Managing Hepatic Disorders

1. Managing Hepatic Disorders

3. Diagnostic Tests Liver Function Tests (LFTs) serum aminotransferases Alanine aminotransferase (ALT) Aspartate aminotransferase (AST) Gamma-glutamyl transferase (GGT) Alkaline phosphatase Lactic dehydrogenase Serum protein concentrations Bilirubin Ammonia Clotting factors Lipids Other Liver biopsy Ultrasonography CT MRI Laparoscopy

4. Case Study After reviewing labs and determining that Mr. T�s coagulation profile is within normal limits you proceed with preparing him for percutaneous liver biopsy. What is included in a coagulation profile? What other baseline data should be recorded? What else needs to be present in order to proceed with this procedure? What complication must be anticipated?

5. Case Study Unfolds You have positioned Mr. T. supine with the right upper abdomen exposed. You placed a folded bath blanket under his back to elevate the area and instructed Mr. T. to raise his right arm above his shoulder with elbow flexed. The areas has been prepped and the doctor is ready to proceed. What instructions do you give Mr. T. to facilitate the procedure and prevent complications? What complications could occur?

6. Case Study Further Unfolds The doctor has completed the biopsy and has left Mr. T. in your care. What position must Mr. T. assume after the biopsy? Why? What are the nursing responsibilities in the immediate post-procedure period? What should Mr. T. know about activity prior to discharge?

7. Hepatic Dysfunction: Manifestations Jaundice Hemolytic Hepatocellular Obstructive Portal hypertension Ascities

8. Ascites Clinical manifestations ? abdominal girth Rapid weight gain Shortness of breath Striae Distended veins Umbilical hernias Electrolyte imbalances Assessment and Diagnostics Percussion Shifting dullness Fluid wave Flanks bulge when supine Daily weight and measurement of abdominal girth are essential

9. Management Medical Dietary modification Diuretics Bedrest Paracentesis Transjugular intrahepatic portosytemic shunt (TIPS) Nursing Measure and document I&O Abdominal girth Daily weight Monitor Serum ammonia Electrolytes

10. Case Study T.J. is a 53 year male who has been admitted because of increasing shortness of breath, abdominal distention and a weight gain of 20 pounds in the last 4 weeks. He does not have heart disease. He indicates that his urine output has been decreasing. His serum albumin level is critically low. He admits to drinking beer daily. What do you suspect is causing these symptoms? How will you position T.J.?

11. Case Study Unfolds The doctor percussed shifting dullness and elicited a fluid wave. After completing the assessment the doctor has asked you to prepare T.J. for an abdominal paracentesis. What will you do to prepare for this procedure? Why should the patient void before procedure? What must be maintained during procedure?

12. Case Study Further Unfolds The doctor cleanses T.J.�s lower abdomen and introduces the trocar through a puncture wound below and to the right of the umbilicus. The trocar is connected to drainage tubing which inserted into a collection bottle. What do you expect the fluid to look like? How much fluid will be collected? What patient responses would indicate complications?

13. Case Study Unfolds Further After the procedure you assist T.J. back to bed and ensure that he is comfortable. You have labeled the required specimens and sent to lab. You have disposed of the fluid bottles appropriately. Where should fluid collected be documented? What are post-procedure nursing responsibilities?

14. Esophageal Varices Clinical Manifestations Hematemesis Melena General deterioration in mental or physical status Often history of alcoholism Signs of shock Cool, clammy skin Hypotension Tachycardia Assessment and Diagnostics Endoscopy Portal hypertension measurements Direct vs Indirect Laboratory tests LFTs Splenoportography Hepatoportography Celiac angiography

15. Hepatic Encephalopathy Assessment and Diagnostics EEG Fetor hepaticus Alterations in LOC Coma Seizures Manifestations Early: minor mental and motor changes; ? DTR Sleeps during day, restlessness and insomnia at night Asterixis (liver flap) Progressive decline in ability to write Constructional apraxia Absent DTR, flaccidity

16. Hepatic Encephalopathy: Management Medical Lactulose (Cephulac) Must monitor for hypokalemia and dehydration IV glucose Vitamins; electrolytes Principles of management: column two, page 1306 Nursing Maintain safe environment Prevent injury, bleeding and infection Monitor for potential complications Communicates with family Provide education regarding rehabilitation and preventing recurrence if patient survives

17. Hepatitis-- Overview Widespread inflammation of hepatocytes Viral hepatitis most common Five major categories of viruses Enteral forms: Hepatitis A and E Fecal-oral transmission Parenteral forms: Hepatitis B, C, D Venous blood/sexual contact Acute or chronic

18. Hepatitis: Etiology Hepatitis viruses Drugs, chemicals, toxins Blood transfusion reactions Hyperthyroidism Ingestion of EOTH Other viruses: Epstein-Barr, CMV, Yellow Fever

19. Hepatitis: Clinical Manifestations Abdominal pain Arthralgia and myalgia Diarrhea/constipation Fever Irritability Lethargy Malaise Nausea/vomiting Rash

20. Hepatitis Diagnositics ALT AST Alkaline Phosphatase Bilirubin Presence of serum antigens Presence of serum antibodies Percutaneous liver biopsy

21. Hepatitis Interventions Nonsurgical Physical rest Psychological rest Diet therapy Drug therapy Comfort measures Surgical Liver Transplantation Prevention measures Immunization Handwashing/sanitation Standard precautions Avoid sharing personal items Avoid sharing eating utensils, drinks Condom use

22. Liver Damage from Hepatitis

23. Cirrhosis Overview Chronic, progressive Irreversible reaction to hepatic inflammation/necrosis Alteration in vascular system/lymphatic bile duct channels Types Alcoholic Postnecrotic Biliary Cardiac

24. Cirrhosis: Complications Portal hypertension Ascites Bleeding esophageal varicies Coagulation defects Jaundice Portal-systemic encephalopathy with hepatic coma Hepatorenal syndrome

25. Cirrhosis: Clinical Manifestation Early Signs Generalized weakness Weight loss GI symptoms Abdominal pain Liver tenderness Late signs GI bleeding Jaundice Ascities Spontaneous bruising

26. Cirrhosis: Interventions Nonsurgical Diet and drug therapy Paracentesis Comfort measures Fluid and electrolytes Gastric intubation Esophagogastric balloon tamponade

27. Cancer of the Liver Malignant or benign Primary liver tumors Hepatocellular carcinoma (HCC) Cholangiocellular carcinoma Combined HCC and Cholangiocellular carcinoma Metastatic liver tumors Present in 36-42% dying of advanced cancer

28. Cancer of the Liver Clinical Manifestations Pain Weight loss Loss of strength Anorexia Anemia Enlarged, irregular liver Jaundice Ascities Diagnosis will be based upon clinical signs and symptoms, history and physical examination, and lab and xray results. Diagnosis will be based upon clinical signs and symptoms, history and physical examination, and lab and xray results.

29. Diagnostics Bilirubin AST, GGT, LDH Leukocytosis Erythrocytosis Hypercalcemia Hypoglycemia Hypocholestrolemia ? AFP ?CEA Xray Scans CT Ultrasound MRI Arteriography Laparoscopy

30. Management Medical Radiation therapy Chemotherapy Percutaneous Biliary Drainage Other: laser hyperthermia, immunotherapy, transcatheter arterial embolization Surgical Lobectomy Cryosurgery Transplantation Nursing Monitor for and manage potential complications If cryosurgery- monitor closely for hypothermia, hemorrhage, bile leak, myoglobinuris May go home with biliary drainage May have hepatic artery port for chemotherapy