1 Hepatic Disorders: Hepatitis/Cirrhosis Lisa Randall, RN, MSN, ACNS-BC RNSG 2432 2 Objectives • Compare and contrast risk factors associated with hepatitis and cirrhosis • Analyze the etiology and pathophysiology of hepatitis and cirrhosis • Integrate diagnostic tests with etiology, pathophysiology, and signs/symptoms of both disorders • Formulate relevant prioritized nursing diagnoses that address physical, pyschosocial, and learning needs and evaluate nursing interventions 3 Anatomy & Physiology 4 • • • • • • • • A Liver B Hepatic vein C Hepatic artery D Portal vein E Common bile duct F Stomach G Cystic duct H Gallbladder 5 Pathophysiology • Largest organ • Metabolic functions • Bile synthesis ▫ Hepatocytes  Bile secretion • Storage • Mononuclear phagocyte system ▫ Kupffer cells  Phagocytic activity 6 Metabolic functions • • • • Metabolism of glucose Protein Fatty acids Cholesterol 7 Other Functions • • • • • • • • • • Immunologic Blood storage Plasma protein synthesis Clotting Storage of vitamins and minerals Waste products of hemoglobin Bile formation and secretion Steroids and hormones Ammonia Drugs, ETOH, toxin metabolism 8 HEPATITIS 9 Pathophysiology • • • • • Inflammation Hepatic cell necrosis Proliferation/enlargement Kupffer cells Cholestasis Regeneration 10 11 Types • • • • Chronic Fulminant Toxic Hepatobillary 12 Hepatitis Types (Viral) • • • • • • A B C D E G *see handout 13 Clinical Manifestations Acute • • • • • • • • • • • • • • • • • • Anorexia N/V RUQ pain Bowel irregularity Malaise HA Fever Arthralgias Uticaria Weight loss Jaundice Hepatomegaly Splenomegaly Pruritus Dark urine Bilirubinuria Light stools Fatigue Chronic • Malaise • Easy fatigability • Hepatomegaly 14 Phases • Preicteric ▫ Prodromal • Icteric ▫ Jaundice • Posticteric ▫ Convalescent 15 Hepatitis A • Fecal/oral • 15-50d • S/S • • • • ▫ ▫ ▫ ▫ ▫ Light stools Dark urine Fatigue Fever Jaundice Labs Vaccine IgG Prevention 16 Hepatitis B • • • • • Percutaneous/permucosal Sexual contact Perinatal 45-180d S/S ▫ ▫ ▫ ▫ ▫ ▫ ▫ 30% asymptomatic Flu Light stools Dark urine Fatigue Fever Jaundice • Labs • Prevention ▫ ▫ ▫ ▫ Vaccine IgG Safe sex No sharing of razors, toothbrushes, needles • Chronicity ▫ Antivirals 17 18 Hepatitis C • • • • • Percutnaeous/mucosal Sexual contact Perinatal 14-180d S/S ▫ 80% asymptomatic ▫ HBV • http://youtu.be/y6osMO5xnag • Labs • Prevention ▫ Safe sex ▫ No sharing of razors, toothbrushes, needles • Chronicity ▫ Interferon ▫ antivirals 19 20 Hepatitis D • • • • • • HBV 2-26wk Labs Interferon HBV vaccine S/S ▫ HBV 21 Hepatitis E • • • • • • Fecal/oral Contaminated water Poor sanitation 15-64d Labs S/S ▫ HBV • No vaccine 22 Diagnostics • • • • • LFT ALP Serum bilirubin Liver biopsy Antigen specific 23 Treatment • Diet ▫ High cal/protein, low fat ▫ Vitamins (B, K) ▫ ETOH/Drugs • Fluid management • Bed rest • Drug therapy ▫ ▫ ▫ ▫ ▫ Prevention of HAV and HBV Interferon Lamivudine Ribavirin Acetaminophen 24 Nursing Diagnoses • • • • Risk for infection (transmission) Imbalanced nutrition Disturbed body image Knowledge deficit Cirrhosis 26 Pathophysiology • Caused by destruction of liver cells, fibrosis and nodule formation restricting blood and bile flow • Normal hepatic blood pressure is near zero. Restriction of blood flow in liver dysfunction causes hypertension, and blood will attempt to find other pathways, bypass liver • Results in significant impairment of liver function • 80% destroyed before signs and symptoms • Liver can regenerate itself if good nutrition, rest, and no alcohol Types of Cirrhosis Classified by risk factors • Post necrotic ▫ Hepatitis • Alcoholic Cirrhosis ▫ Laennec’s ▫ metabolic changes in liver, particularly fat • Biliary ▫ obstructive • Cardiac ▫ right side heart failure • Drug induced ▫ INH, rifampin, Tylenol 28 Signs & Symptoms • • • • • • Liver enlarged Dull pain RUQ Weakness Anorexia Skin Sclera • • • • • • • Portal hypertension Splenomegaly Ascites Esophageal varices Hepatic encephalopathy Hepatorenal Syndrome Liver failure 29 Signs & Symptoms 31 Jaundice • Excess bilirubin • Heptocellular ▫ Cirrhosis • Obstructive • Hemolytic ▫ Excessive destruction of RBCs  Transfusion reaction  Autoimmune  Faulty hemoglobin  Sickle cell 32 Diagnostics • • • • • • • • LFT CBC Coags Bilirubin Albumin Ammonia Esophagascopy Liver biopsy *See Table 44.15 33 Liver Biopsy • 3 types ▫ Needle ▫ Laparoscopic ▫ Transvenous  Catheter  Blood clotting problems  Excess fluid • Complications ▫ ▫ ▫ ▫ Puncture of lung or gallbladder Infection Bleeding Pain Liver Biopsy • • • • • • • • • Adequacy of clotting- PT/ INR, Platelets (Vit. K?) Type and cross match for blood Stop aspirin, ibuprofen, and anticoagulants 1 wk. before Chest x-ray Consent form & NPO 4 to 8 hr. Vital signs & Empty bladder Supine position, R arm above head Hold breath after expiration when needle inserted Be very still during procedure – 20 minutes After Needle Liver Biopsy • Pressure • Right side • • • • ▫ minimum of 2 hrs ▫ flat 12-14 hrs Vital signs & check for bleeding NPO X 2 hr after Assess for peritonitis, shock, & pneumothorax Rt. shoulder pain common ▫ caused by irritation of the diaphragm muscle ▫ usually radiates to the shoulder a few hours or days. • Soreness at the incision site • Tylenol ▫ avoid aspirin or ibuprofen for the first week because they decrease blood clotting, which is crucial for healing. • Avoid coughing, straining, lifting x 1-2 weeks 37 Nursing Assessment • LOC • Reflexes ▫ Hyperreflexia • Pupils • Orientation • Sensory/motor ▫ Asterexis ▫ http://www.youtube.com/watch?v=pAOWjYo-sX4 • Coordination ▫ Dysmetria • Fluid/electrolytes ▫ Acid/base imbalances See table 44.17 38 39 Nursing care • Safe environment • Sustain life 40 Nursing Diagnoses Hepatitis Cirrhosis • Risk for infection (transmission) • Imbalanced nutrition • Disturbed body image • Knowledge deficit • • • • • • Excess fluid volume Disturbed thought process Ineffective protection Impaired skin integrity Imbalanced nutrition Knowledge deficit 41 Treatment • Diet ▫ ▫ ▫ ▫ Sodium restriction High carbs Mod fat 75-100gm protein  60-80gm/d (hep encephalopathy) • Fluid management • Drug therapy ▫ Diuretics ▫ Laxatives ▫ Anti-infective agents • Surgical/medical interventions Major Complications of Cirrhosis Portal hypertension Variceal bleeding Ascites Spontaneous bacterial peritonitis Splenomegaly Hepatorenal syndrome Hepatic encephalopathy 43 Portal Hypertension • Arteriovenous shunting • Marked ascites • Caput medusae ▫ Dilated abdominal veins • Esophageal varices • Hemorrhoids • Hyperslenism ▫ Mod anemia ▫ Neuropenia ▫ Thrombocytopenia 44 Surgical/Medical Interventions • • • • • • Paracentesis Gastric lavage Balloon tamponade Schlerotherapy Banding TIPS (transjugular intrahepatic portosystemic shunt) • Liver transplant 45 Ascites • Sodium restriction • Bedrest initially • Diuretics ▫ Spironolactone ▫ Lasix ▫ HCTZ • Fluid removal ▫ Paracentesis ▫ Peritoneovenous Shunt Ascites Caput medusae 47 Paracentesis • • • • • Only used if respiratory distress Pt will loose 10-30 grams of protein Pt in sitting position Empty bladder first Post--watch for hypotension, bleeding, shock & infection 48 49 50 Esophageal varices • Collateral vessels • Complex of swollen, enlarged veins ▫ Portal hypertension • 2/3-3/4 • Bleeding ▫ LIFE-THREATENING 51 Esophageal varices treatment Active bleeding • Central line & pulmonary artery pressures • Blood transfusions & fresh frozen plasma for clotting factors • Somatostatin or Vasopressin – constrict gut vessels • Airway/trach Later prevention of re-bleeding • Beta-blockers • Long-acting nitrates • Soft food, chew well, avoid intra-abdominal pressure • Protonix Sclerotherapy sclerosant solution (ethanolamine oleate or sodium tetradecyl sulphate) Complications fever, dysphagia and chest pain, ulceration, stricture, and (rarely) perforation. Band ligation Fewer treatment sessions and complications than sclerotherapy. Balloon tube tamponade Tube is inserted through the mouth Correct placement within the stomach is checked by auscultation while injecting air through the gastric lumen Gastric balloon is then inflated with 200 ml of air Gastric balloon is pulled up against the esophagogastric junction, compressing the submucosal varices Tension is maintained by strapping a split tennis ball to the tube at the patient's mouth Complications gastric and esophageal ulceration aspiration pneumonia esophageal perforation. Minnesota Tube SengstakenBlakemore tube – has only 3 lumens **Respiratory assessment** 57 Hepatic encephalopathy • Neuropsychiatric manifestation • Decreased liver detoxification>>> ▫ Increased ammonia • Terminal complication • Changes in LOC • Asterixis 58 Treatment HE • Reduce ammonia ▫ ▫ ▫ ▫ ▫ Lactulose Neomycin sulfate Cathartics Enemas Liver transplantation 59 Hepatorenal syndrome • Portal HTN + liver decompensation ▫ Systemic vasodilation ▫ Decreased arterial BF ▫ Renal vasoconstriction • Functional renal failure ▫ Azotemia ▫ Oliguria • Liver transplantation Liver Transplant 61 Liver Transplant Liver transplant complications • Rejection ▫ 70% ▫ Medications • Infection ▫ immunosuppression • Cancer 63 Patient Teaching • • • • • • • Therapeutic communication Diet* Exercise Lifestyle modifications Drugs Follow-up Resources 64 65 Legal/Ethical Considerations • Advance directives • Palliative care • Organ donation 66 Donors • Live donor • Liver regenerates ▫ 5 years • Survival rates increase / shorter wait time • Medical and psychological evaluations • Potential donors evaluated for: ▫ ▫ ▫ ▫ liver disease, alcohol or drug abuse, cancer, or infection. hepatitis, AIDS, and other infections. matched according to blood type and body size. Age, race, and sex are not considered. • Cadaver donor have to wait for brain dead donor Review 1. Pathophysiology 1. Cirrhosis 2. Portal hyperetension 3. Liver failure 1. Encephalopathy 2. Hepato-renal syndrome 2. Signs & Symptoms 3. Treatment 4. Nsg. Care 5. Complications 68 Question • A client presenting with ascites s/t liver failure is being evaluated for fluid balance. Which of the following provides the best indicator of fluid status? ▫ ▫ ▫ ▫ a. I&O b. LFT c. caloric intake and serum protein levels d. daily weight 69 Question • When providing DC teaching to the patient with cirrhosis, his wife asks the RN to explain why there is so much emphasis on bleeding precautions. Which of the following provides the most appropriate response? ▫ a. “The liver affected by cirrhosis is unable to produce clotting factors.” ▫ b. “The low protein diet will result in reduced clotting factors.” ▫ c. “The increased production of bile decreases clotting factors.” ▫ d. “The required medications reduce clotting factors.” 70 Question • When explaining the rationale for the use of lactulose syrup ot the patient with chronic cirrhosis, the nurse would choose which of the following statements? ▫ a. “lactulose reduces constipation, which is a frequent complaint with cirrhosis.” ▫ b. lactulose suppresses the metabolism of ammonia and aids in its elimination through feces.” ▫ c. lactulose helps to reverse cirrhosis of the liver.” ▫ d. lactulose can be taken intermittingly to reduce side effects.” 71 Question • The patient has just had a liver biopsy. Which of the following nursing actions would be the priority after the biopsy? ▫ A. monitor pulse and BP every 30 minutes until stable and then hourly for up to 24 hours. ▫ B. ambulate every 4 hours for the first day, as long as the patient can tolerate it. ▫ C. measure urine specific gravity every 8 hours for the next 48 hours. ▫ D. maintain NPO status for 24 hours post-biopsy. 72 Question • A male client is being treated for ruptured esophageal varices with a Sengstaken-Blakemore tube. His VS have been stable, and the suction port is draining scant amounts of drainage. He suddenly becomes acutely dyspneic, and oximetry reveals an O2 sat of 74%. The nurse’s immediate action is to ▫ ▫ ▫ ▫ A. release the esophageal balloon B. release the gastric balloon C. increase the suction D. irrigate the gastric balloon 73 Question • A newly admitted client with cirrhosis of the liver has a distended abdomen and the umbilicus is protruding. The nurse knows the pathological basis for this is ▫ A. increased fluid intake resulting from excessive use of alcohol causing overhydration ▫ B. increased size of the liver resulting in abdominal distention ▫ C. hypoalbuminemia causing fluid to leave the vascular system and enter the peritoneal cavity ▫ D. shunting of the blood to the collateral circulation in the esophagus resulting in decreased blood volume and accumulation of fluid 74 Case Study