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Alteration in Nutrition, less than body requirements Hepatitis/Cirrhosis Liver: Largest internal organ 1 Hepatic Artery 1/3 blood supply Portal Vein 2/3 blood supply 2 Organs of the Gastrointestinal Tract Liver (hepatitis, cirrhosis) Gallbladder (biliary diseases) Pancreas (pancreatitis, diabetes) 3 Major Functions (pg 904/Table 39-4) Review Metabolic CHO, Protein, and Fat metabolism Albumin, clotting factors Detoxification – Ammonia (NH3) to Urea Bile/Bilirubin (Production/Excretion) Liver cells destroyed – scar tissue forms – alters blood flow in liver – BP in GI system elevates 4 Inflammatory (Hepatitis) Disorders of Liver Inflammation of the liver caused by virus, autoimmune, drugs Liver cell damage results in hepatic cell necrosis. Viral hepatitis (A, B, C, D, E, G) Toxic Hepatitis (most common – Acetaminophen, ETOH) Autoimmune (Wilson’s disease, PBC) Non-Alcoholic Fatty Liver Disease (NAFLD) 5 Table 44-1 Viral Hepatitis Type A (HAV) Fecal oral transmission Onset Acute-Flu like symptoms Hepatitis A vaccine Type B (HBV) Blood and body fluid transmission (not urine, feces, breast milk, tears, sweat) Onset slow-symptoms more severe Hepatitis B vaccine Type C (co-infection HIV) Percutaneous transmission (needle thru skin) Asymptomatic or mild symptoms 20% will progress to cirrhosis 20-30 years Liver damage 15-20 years after infection 6 Other causes of Hepatitis (hepatoxicity) Toxic & Drug induced Table 39-6: Toxic agents causing liver damage Wilson’s disease Neurological disease associated with disorder of copper storage DX by brownish/red rings around corneas Also neuro changes such as drooling, tremors, migraines 7 Other causes of Hepatitis Hemochromatosis Iron storage disorder Autoimmune hepatitis – primary biliary cirrhosis (PBC) NAFLD and NASH hepatic steatosis, elevated ALT Linked to obesity, certain drug (steroids) 8 Assessment History Exposure, foreign travel, Sexual practices, etc Medications/Toxic exposures misuse of acetaminophen, illicit drugs, chemical exposures Physical Assessment Findings (table 44-2) Depend on phase of infection 30% of patients with acute HBV and 80% of patients with acute HCV will be asymptomatic. 9 Phases of Infections fulminant hepatic failure Incubation/Prodromal Asymptomatic to vague SX (anorexia, N/V, malaise, fatigue, pruritis, arthralgia) May be dx as a flu/virus gastro Virus load can be detected Icteric Phase Classic presentation of jaundice, dark urine, clay-colored stools, rt upper quad pain Abnormal LFTs Convalescent phase Sx & jaundice resolve, LFTs return to normal 10 Diagnostics - Lab values Elevated liver enzymes Serum/Urinary bilirubin Coagulopathy – prolonged PT/PTT Serum proteins (albumin) decreased Hepatitis panel for high-risk exposures (consider HIV co-infection) Hep A – one dx test for active infection Hep B – many DX tests for active infection Genotyping Hep C important in TX 11 Treatment of Hepatitis Acute and Chronic Well-balanced diet Vitamin supplements Rest (degree of strictness varies) Avoidance of alcohol intake and drugs detoxified by the liver 12 Nursing Implementation Acute interventions Rest Jaundice/ pruritus Small, frequent meals Ambulatory and home care Dietary teaching (avoid ETOH) (low fat, high CHO) Assessment for complications Regular follow-up for 1 year after diagnosis Medication teaching 13 Collaborative Care: Drug therapy No specific drug therapies (acute hepatitis) Supportive therapy Antiemetics Watch for drugs metabolized by liver Vitamins Milk Thistle (Silymarin) 14 Drug therapies: Chronic HBV & HCV Anti-virals: Interferon ↓ viral load ↓ liver enzyme levels ↓ rate of disease progression Side effects Flu-like SX Anemia, anorexia Depression, insomnia 15 Prevention/Health Promotion Hepatitis A Hepatitis B and C Hand washing! Food Screen donated blood Washing Use disposable needles Proper personal hygiene Hand washing Immunization: HAV Safe sex vaccine (2 shots, Avoid sharing immunity in 30 days) toothbrushes/razors Immune Globulin Immunization: HBV 1-2 weeks post exposure Table 44-8: preventative measures for Hepatitis vaccine (3 doses, 1st @ birth/complete by 18m/o) 16 Table 44-6 Plan of Care (see Moodle) Imbalanced Nutrition: less than body requirements r/t anorexia, N/V, metabolic problems Goals: maintain weight, food/fluid intake to meet nutritional needs Activity Intolerance r/t fatigue, weakness Goals: gradual increase in activity, able to perform ADLs Risk for impaired Liver Function r/t viral infection Goal: maintain adequate liver FX throughout infectious process 17 Chronic HBV, HCV Long-term goals Prevention of cirrhosis and hepatocellular cancer Not all patients respond to current therapeutic regimens. 18 Evaluation: Expected outcomes Adequate nutritional intake Increased tolerance for activity Verbalization of understanding of follow-up care Able to explain to others methods of transmission and methods of preventing transmission 19 Major Functions (pg 870/Table 39-4) Review Metabolic CHO, Protein, and Fat metabolism Albumin, clotting factors Detoxification – Ammonia (NH3) to Urea Management of Bilirubin (Production/Excretion) Liver cells destroyed – scar tissue forms – alters blood flow in liver – BP in GI system elevates 20 Cirrhosis Pg 1018 Acute liver failure 21 Continuum of Liver dysfunction Early S/SX of liver DX Pain, Fever, Anorexia (N/V) Fatigue Physical exam may reveal hepatomegaly, lymphadenopathy, and splenomegaly. Complications: Progressive S/SX - Fulminant/acute hepatic failure Jaundice - Chronic hepatitis Ascites, anasarca - Cirrhosis Skin Lesions/bruising - carcinomas Patho Map – figure 44-5 pg 1018/Text 22 23 Liver Dysfunction Bleeding Inability to make clotting factors Development of collateral circulation r/t portal hypertension Increased serum Ammonia Inability to convert NH3, from metabolism of protein, to urea Third spacing – ascites Inability make plasma protein (albumin) Other: altered drug metabolism, electrolyte imbalances, etc 24 Nursing Assessment (table 44-14) Past health history Chronic alcoholism Viral hepatitis Chronic biliary disease Medications Physical examination Weight loss Jaundice Abdominal distention Nausea/vomiting Altered mentation/asterixis RUQ pain Abnormal laboratory values 25 Complications of liver failure Portal hypertension Esophageal and gastric varices Peripheral edema and ascites (table 44-9) Portal HTN, Hypoalbuminemia, hyperaldosteronism Hepatic encephalopathy (table 44-10) Protein metabolism dysfunction produces elevated ammonia levels (conversion of ammonia to urea) Hepatorenal syndrome Kidney failure related poor circulating blood volume 26 Esophageal Varices No special assessment findings – obvious GI bleed, low H & H, occult Sengstaken-Blakemore Tubeblood Goal: Avoid bleeding/hemorrhage Avoid alcohol, aspirin, irritating foods, straining. Supportive measures for acute bleeds Next slide Treatment Measures Endoscopic sclerotherapy, Endoscopic ligation Balloon tamponade (Blakemore tube) – old TX Shunting procedures (TIPS) (portacaval shunt) 27 Treatment for acute UGI bleed Support ABCs, fluid resuscitation Drug therapy may include Octreotide (Sandostatin) Vasopressin (VP, Terlipressin) Fresh frozen plasma, Packed RBCs Vitamin K Histamine blockers, Proton pump inhibitors Lactulose & Neomycin – prevents hepatic encephalopathy from increased RBC breakdown/ammonia 28 Treatment of Ascites High-carbohydrate, low-Na+ diet (2 g/day) Diuretics, albumin infusion Paracentesis Peritoneovenous shunt Continuous reinfusion of ascitic fluid from abdomen to vena cava Complications : Thrombosis, infection, fluid overload 29 Paracentesis Patient Positioning – sitting upright, HOB ↑ Empty bladder Complications: Persistent leak from the puncture site, bruising Hypotension after a large-volume paracentesis Perforation of bowel, infection, Major blood vessel laceration Post procedure Position on right side to splint puncture site 30 Hepatic encephalopathy S/SX: altered mentation, asterixis (liver flap), fetor hepaticus, NH3 (ammonia) Goal: Decrease ammonia formation May reduce protein in diet Sterilization of GI tract with antibiotics (e.g., neomycin) Lactulose (Cephulac) traps NH3 in gut. Cathartics/enemas Treatment of precipitating cause 31 32 Nursing Dx: Liver Failure See Nursing Care Plan (44-2) Imbalanced nutrition Impaired skin integrity (jaundice /pruritis) Ineffective breathing pattern Excess fluid volume Dysfunctional family processes: Alcoholism Overall goals Relief of discomfort Minimal to no complications Return to as normal a lifestyle as possible 33 Generalized Collaborative Care Rest, avoid further liver damage Avoidance of alcohol, aspirin, acetaminophen, and NSAIDs Monitor LFTs, electrolytes Management of ascites Accurate I/O, Daily weights, Abdominal girth, extremities measurement Nursing care r/t paracentesis Prevention and management of esophageal variceal bleeding Management of encephalopathy 34 Nutritional Treatment High in calories (3000 kcal/day) ↑ carbohydrate Moderate to low fat Protein restriction depends on degree of hepatic encephalopathy Low-sodium diet for patient with ascites and edema Between-meal nourishment, Explanation of dietary restrictions Administration of B-complex vitamins, vitamin K 35 Nursing Evaluation Maintenance of food/fluid intake to meet needs Maintenance of muscle tone and energy Maintenance of skin integrity Normalization of fluid balance Maintenance of blood pressure and urinary output Reports increased ease of breathing Experiences normal respiratory rate/rhythm 36