LIVER FAILURE
NUR2020: Physiological Integrity-II
Competency #6
Rib Cage & Liver
Student Learning Outcomes (SLO) for Competency #6
Program Outcome: Evaluate nursing management of patients with chronic kidney disease and cirrhosis of the liver.
Client Needs Category: Physiological Integrity: Alteration in Hepatic Integrity - Liver Failure
QSEN Competencies: Patient-Centered Care, Evidence-Based Practice and Safety
Student Learning Outcomes
After completion of this competency, given an actual or simulated patient situation or exam, the student will be able to:
Identify the possible causes and clinical manifestations of liver dysfunction.
Compare diagnostic tests, lab values, and nursing care for patients undergoing a liver biopsy, liver scan, or paracentesis.
List the functions of the liver and its effect on the body.
Apply principles of self-care, health promotion and maintenance, and psychological adaptation to care of the patient with chronic liver failure.
Examine nursing assessment, nursing outcomes, and nursing interventions needed in the care of a patient with chronic liver dysfunction.
Evaluate nursing interventions to correct malnutrition and weight gain or loss in chronic hepatic health disruptions.
Differentiate between medical and nursing management for a patient with hepatic encephalopathy.
Evaluate nursing outcomes and nursing management for a patient with bleeding esophageal varices.
State the classification, therapeutic and side effects, and patient teaching for the following medications: lactulose, neomycin, spironolactone (Aldactone), Vitamins A, B complex, C, D, and K.
Given a patient situation, utilize the nursing process to provide care for a person experiencing chronic liver failure.
Anatomy and Physiology of the Liver
Largest gland of the body
Location: Upper right abdomen
Characteristics: A very vascular organ that receives blood from the GI tract via the portal vein and from the hepatic artery.
Blood Supply to the Liver
One-third of the blood supply comes from the hepatic artery.
Two-thirds of the blood supply comes from the portal vein.
The portal vein carries blood from the stomach, intestines, spleen, and pancreas, bringing absorbed products of digestion into the liver.
Functions of the Liver
Detoxification:
Drugs/Alcohol
Fatty acids
Steroid hormones
Ammonia → Urea
Environmental toxins/allergens
Production of Cholesterol:
Precursor to sex hormones and Vitamin D.
Metabolism:
Conversion of T4 → T3
Detoxification of fat.
Storage of Micronutrients:
Minerals: Copper, Zinc, Magnesium, Iron
Vitamins: Vitamin A, D, E, K, B12
Blood Sugar Balance:
Storage of glycogen.
Immune System:
Contains viruses and pathogens.
Maintenance of hepatic and portal vein immune systems.
Protein Synthesis:
Production of Bile:
Needed for digestion
Antimicrobial properties.
Blood clotting (prothrombin)
Cholesterol transport (lipoproteins)
Immune Function (globulins)
Oncotic pressure (albumin)
Copper bioavailability (ceruloplasmin)
Liver Function Studies & Laboratory Values
Essential Lab Tests
Serum aminotransferases:
Indicators of injury to liver cells; useful in detecting hepatitis.
Alanine aminotransferase (ALT):
Levels increase primarily in liver disorders; used to monitor course of hepatitis and cirrhosis.
Aspartate aminotransferase (AST):
Not specific to liver disease, but levels can be increased in cirrhosis, hepatitis, and liver cancer.
Gamma-glutamyl transferase (GGT):
Associated with cholestasis and alcoholic liver disease.
Serum protein studies:
Total serum albumin levels decrease in patients with severe liver disease due to decreased synthesis.
Prothrombin time/international normalized ratio (PT/INR):
Prolonged due to decreased production from liver, increasing bleeding risk.
Other tests:
Serum alkaline phosphatase, serum ammonia, lipids, and bilirubin levels.
Cirrhosis of the Liver
Types of Cirrhosis
Compensated Cirrhosis:
Liver is scarred and cellular regulation is impaired, but essential functions persist without major symptoms.
Decompensated Cirrhosis:
Liver function is impaired with obvious signs and symptoms of liver failure.
Pathophysiology
Widespread fibrotic bands of connective tissue change the liver.
Inflammation causes degeneration and destruction of hepatocytes.
Tissue becomes nodular, blocking bile ducts and disrupting blood flow.
Compression from excessive fibrous tissue leads to impaired blood and lymph flow.
Consequences of advanced cirrhosis:
Liver may shrink; function decreases over weeks to years.
Symptoms often absent until serious complications arise.
Elevated serum liver enzymes indicate impaired function.
Assessment of Cirrhosis
Gather Patient History
Age, gender, employment history, substance use (alcohol, drugs), exposure to chemicals, travel history.
Physical Assessment/Signs and Symptoms
Common Symptoms:
Dry skin, rashes, purpuric lesions (petechiae and ecchymoses), jaundice (yellow skin and sclerae).
Palmar erythema (warm and bright red palms).
Spider angiomas (vascular lesions).
Ascites, often causing dyspnea because of increased abdominal distention.
Peripheral edema in extremities and sacrum.
Peripheral neuropathy (calcium/vitamin deficiencies) leading to numbness and tingling.
Vital Signs and Mental Status:
Mental status may progress to coma; assess for asterixis (hand-flapping tremor) and psychosocial changes (agitation).
Complications of Cirrhosis
Portal Hypertension
Increased pressure in the portal vein system due to obstructed flow.
Leads to ascites and esophageal varices.
Ascites
Collection of free fluid in the peritoneal cavity due to portal hypertension.
Increased abdominal pressure on blood vessels.
Gastroesophageal Varices
Distended esophageal veins that can lead to severe bleeding; a medical emergency.
Biliary Obstruction
Impairs bile production and absorption of fat-soluble vitamins; can lead to coagulopathy.
Hepatic Encephalopathy
Life-threatening condition caused by the accumulation of ammonia and other toxic metabolites.
Nursing Management of Cirrhosis
Nursing Interventions Related to Ascites
Monitor daily weight and abdominal girth.
Provide dietary modifications: Low sodium diet and fluid restrictions.
Pharmacological therapy with diuretics (e.g., spironolactone, furosemide).
Assess shifting dullness and document patient intake and output.
Nursing management involves assessing respiratory status.
Management of Esophageal Varices
Administer IV fluids, and electrolytes; manage airway and oxygen levels.
Utilize medications to reduce portal venous pressure (e.g., propranolol).
Emergency interventions (e.g., endoscopic variceal ligation, balloon tamponade) may be necessary.
Interventions for Hepatic Encephalopathy
Goal: reduce ammonia formation by dietary protein restriction.
Administer lactulose and neomycin to reduce ammonia levels.
Monitor for electroencephalogram (EEG) changes and provide supportive care.
Key Points for NCLEX Examination Client Needs Category
Collaborate interdisciplinary care focusing on comprehensive approaches for patients with liver disorders.
Teach patients about avoiding alcohol and illicit drugs to manage liver health.
Recognize mental and emotional changes in patients due to hepatic encephalopathy.
Understand patients might feel guilt regarding their condition due to their lifestyle choices.
Summary of Nursing Interventions for Patients with Cirrhosis
Promoting Rest:
Include planned exercise and periodic rest. Monitor nutritional status to enhance strength.
Improving Nutritional Status:
Advise on small frequent meals, high-calorie diet, and modifying protein intake based on encephalopathy risk.
Providing Skin Care:
Frequent position changes and gentle skin care to prevent skin breakdown due to scratching.
Preventing Injury:
Through monitored mobility and fall prevention measures.
Case Study: Ray Jones
Case Summary:
62-year-old male with a significant history of alcoholism, presenting with hematemesis and melena, along with associated laboratory findings.
Focus on managing fluid and electrolyte balance, potential for serious complications including hepatic encephalopathy, and emphasize patient education for lifestyle modifications.