NURS 308 - Liver Disease

hepatitis

inflammation of the liver

fibrosis and cirrhosis

if acute hepatitis become chronic hepatitis, _____ can result

- viruses: hepatitis A, B, C, D & E

- alcohol

- hepatotoxic medications

- chemicals

- autoimmune diseases: ex. lupus

- metabolic abnormalities

etiology of hepatitis

viral hepatitis

the most common type of hepatitis

non-alcoholic steatohepatitis (non-alcoholic fatty liver disease)

metabolic syndrome can lead to:

non-alcoholic steatohepatitis (non-alcoholic fatty liver disease)

type of hepatitis: fat infiltrates the liver and decreases the function of the liver, leading to scarring and inflammation (hepatitis)

fecal-oral

transmission of hepatitis A:

via blood and body fluids (sexually transmitted, blood to blood contact)

transmission of hepatitis B:

via blood and body fluids (sexually transmitted, blood to blood contact)

transmission of hepatitis C:

fecal-oral

transmission of hepatitis E:

hepatitis A

type of viral hepatitis: mild symptoms, but can be so severe that it leads to acute liver failure

hepatitis D

type of viral hepatitis: occurs as a co-infection with hepatitis B, cannot infect on its own

hepatitis A and B

types of viral hepatitis in which a vaccine is available

hepatitis E

type of viral hepatitis: occurs primarily in developing countries who don't have access to good sanitation and clean water

hepatitis A

type of viral hepatitis that is acute, but does not become chronic

hepatitis B and C

types of viral hepatitis in which can be acute or chronic

1-6 months

maximal infectivity of acute hepatitis lasts for _____ - this is the time that the antigens in the patient's body are at their highest level, so the patient is most-likely to spread the infection to other people

- anorexia

- lethargy

- weight loss

- fatigue

- nausea, vomiting

- RUQ tenderness

- distaste for cigarettes

- decreased sense of smell

- low-grade fever

- skin rashes

- myalgias, arthralgias

- hepatomegaly

- lymphadenopathy

- splenomegaly

- icteric (jaundice) or anicteric

clinical manifestations of the acute phase of hepatitis:

RUQ

where is the liver located?

- dark, tea-colored urine

- light or clay colored-stools

- pruritus

if icteric, the patient may have:

anicteric

the absence of jaundice

jaundice

the convalescent phase of hepatitis begins as the _____ disappears, and lasts weeks to months

- jaundice subsides

- malaise

- easy fatigability

- hepatomegaly persists

- splenomegaly subsides

clinical manifestations of the convalescent phase of hepatitis:

hepatitis B and C

*however, a hepatitis C infection is more likely to become chronic

chronic hepatitis is a major complication of which types of viral hepatitis?

male

ETOH use

fatty liver

excess iron

metabolic syndrome

HIV

risk factors of chronic hepatitis:

asymptomatic

many patients with chronic hepatitis, especially hepatitis C, are _____

- malaise

- fatigue

- myalgias, arthralgias

- RUQ tenderness

- anemia

- coagulation problems: bruising, bleeding

- rash, pruritus

clinical manifestations of chronic hepatitis:

ascites

cirrhosis

portal hypertension

liver cancer

acute liver failure

complications of chronic hepatitis:

acute liver failure

*the liver is our organ of metabolism, and if we are not able to metabolize our nutrients, then our life will no longer be supported

one of the most serious complications of hepatitis - the liver is not functioning well enough to support the functions of life

encephalopathy

gastrointestinal bleeding

disseminated intravascular coagulation (DIC)

clinical manifestations of fulminant (acute) liver failure:

disseminated intravascular coagulation (DIC)

*with excessive bleeding, all of the clotting factors in the body are activated and get used up, leaving the body with none

abnormal blood clotting throughout the body's blood vessels

liver transplantation

treatment of acute liver failure:

↑ liver enzymes - ↓ plasma protein - ↑ plasma bilirubin - urinary urobilinogen - ↑ PT

what lab values indicate hepatitis?

vitamin B complex and vitamin K

*vitamin K helps with clotting

a patient with hepatitis should supplement _____

alcohol intake and drugs metabolized by the liver

patients with hepatitis should avoid:

restaurant

the most common reason for a hepatitis A outbreak is traced back to a:

hepatitis B or C

patients with hepatitis _____ must notify sexual partners

hepatitis A

if someone with hepatitis _____ is working as a cook in a restaurant, they can pass the virus onto people through food preparation if they are not handwashing very effectively

hepatitis A

type of viral hepatitis with no drug therapy - generally the body will clear the virus on its own

pegylated interferon + direct acting antivirals (DAAs)

*has a > 98% cure rate, very effective

drug therapy for hepatitis C:

no drug therapy - provide supportive therapy: fluids, maintain nutrition, antidiarrheals, comfort measures

drug therapy for hepatitis A:

suppress virus replication while the body's own immune system destroys the virus that is present

the goal of hepatitis B treatment is to:

- nutritionally compromised: the liver is not metabolizing nutrients, so they aren’t being absorbed

- activity intolerance

- risk for bleeding

clinical problems for hepatitis:

- take general measures to prevent infection and transmission: hand hygiene, food handling, environmental sanitation

- teach the patient NOT to prepare food for other people or share food with other people

- teach patients NOT to drink water from a stream or a lake to prevent infection of hepatitis A

implementation for hepatitis A:

immune globulin

post-exposure prophylaxis for hepatitis A:

vaccine and hepatitis B immune globulin (HBIG)

post-exposure prophylaxis for hepatitis B:

none - baseline and follow-up testing

post-exposure prophylaxis for hepatitis C:

no vaccination – main prevention: safe sex practices, no sharing of needles

hepatitis C prevention:

hepatitis C

it is recommended that all adults age 18-79 are screened at least one in their life for hepatitis _____

- small, frequent meals

- take measures to stimulate appetite (carbonated beverages)

- maintain adequate fluid intake

- calm environment, non-cluttered table

implementation to maintain adequate nutrition for a patient with hepatitis:

acetaminophen

hepatotoxic agents include OTC medications, like _____

cirrhosis

end-stage of liver disease - occurs when there has been extensive degeneration and destruction of liver cells

2+ complications

decompensated cirrhosis is classified with _____

- excessive alcohol intake

- non-alcoholic fatty liver disease (NAFLD)

- chronic hepatitis B or C

- primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC)

- long-standing, severe, right-sided heart failure

etiology of cirrhosis:

excessive alcohol intake

the most common cause of cirrhosis

primary biliary cholangitis (PBC) and primary sclerosing cholangitis (PSC)

the flow of bile is blocked off, causing bile to back up into the liver and cause scarring

- portal hypertension

- esophageal/gastric varices

- peripheral edema

- abdominal ascites

- hepatic encephalopathy

- hepatorenal syndrome

- acute liver failure

complications of cirrhosis:

portal hypertension

the elevation of blood pressure within the portal venous system

- splenomegaly

- large collateral veins (caput medusae)

- ascites

- gastric and esophageal varices

clinical manifestations of portal hypertension:

gastric and esophageal varices - if the varices rupture and start bleeding, the patient can bleed to death very very quickly

the most life-threatening complication of cirrhosis

abdominal ascites

an accumulation of serous fluid in the peritoneal or abdominal cavity (third space fluids)

portal hypertension

hypoalbuminemia

hyperaldosteronism

abdominal ascites results from several mechanisms, including:

hepatic encephalopathy

occurs when the liver is unable to convert increased ammonia, therefore ammonia crosses the blood-brain barrier, causing neurologic changes

- changes in neurologic and mental responsiveness

- impaired consciousness and/or inappropriate behavior

- sleep disturbances

- trouble concentrating

- coma

- asterixis

- impairment in writing (difficulty in moving pen from left to write), apraxia

- fetor hepaticus

clinical manifestations of hepatic encephalopathy:

asterixis

flapping tremors, common in arms and hands

apraxia

the loss of ability to execute or carry out skilled movement and gestures, despite having the physical ability and desire to perform them

apraxia

when the patient writes, the pen stays in the same place and they are writing letters on top of eachother

fetor hepaticus

a musty, sweet smell to the breath that is a result of buildup of ammonia (rotten nail polish remover)

hepatorenal syndrome

renal failure occurs as a result of cirrhosis - no structural abnormality of the kidneys

azotemia

oliguria

intractable ascites

clinical manifestations of hepatorenal syndrome:

azotemia

waste products build up in the blood due to decreased renal function

oliguria

decreased urine output

liver transplantation

treatment of hepatorenal syndrome:

acute liver failure

complication of cirrhosis that is usually due to drug/alcohol combination in someone with cirrhosis

- mental status changes: due to hepatic encephalopathy or cerebral edema

- jaundice

- renal failure

- hypoglycemia

- metabolic acidosis

- sepsis

- multi-organ failure

clinical manifestations of acute liver failure:

liver transplantation

treatment of acute liver failure

liver biopsy

the gold standard for diagnosis of cirrhosis

- acetaminophen (very hepatotoxic)

- aspirin and NSAIDs (risk for bleeding)

which medications should a patient with cirrhosis avoid?

- sodium restriction

- IV albumin

- diuretics

- medications

- paracentesis

- transjugular intrahepatic portosystemic shunt (TIPS)

interprofessional care for ascites:

albumin

creates an osmotic pull to pull the fluid back into the intravascular space

paracentesis

a procedure in which a catheter is inserted into the abdominal cavity to remove excess fluid

transjugular intrahepatic portosystemic shunt (TIPS)

a procedure that involves inserting a stent to connect the portal veins to adjacent blood vessels that have lower pressure - relieves the pressure of blood flowing through the diseased liver and can help stop bleeding and fluid back up

nonselective beta blockers

drug indicated to decrease the pressure within the esophageal varices and prevent them from rupturing

- stabilize the patient

- manage the airway: sit them up and suction the blood out of the oral cavity to try and keep the airway patent !!!

- provide IV therapy and blood products to replace loss blood and fluids

what should a nurse do if bleeding esophageal or gastric varices occurs?

octreotide, vasopressin

patient presents with bleeding esophageal varices. what medication is often given IV to stop the bleeding?

band ligation

a procedure in which a band is placed and tightened around the varices to clot them off and prevent further bleeding

sclerotherapy

a procedure in which a high-saline solution is injected into the varices, which cauterizes it and clots it off

balloon tamponade: sengstaken-blakemore tube, minnesota tube

mechanical compression of esophageal or gastric varices to stop bleeding - indicated for patients with an active bleeding episode

- label the ports: esophageal balloon port, gastric aspiration port, gastric balloon port

- once every 8 hours, partially deflate each balloon to restore

blood flow and prevent erosion and ulceration

nursing implications for a sengstaken-blakemore tube:

- fresh frozen plasma

- packed RBCs

- vitamin K

- proton pump inhibitors

- lactulose and rifaximin

- antibiotics

management of acute bleeding of esophageal/gastric varices:

proton pump inhibitors

drugs indicated to decrease the acidity in the stomach and reduce erosion of the stomach and esophageal linings

rifaximin

drug that binds to ammonia and keeps the ammonia in the GI tract, preventing it from being absorbed in the blood and traveling to the brain

lactulose

a laxative that binds to ammonia, allowing the excess ammonia to be eliminated into the feces

- nonselective beta blockers

- repeated band ligation

- portosystemic shunts

long-term management for bleeding:

protein, blood

breaks down into ammonia in the stomach

high in calories (3000 cal/day)

↑ carbohydrates

moderate to low fat

*their metabolism is impaired, so many of the nutrients they are ingesting are not getting metabolized and absorbed

diet for a patient with cirrhosis without complications:

low-sodium

diet for a patient with cirrhosis with ascites and edema:

symptom management

we cannot cure cirrhosis without a liver transplant, so focus on _____

- cholestyramine: binds with bile acid salts

- hydroxyzine: antihistamine

- baking soda or alpha keri baths

- lotions, soft linen

- temperature control

- keep nails short, teach to scratch with knuckles (put socks on the hands of a patient with hepatic encephalopathy)

nursing implications to relieve pruritus r/t jaundice

daily weights

the most accurate indicator of fluid volume excess