HIT, GI Bleed, & Hepatic and Renal Disorders

Exogenous heparin administration > immune response where the body produces antibodies against foreign heparin > platelet count falls as platelets are used to form new blood clots

Pathophysiology of HIT

• Thrombocytopenia

• Blood clots causing DVT, PE, stroke, or MI

• Systemic reaction like fever, chills, HTN, tachycardia, SOB, flushing

• Injection site reaction like tenderness, redness, necrosis

S/S of HIT

• Thrombocytopenia: Usually a > 50% drop in platelet count

• Timing of platelet drop: Usually within 5-10 days of starting heparin

• Thrombosis: Evidence of blood clots like DVT, PE, or skin necrosis

• Other causes: Ruling out other causes

4 Ts used to diagnose HIT

Diagnostic tests for HIT

ELISA and SRA

Detects antibodies formed against the exogenous heparin

ELISA

Measures how much radioactive serotonin is released from donor platelets when mixed with patient’s serum in the presence of heparin

SRA

• Stopping heparin administration

• Replacing heparin with danaparoid, lepirudin, or argatroban

• Platelet transfusions are discouraged because they may increase thrombus formation

Treatment for HIT

DVT, PE, MI, stroke

Complications of HIT

• PUD: Ulcer deepens, cuts through the submucosa lining of the stomach, and exposes the arteries to damage

• Gastritis: Protective barrier of stomach lining breaks down > Inflammation and erosion exposes the arteries to damage

Pathophysiology of upper GI bleed

Hematemesis, melena, hypovolemia

S/S of upper GI bleed

• Fluid resuscitation with normal saline

• PPIs (omeprazole) to reduce the risk of bleeding

• RBC transfusion for Hgb < 7 g/dL

Treatment for upper GI bleed

Complication of upper GI bleed

Hypovolemic shock

• Monitor VS for s/s of hypovolemic shock

• Insert two 18 gauge peripheral IVs

• Administer IV normal saline for fluid resuscitation

• Prepare the patient for endoscopy and/or x-rays

Nursing interventions for upper GI bleed

• Fecal-oral transmission

• Exposure to blood and body fluid

• Chronic alcohol use

• Medications

• Toxins

• Autoimmune disorders

Risk factors for hepatitis

• Fecal-oral transmission

• Acute

• Vaccine available

• Treatment based on symptoms

Hepatitis A

• Blood transmission

• Acute and chronic

• Vaccine available

• Treated using interferon and antivirals

Hepatitis B

• Blood transmission

• Acute and chronic

• Vaccine unavailable

• Treated using interferon and antivirals

Hepatitis C

• ABD pain

• Irritability

• Pruritus

• Anorexia

• Fever

• N/V

• Ascites

• Jaundice

• Flu-like symptoms

• Clay-colored stools

• Dark amber urine

S/S of hepatitis

ALT, AST, GGT, ALP, bilirubin, serum ammonia, albumin, LDH

Diagnostic labs for hepatitis

Used to monitor bile flow abnormalities

GGT and ALP

ALT, AST, GGP, ALP, bilirubin, serum ammonia, LDH

Increased in hepatitis

Decreased in hepatitis

Albumin levels

• Antivirals like tenofovir, lamivudine, ribavirin

• Interferons for viral suppression

• Liver transplant for cirrhosis from hepatitis C

Treatment for hepatitis

• Small, frequent meals due to liver’s inability to store large glycogen stores

• Low fat due to liver’s inability to process bile

• Avoidance of alcohol and hepatotoxic meds like acetaminophen

• Supplements of vitamins A, D, E, and K (fat-soluble vitamins)

Diet for hepatitis

Hepatic encephalopathy, cirrhosis, liver failure, liver cancer

Complications of hepatitis

Accumulation of ammonia in the blood in severe hepatic failure due to its inability to remove waste from the blood

Hepatic encephalopathy

• Impaired mental status

• Altered LOC

• Confusion

• Somnolence

• Insomnia

S/S of hepatic encephalopathy

• Administer meds as ordered

• Provide small, frequent meals and supplements

• Administer antiemetics to decrease symptoms of N/V

• Promote balance between physical activity and rest because rest decreases metabolic demands on the liver

• Encourage rest periods between walking and physical activity to maintain strength

Nursing interventions for hepatitis

• Small frequent meals because liver cannot store large amounts of glycogen

• Adequate hydration to prevent dizziness, fatigue, skin and mucous membrane dryness

• Avoid alcohol and caffeine to prevent dehydration

• Hand hygiene before and after meals and use of the bathroom to decrease transmission from fecal-oral route

• Avoid sharing needles and unprotected sex to decrease transmission from bloodborne route

• Importance of hepatitis A and B vaccines

• Consider whether the public water supply is safe from sewage

Client education for hepatitis

• Hepatitis B and C

• Alcohol use disorder

• Nonalcoholic steatohepatitis (NASH)

• Postnecrotic or micronodular cirrhosis

Causes of cirrhosis

• Chronic hepatitis B or C

• Alcohol use

• Hepatic fat accumulation from obesity

• Autoimmune diseases

Risk factors for cirrhosis

Alcohol-induced, micronodular, biliary, NASH, cardiac

Types of cirrhosis

Type of cirrhosis where fibrosis occurs around the central and portal veins

Alcohol induced

Type of cirrhosis where bands of scar tissue in the liver due to previous acute viral hepatitis or exposure to hepatotoxins

Micronodular

Type of cirrhosis where liver tissue scarring around the bile ducts and lobes of the liver due to chronic biliary obstruction and infection or cholangitis

Biliary

Accumulation of fat in the liver > Liver cell inflammation > Cirrhosis

NASH

Type of cirrhosis where severe long-term right HF > Decreased liver cell oxygenation > Liver cell death

Cardiac

1. Constant liver injury over time causes functional liver cells to die

2. Damaged liver cells regenerate into nodules surrounded by fibrous tissue

3. Blood and lymph flow to the fibrotic area is altered

4. Scarring causes portal vein to be blocked

5. Blood cannot pass through the liver using the portal vein

6. Hepatic insufficiency and portal vein hypertension

7. Blood backs up due to being unable to pass through the liver

8. Hemorrhoids, esophageal varices, and gastric varices from back-up of blood

Pathophysiology for cirrhosis

• ABD vascular or arterial spider angiomas

• Palmar edema

S/S of alcohol induced cirrhosis

Severe itching due to retained biliary salts

S/S of biliary cirrhosis

• Asterixis

• Ascites

• Thrombocytopenia

• Prolonged PT

• Hepatic encephalopathy

• SOB

• Jaundice

• ABD pain and bloating

• Hemorrhoids

• Splenomegaly

• LOC changes

S/S of cirrhosis

Electrolyte levels, albumin, and platelets in cirrhosis

Decreased

ALT, AST, ALP, bilirubin, and ammonia in cirrhosis

Increased

aPTT and PT in cirrhosis

Prolonged

ABD ultrasound and CT scan, Esophagogastroduodenoscopy (EGD), percutaneous transhepatic cholangiography and portal angiography

Diagnostic tests for cirrhosis

Diagnostic tests used to determine liver abnormalities

ABD ultrasound and CT scan

Used to visualize the GI tract from the esophagus to the duodenum to evaluate for esophageal varices or bleeding

EGD

Used to visualize the portal venous system

Percutaneous transhepatic portal angiography

Uses a contrast medium injected into the hepatic bile duct to visualize the biliary tract and identify any obstruction

Percutaneous transhepatic cholangiography

A sample of liver tissue is collected to determine the severity of liver disease

Liver biopsy

• Maintain bedrest for several hours postop

• Sometimes a 5-10 lb sandbag is placed over the biopsy site

• High risk for hemorrhage postop, monitor closely for:

  • Change in LOC

  • Hypotension and tachycardia

Liver biopsy postop care

• Sodium restriction of 2 g/day and diuretics for ascites

• Frequent paracentesis for ascites in end-stage liver disease

• Transjugular intrahepatic portosystemic shunt (TIPS)

• Liver transplant for end-stage liver disease

Treatment for cirrhosis

• Banding

• Sclerotherapy

• Balloon tamponade

Treatment for varices

Placing bands around varices to block the bleeding

Banding

Injection of a solution into varices to make them shrink to stop bleeding

Sclerotherapy

Compression and traction in the esophagus and stomach to stop hemorrhage using a Sengstaken-Blakemore tube

Balloon tamponade

Airway obstruction, esophageal rupture, and aspiration pneumonia

Complications of balloon tamponade

• Small frequent meals

• Neomycin to destroy GI tract bacteria to decrease protein breakdown and ammonia production

• Lactulose to promote the excretion of ammonia through the stool

• Supplements for vitamins A, B complex, C, and K, and folic acid

Treatment for hepatic encephalopathy

A shunt is placed between the portal venous system and the systemic venous system to reduce portal pressure to reduce fluid accumulation

TIPS

• Disseminated intravascular coagulation (DIC)

• Pleural effusion

• Hepatorenal syndrome

• Spontaneous bacterial peritonitis

Complications of cirrhosis

Small blood clots form inside blood vessels which disrupt blood flow to organs and disrupt normal coagulation causing excessive bleeding

DIC

Fluid traveling across the diaphragm to the pleural space around the lungs due to ascites

Pleural effusion

Rapid deterioration of kidney function as a result of altered blood flow to the kidneys from cirrhosis

Hepatorenal syndrome

Hyponatremia, decreased serum osmolality, and elevated BUN and creatinine levels

S/S of hepatorenal syndrome

Peritonitis from ascites diagnosed using a paracentesis and ascites fluid culture

Spontaneous bacterial peritonitis

Fever, abdominal pain, encephalopathy, acute hemodynamic decompensation

S/S of spontaneous bacterial peritonitis

• Administer diuretics to decrease fluid overload and edema

• Administer potassium supplements for hypokalemia from vomiting, diarrhea from lactulose, and diuretics

• Administer magnesium supplements for hypomagnesemia from poor nutrition and diarrhea from chronic alcohol use

• Administer phospohate supplements for hypophosphatemia from chronic alcohol use poor nutrition, and diuretics

• Sodium and fluid restrictions to prevent fluid accumulation and edema

• Restrict protein intake to prevent increased ammonia levels

• Elevated HOB and legs to decrease pressure on diaphragm from ascites and decrease dependent edema

• Promote rest periods between activities to decrease metabolic demand on liver and decrease oxygen consumption

Nursing interventions for cirrhosis

• Dietary restrictions: Protein, sodium, fluid

• No alcohol intake

• Avoid meds metabolized in the liver like acetaminophen

• Consume adequate calories to prevent malnutrition

• Bleeding precautions

Client education for cirrhosis

• Chronic hepatitis B or C infection

• Chronic alcohol use

• Autoimmune disorders

• Hemochromatosis

• Obesity

• Diabetes

• Aspergillus flavus mold

Risk factors for liver cancer

Usually fatal within 6 to 12 months of diagnosis because patients are usually not diagnosed until late stage

Liver cancer

Excess build-up of iron in the body due to a genetic disorder, massive transfusions, chronic alcohol use, or hemolytic anemia

Hemochromatosis

• Increased risk of primary cancer from cirrhotic changes

• Secondary cancer metastasizes from colorectal cancer

Pathophysiology of liver cancer

• ABD pain

• Weight loss

• Anorexia

• Weakness

• Fatigue

• Jaundice

• Ascites

S/S of liver cancer

Diagnostic lab for liver cancer

Alpha fetoprotein

Cross-sectional imaging studies, liver ultrasound and contrast CT scans, liver biopsy

Diagnostic tests for liver cancer

• Selective internal radiation therapy

• Transcatheter arterial chemoembolization

• Radioembolization

• Radiofrequency ablation

• Cryotherapy

• Partial hepatectomy

• Hepatic surgical resection

• Liver transplant

Treatment for liver cancer

• Administer pain meds to provide symptomatic relief

• Daily ABD girth measurements to determine fluid accumulation

• Administer antibiotics and antipyretics for infection

• Apply stockings to legs and elevate them to promote venous return

• Fluid, sodium, and protein restriction to prevent FVO and increased ammonia

Nursing interventions for liver cancer

Blunt injuries like motor vehicle accidents and penetrating injuries like stab wounds

Causes of liver trauma

Trauma > hemorrhage and liver dysfunction

Pathophysiology for liver trauma

• Hemorrhage > Hypotension, tachycardia, tachypnea, decreased LOC, pallor, cool skin, decreased urine output

• RUQ pain, guarding, rebound tenderness

• Diminished bowel sounds

• Bowel sounds heard in the chest due to a diaphragmatic tear

S/S of liver trauma

• CBC to monitor blood loss and infection

• Coagulation profile, serum electrolytes, LFTs, and drug and alcohol screens

• Type and cross for possible blood transfusion

Diagnostic labs for liver trauma

• Fluid resuscitation for blood loss

• Frequent monitoring of vital signs and CBC

• Blood transfusions depending on the severity of bleeding

• Hemodynamic monitoring for shock

• Bed rest and activity restrictions for as long as 6 weeks with

• Hepatic resection to control excessive bleeding or bile leaks

• Packing around the liver to control bleeding

Treatment for liver trauma

• Hemorrhage

• Hypovolemic shock

• Peritonitis

• Death

Complications of liver trauma

• Fluid resuscitation as ordered to maintain hemodynamic stability and promote organ perfusion

• Administer blood products as ordered to maintain H&H

• Administer antibiotics as ordered for peritonitis

• Bed rest and activity restrictions to decrease metabolic demands on the liver

Nursing interventions for liver trauma