Week 9: Caring for People with Liver Failure, Cirrhosis, and Upper GI Bleeding

Cirrhosis

-end stage of chronic liver failure

-scar tissue blocks the flow of blood and bile thru the liver

-portal hypertension occurs (blood cannot freely pass thru now)

S/s of compensated Cirrhosis:

-minimal symptoms

-fatigue

-enlarged liver

-RUQ abdominal discomfort

S/s of decompensated Cirrhosis:

-jaundice

-hematological problems

-endocrine problems

-portal hypertension and esophageal and gastric varices (life threatening if pop)

-abdominal ascities and peripheral edema

S/s of upper GI bleed:

-melena (shiny, tar-like, fetid smelling stools), hematemesis

Hematochezia

passing of bright red blood per rectum indicating lower GI bleed source

Lab tests for Cirrhosis:

-liver enzymes: ELEVATED

-bilirubin: ELEVATED

-Albumin: DECREASED

-PT: EXTENDED

Nursing considerations for blood problems from Cirrhosis:

-cirrhosis causes blood problems: liver cannot produce vit K and clotting factors

-monitor for s/s of bleeding

-avoid aspirin and NSAID

-avoid IM injections, NG tube, unnecessary trauma

Major complications from Cirrohsis:

-portal hypertension

-esophageal and gastric varices

nursing considerations for active bleeding varices

PROTECT airway

RRT

2 large bore IV

crystalloids and blood products

VS monitoring

somatostatin and octreotide- vasoconstrict

vasopressin- decreases blood flow to abdomen → lower portal pressure

beta blockers

endoscopic sclerotherapy

banding

minnesota tube

How to prevent varices from bleeding:

-administer beta adrenergic blockers (decreases force of heart contraction--> decreases BP--> decreased pressure)

-advise avoiding NSAID, aspirin, and alcohol

-shunts can be placed

causes of upper GI bleed

50% is peptic ulcer disease → distended abdomen w/ hyperactive bowel sounds

mallory-weiss tear → vomiting blood, coughing

varices

gastritis

Nursing considerations for upper GI bleed:

-protect patient airway

-maintain hemodynamic stability (2 large bore IV and give blood products)

-monitor for ST changes or MI

-administer sedation and monitor patient during endoscopic procedures

-have suction ready and nearby

Transjugular intrahepatic portosystemic shunt (TIPS)

a stent is placed between the portal vein and the hepatic vein

-opens channels and decreases pressure

-used to control esophageal varices and ascities

Ascites

accumulation of serous fluid in the peritoneal cavity

-caused by portal hypertension and excess fluid absorption

Nursing considerations for ascities:

-maintain HOB at 30-45*

-monitor VS

-auscultate lung sounds

-administer diuretics furosemide(K wasting) and Spironolactone (K sparing) (monitor Na and K before and after admin)

-administer 25% albumin IV solution to increase pressure (pulls fluid into blood vessels)

-place patient on sodium and fluid restriction

Nursing considerations for Abdominal paracentesis:

removal of many liters of ascites fluid to temporally reduce intra abdominal pressure

-have patient empty bladder prior to procedure

-cover puncture site with dry sterile gauze

-monitor for hypovolemia (lots of fluid lost)

Hepatic encephalopathy (HE):

potentially reversible decline in brain function that occurs in persons with end stage liver disease

-toxins that are normally removed accumulate in the blood and brain

S/s of hepatic encephalopathy:

-changes in personality, memory, concentration

-asterixis (liver flap)

-slurred speech

-hyperreflexia

-lethargy that can go to coma

Diagnostic test for Hepatic encephalopathy:

connect the numbers test

-diagnosis cognitive impairment

serum ammonia levels (increased)

Nursing considerations for hepatic encephalopathy:

-ensure patient safety

-identify and remove cause (GI bleed, infection, constipation, high protein)

-HC can worsen after shunt placement

-administer lactulose or rifaximin

How does Lactulose work?

laxative that prevents absorption of ammonia in the colon

-goal is 2 to 3 stools per day

Hepatorenal syndrome

development of renal failure in a person with end stage liver disease

-rare but serious

Nursing considerations with nutrition and cirrhosis:

-should be on high calorie, low sodium diet

-Hepatic Aid 2 is a dietary supplement

-encourage frequent small snacks

-vitamin supplements

-may need supplemental enteral feedings

indications and purpose of minnesota tube

last resort-emergency measure when other treatments are unavailable for gastric/esophageal bleeding

compresses bleeding

why does HE become worse after TIPS procedure?

blood flow is diverted away from liver→ inability to breakdown ammonia= increased levels

how can encephalopathy develop?

GI bleed

Infection

constipation

high protein intake

use of psych meds

do patients experience abdominal pain with popped varices?

NO!! no pain is a classic sign that its a varice and not bleeding ulcer

west haven criteria for 4 stages of HE

measures consciousness, intellect and behavior, neuro findings

0=normal

1= mild, impaired

2= lethargic, disoriented, asterixis

3= arousable, bizarre behavior, hyperreflexia

4=coma

purpose of rifaximin in treating HE

reduces normal bowel flora, which diminishes protein breakdown