Clear liquid diet day before, drink GoLYTLEY bowel prep day before and morning of colonoscopy
- Avoid red, purple, or orange food/drinks
- Avoid anticoags, antiplatelets for a few days before
- NPO 4-6 hrs directly before procedure and no water
- Vital signs monitored q5 during procedure, q15 after
- MAC during procedure, client on left side knee bent
- NPO until fully alert and passing gas
- Narcan on hand to reverse opiates
- First stool may have some blood, but monitor and educate about excessive bleeding
- Must have someone to drive them home
Describe the gallbladder. What common obstruction causes problems?
- Small sac-like structure that lies beneath the right lob of the liver
- stores bile from the liver, concentrates it and it is released when eating fatty foods
- Common bile duct is often obstructed by stones
What are acute and chronic cholecystitis? What is cholelithiasis? What are the two types of acute?
- Cholecycstitis is inflammation of the gallbladder
- Acute or chronic
- Calculous cholecystitis is due to gallstones, Acalculous cholecystitis is inflammation without gallstones
- Cholelithiasis is chemical irritation and inflammation resulting in the formation of gallstones
What assessments and diagnostic testing can be done for cholecystitis?
- Moderate to severe pain (biliary colic)
- Blumberg's sign is rebound tenderness indicating gallbladder disease
- Jaundice (Esp chronic)
- GI symptoms such as flatulence, dyspepsia and belching may be present when eating fatty foods
- Ultrasound and lab tests will be done
- Choleoangiogram: iodine injected into the blood stream (ask about allergies) to outline the gallbladder and look for obstructions or stones
What are the treatment options for cholecystitis?
- Cholecystectomy: removal of the gallbladder either by laparaoscopy or lateral incision
- PT will have T-tube in common bile duct if open incision, risk for PCS
What is PCS?
- Postcholecystecomy syndrome
- Repeating abd or epigastric pain several weeks to months after surgery
- Requires f/u surgery
Describe draining techniques post open cholesystectomy
- If it is an open cholecystectomy, there will be a t-tube drain in the CBD to keep it open
- Usually is an external drain into a bag