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

11. Types
Chronic
Fulminant
Toxic
Hepatobillary

12. Hepatitis Types (Viral)B C D E G
*see handout

13. Clinical Manifestations
Acute
Chronic
Anorexia
N/V
RUQ pain
Bowel irregularity
Malaise HA
Fever
Arthralgias
Uticaria
Weight loss
Jaundice
Hepatomegaly
Splenomegaly
Pruritus
Dark urine
Bilirubinuria
Light stools
Fatigue
Malaise
Easy fatigability
Hepatomegaly

14. Phases
Preicteric
Prodromal
Icteric
Jaundice
Posticteric
Convalescent

15. Hepatitis A Fecal/oral 15-50d S/S Labs Vaccine IgG Prevention
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

18. Hepatitis C Percutnaeous/mucosal Sexual contact Perinatal 14-180d S/S
80% asymptomatic
HBV
Labs
Prevention
Safe sex
No sharing of razors, toothbrushes, needles
Chronicity
Interferon
antivirals

20. Hepatitis D
HBV
2-26wk
Labs
Interferon
HBV vaccine
S/S

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 Fluid management Bed rest Drug therapy
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

25. 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

27. 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 Obstructive Hemolytic
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 Complications Needle Laparoscopic Transvenous
Catheter
Blood clotting problems
Excess fluid
Complications
Puncture of lung or gallbladder
Infection
Bleeding
Pain

35. 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

36. After Needle Liver Biopsy
Pressure
Right side
minimum of 2 hrs
flat 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 Pupils Orientation Sensory/motor
Hyperreflexia
Pupils
Orientation
Sensory/motor
Asterexis
Coordination
Dysmetria
Fluid/electrolytes
Acid/base imbalances
See table 44.17

39. Nursing care
Safe environment
Sustain life

40. Nursing Diagnoses Risk for infection (transmission)
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 Fluid management Drug therapy
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

42. 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
Neutropenia
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 Fluid removal
Spironolactone
Lasix
HCTZ
Fluid removal
Paracentesis
Peritoneovenous Shunt

46. Ascites
Caput medusae

47. Paracentesis Only used if respiratory distress
Pt will loose grams of protein
Pt in sitting position
Empty bladder first
Post--watch for hypotension,
bleeding, shock & infection

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

53. Sclerotherapy
sclerosant solution (ethanolamine oleate or sodium tetradecyl sulphate) Complications
fever, dysphagia and chest pain, ulceration, stricture, and (rarely) perforation.

54. Band ligation
Fewer treatment sessions and complications than sclerotherapy.

55. 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.

56. Minnesota Tube Sengstaken-Blakemore 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

60. Liver Transplant

61. Liver Transplant

62. Liver transplant complications
Rejection
70%
Medications
Infection
immunosuppression
Cancer

63. Patient Teaching Therapeutic communication Diet* Exercise
Lifestyle modifications
Drugs
Follow-up
Resources

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

67. Review Pathophysiology Cirrhosis Portal hyperetension Liver failure
Encephalopathy
Hepato-renal syndrome
Signs & Symptoms
Treatment
Nsg. Care
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