Showing posts with label liver disorder. Show all posts
Showing posts with label liver disorder. Show all posts

DISORDERS OF THE LIVER

Thursday, May 22, 2008 | Labels: | 0 Comments  

Cancer of the Liver

  1. General information
    1. Primary cancer of the liver is extremely rare, but it is a common site for metastasis because of liver's large blood supply and portal drainage. Primary cancers of the colon, rectum, stomach, pancreas, esophagus, breast, lung, and melanomas frequently metastasize to the liver.
    2. Enlargement, hemorrhage, and necrosis are common occurrences; primary liver tumors often metastasize to the lung.
    3. Higher incidence in men.
    4. Prognosis poor; disease well advanced before clinical signs evident.
  2. Medical management
    1. Chemotherapy and radiotherapy (palliative) to decrease tumor size and pain
    2. Resection of liver segment or lobe if tumor is localized
  3. Assessment findings
    1. Weakness, anorexia, nausea and vomiting, weight loss, slight increase in temperature
    2. Right upper quadrant discomfort/ tenderness, hepatomegaly, blood-tinged ascites, friction rub over liver, peripheral edema, jaundice
    3. Diagnostic tests: same as cirrhosis of the liver (see Cirrhosis of the Liver) plus
      1. Blood sugar decreased
      2. Alpha fetoprotein increased
      3. Abdominal x-ray, liver scan, liver biopsy all positive
  4. Nursing interventions: same as for cirrhosis of the liver plus
    1. Provide emotional support for client/significant others regarding poor prognosis.
    2. Provide care of the client receiving radiation therapy or chemotherapy.
    3. Provide care of client with abdominal surgery plus
      1. Preoperative
        1. Perform bowel prep to decrease ammonium intoxication.
        2. Administer vitamin K to decrease risk of bleeding.
      2. Postoperative
        1. Administer 10% glucose for first 48 hours to avoid rapid blood sugar drop.
        2. Monitor for hyper/hypoglycemia.
        3. Assess for bleeding (hemorrhage is most threatening complication).
        4. Assess for signs of hepatic encephalopathy.

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Hepatic Encephalopathy

  1. General information
    1. Frequent terminal complication in liver disease
    2. Diseased liver is unable to convert ammonia to urea, so that large quantities remain in the systemic circulation and cross the blood/brain barrier, producing neurologic toxic symptoms.
    3. Caused by cirrhosis, GI hemorrhage, hyperbilirubinemia, transfusions (particularly with stored blood), thiazide diuretics, uremia, dehydration
  2. Assessment findings
    1. Early in course of disease: changes in mental functioning (irritability); insomnia, slowed affect; slow slurred speech; impaired judgment; slight tremor; Babinski's reflex, hyperactive reflexes
    2. Progressive disease: asterixis, disorientation, apraxia, tremors, fetor hepaticus, facial grimacing
    3. Late in disease: coma, absent reflexes
    4. Diagnostic tests
      1. Serum ammonia levels increased (particularly later)
      2. PT prolonged
      3. Hgb and hct decreased
  3. Nursing interventions
    1. Conduct ongoing neurologic assessment and report deteriorations.
    2. Restrict protein in diet; provide high carbohydrate intake and vitamin K supplements.
    3. Administer enemas, cathartics, intestinal antibiotics, and lactulose as ordered to reduce ammonia levels.
    4. Protect client from injury: keep side rails up; provide eye care with use of artificial tears/eye patch.
    5. Avoid administration of drugs detoxified in liver (phenothiazines, gold compounds, methyldopa, acetaminophen).
    6. Maintain client on bed rest to decrease metabolic demands on liver.

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Esophageal Varices

  1. General information
    1. Dilation of the veins of the esophagus, caused by portal hypertension from resistance to normal venous drainage of the liver into the portal vein
    2. Causes blood to be shunted to the esophagogastric veins, resulting in distension, hypertrophy, and increased fragility.
    3. Caused by portal hypertension, which may be secondary to cirrhosis of the liver (alcohol abuse), swallowing poorly masticated food, increased intra-abdominal pressure
  2. Medical management
    1. Iced normal saline lavage
    2. Transfusions with fresh whole blood
    3. Vitamin K therapy
    4. Sengstaken-Blakemore tube: a three-lumen tube used to control bleeding by applying pressure on the cardiac portion of the stomach and against bleeding esophageal varices. One lumen serves as NG suction, a second lumen is used to inflate the gastric balloon, the third to inflate the esophageal balloon.
    5. Intra-arterial or IV vasopressin
    6. Injection sclerotherapy
    7. Surgery for portal hypertension (decompresses esophageal varices and helps to maintain optimal portal perfusion)
      1. Ligation of esophageal and gastric veins to stop acute bleeding
      2. Portacaval shunt: end-to-side or side-to-side anastomosis of the portal vein to the inferior vena cava
      3. Splenorenal shunt: end-to-side or side-to-side anastomosis of the splenic vein to the left renal vein
      4. Mesocaval shunt: end-to-side or use of a graft to anastomose the inferior vena cava to the side of the superior mesenteric vein
  3. Assessment findings
    1. Anorexia, nausea and vomiting, hematemesis, fatigue, weakness
    2. Splenomegaly, increased splenic dullness, ascites, caput medusae, peripheral edema, bruits
    3. Diagnostic tests
      1. PT prolonged
      2. Hematest of vomitus positive
      3. Serum albumin, RBC, Hgb, and hct decreased
      4. LDH, SGOT (AST), SGPT (ALT), BUN, increased
  4. Nursing interventions
    1. Monitor/provide care for client with Sengstaken-Blakemore tube.
      1. Facilitate placement of the tube: check and lubricate tip and elevate head of bed.
      2. Prevent dislodgment of the tube by placing client in semi-Fowler's position; maintain traction by securing the tube to a piece of sponge or foam rubber placed on the nose.
      3. Keep scissors at bedside at all times.
      4. Monitor respiratory status; assess for signs of distress and if respiratory distress occurs cut the tubing to deflate the balloons and remove tubing immediately.
      5. Label each lumen to avoid confusion; maintain prescribed amount of pressure on esophageal balloon and deflate balloon as ordered to avoid necrosis.
      6. Observe nares for skin breakdown and provide mouth and nasal care every 1-2 hours (encourage client to expectorate secretions, suction gently if unable).
    2. Promote comfort: place client in semi-Fowler's position (if not in shock); provide mouth care.
    3. Monitor for further bleeding and for signs and symptoms of shock; hematest all secretions.
    4. Administer vasopressin as ordered and monitor effects.
    5. Provide routine pre- and post-op care if the client has portasystemic or portacaval shunt.
    6. Provide client teaching and discharge planning concerning
      1. Minimizing esophageal irritation (avoidance of salicylates, alcohol; use of antacids as needed; importance of chewing food thoroughly)
      2. Avoidance of increased abdominal, thoracic, and portal pressure
      3. Recognition and reporting of signs of hemorrhage

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Ascites

  1. General information
    1. Accumulation of free fluid in the abdominal cavity
    2. Most frequently caused by cirrhotic liver damage, which produces hypoalbuminemia, increased portal venous pressure, and hyperaldosteronism
    3. May also be caused by CHF
  2. Medical management
    1. Supportive: modify diet, bed rest, salt-poor albumin
    2. Diuretic therapy (see Antihypertensive Drugs, Table 2.17, in Unit 2)
    3. Surgery
      1. Paracentesis: insertion of a needle into the peritoneal cavity through the abdomen to remove abnormally large amounts of peritoneal fluid.
        1. peritoneal fluid assessed for cell count, specific gravity, protein, and microorganisms.
        2. used in clients with acute respiratory or abdominal distress secondary to ascites.
      2. LeVeen shunt (peritoneal-venous shunt): used in chronic, unmanageable ascites
        1. permits continuous reinfusion of ascitic fluid back into the venous system through a silicone catheter with a one-way pressure-sensitive valve.
        2. one end of the catheter is implanted into the peritoneal cavity and is channeled through the subcutaneous tissue to the superior vena cava, where the other end of the catheter is implanted; the valve opens when pressure in the peritoneal cavity is 3-5 cm of water higher than in superior vena cava, thereby allowing ascitic fluid to flow into the venous system.
  3. Assessment findings
    1. Anorexia, nausea and vomiting, fatigue, weakness, changes in mental functioning
    2. Positive fluid wave and shifting dullness on percussion, flat or protruding umbilicus, abdominal distension/tautness with striae and prominent veins, abdominal pain
    3. Peripheral edema, shortness of breath
    4. Diagnostic tests
      1. Potassium and serum albumin decreased
      2. PT prolonged
      3. LDH, SGOT (AST), SGPT (ALT), BUN, sodium increased
  4. Nursing interventions
    1. Monitor nutritional status/provide adequate nutrition with modified diet.
      1. Restrict sodium to 200-500 mg/day.
      2. Restrict fluids to 1000-1500 ml/day.
      3. Promote high-calorie foods/snacks.
    2. Monitor/prevent increasing edema.
      1. Administer diuretics as ordered and monitor for effects.
      2. Measure I&O.
      3. Monitor peripheral pulses.
      4. Measure abdominal girth.
      5. Inspect/palpate extremities, sacrum.
      6. Administer salt-poor albumin to replace vascular volume.
    3. Monitor/promote skin integrity.
      1. Reposition frequently.
      2. Apply lotions to stretched areas.
      3. Assess for redness, breakdown.
    4. Promote comfort: place client in mid- to high-Fowler's and reposition frequently.
    5. Provide nursing care for the client undergoing paracentesis.
      1. Confirm that client has signed a consent form.
      2. Instruct client to empty bladder before the procedure to prevent inadvertent puncture of the bladder during insertion of trocar.
      3. Inform client that a local anesthetic will be provided to decrease pain.
      4. Place in sitting position to facilitate the flow of fluid by gravity.
      5. Measure abdominal girth and weight before and after the procedure.
      6. Record color, amount, and consistency of fluid withdrawn and client tolerance during procedure.
      7. Assess insertion site for leakage.
    6. Provide routine pre- and post-op care for the client with LeVeen shunt.

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Cirrhosis of the Liver

  1. General information
    1. Chronic, progressive disease characterized by inflammation, fibrosis, and degeneration of the liver parenchymal cells
    2. Destroyed liver cells are replaced by scar tissue, resulting in architectural changes and malfunction of the liver
    3. Types
      1. Laennec's cirrhosis: associated with alcohol abuse and malnutrition; characterized by an accumulation of fat in the liver cells, progressing to widespread scar formation.
      2. Postnecrotic cirrhosis: results in severe inflammation with massive necrosis as a complication of viral hepatitis.
      3. Cardiac cirrhosis: occurs as a consequence of right-sided heart failure; manifested by hepatomegaly with some fibrosis.
      4. Biliary cirrhosis: associated with biliary obstruction, usually in the common bile duct; results in chronic impairment of bile excretion.
    4. Occurs twice as often in men as in women; ages 40-60
  2. Assessment findings
    1. Fatigue, anorexia, nausea and vomiting, indigestion, weight loss, flatulence, irregular bowel habits
    2. Hepatomegaly (early): pain located in the right upper quadrant; atrophy of liver (later); hard, nodular liver upon palpation; increased abdominal girth
    3. Changes in mood, alertness, and mental ability; sensory deficits; gynecomastia, decreased axillary and pubic hair in males; amenorrhea in young females
    4. Jaundice of the skin, sclera, and mucous membranes; pruritus
    5. Easy bruising, spider angiomas, palmar erythema
    6. Muscle atrophy
    7. Diagnostic tests
      1. SGOT (AST), SGPT (ALT), LDH alkaline phosphatase increased
      2. Serum bilirubin increased
      3. PT prolonged
      4. Serum albumin decreased
      5. Hgb and hct decreased
  3. Nursing interventions
    1. Provide sufficient rest and comfort.
      1. Provide bed rest with bathroom privileges.
      2. Encourage gradual, progressive, increasing activity with planned rest periods.
      3. Institute measures to relieve pruritus.
        1. do not use soaps and detergents
        2. bathe in tepid water followed by application of an emollient lotion.
        3. provide cool, light, nonrestrictive clothing.
        4. keep nails short to avoid skin excoriation from scratching.
        5. apply cool, moist compresses to pruritic areas.
    2. Promote nutritional intake.
      1. Encourage small frequent feedings.
      2. Promote a high-calorie, low- to moderate-protein, high-carbohydrate, low-fat diet, with supplemental vitamin therapy (vitamins A, B-complex, C, D, K, and folic acid)
    3. Prevent infection.
      1. Prevent skin breakdown by frequent turning and skin care.
      2. Provide reverse isolation for clients with severe leukopenia; pay special attention to hand-washing technique.
      3. Monitor WBC.
    4. Monitor/prevent bleeding.
    5. Administer diuretics as ordered.
    6. Provide client teaching and discharge planning concerning
      1. Avoidance of agents that may be hepatotoxic (sedatives, opiates, or OTC drugs detoxified by the liver)
      2. How to assess for weight gain and increased abdominal girth
      3. Avoidance of persons with upper respiratory infections
      4. Recognition and reporting of signs of recurring illness (liver tenderness, increased jaundice, increased fatigue, anorexia)
      5. Avoidance of all alcohol
      6. Avoidance of straining at stool, vigorous blowing of nose and coughing, to decrease the incidence of bleeding

Tuesday, May 20, 2008 | Labels: | 0 Comments  

Hepatitis


  1. General information
    1. Widespread inflammation of the liver tissue with liver cell damage due to hepatic cell degeneration and necrosis; proliferation and enlargement of the Kupffer cells; inflammation of the periportal areas (may cause interruption of bile flow)
    2. Hepatitis A
      1. Incubation period: 15-45 days
      2. Transmitted by fecal/oral route: often occurs in crowded living conditions; with poor personal hygiene; or from contaminated food, milk, water, or shellfish
    3. Hepatitis B
      1. Incubation period: 50-180 days
      2. Transmitted by blood and body fluids (saliva, semen, vaginal secretions): often from contaminated needles among IV drug abusers; intimate/sexual contact
    4. Hepatitis C
      1. Incubation period: 7-50 days
      2. Transmitted by parenteral route: through blood and blood products, needles, syringes
  2. Assessment findings
    1. Preicteric stage
      1. Anorexia, nausea and vomiting, fatigue, constipation or diarrhea, weight loss
      2. Right upper quadrant discomfort, hepatomegaly, splenomegaly, lymphadenopathy
    2. Icteric stage
      1. Fatigue, weight loss, light-colored stools, dark urine
      2. Continued hepatomegaly with tenderness, lymphadenopathy, splenomegaly
      3. Jaundice, pruritus
    3. Posticteric stage
      1. Fatigue, but an increased sense of well-being
      2. Hepatomegaly gradually decreasing
    4. Diagnostic tests
      1. All three types of hepatitis
        1. SGPT (ALT), SGOT (AST), alkaline phosphatase, bilirubin, ESR: all increased (preicteric)
        2. leukocytes, lymphocytes, neutrophils: all decreased (pericteric)
        3. prolonged PT
      2. Hepatitis A
        1. hepatitis A virus (HAV) in stool before onset of disease
        2. anti-HAV (IgG) appears soon after onset of jaundice; peaks in 1-2 months and persists indefinitely
        3. anti-HAV (IgM): positive in acute infection; lasts 4-6 weeks
      3. Hepatitis B
        1. HBsAg (surface antigen): positive, develops 4-12 weeks after infection
        2. anti-HBsAG: negative in 80% of cases
        3. anti-HBc: associated with infectivity, develops 2-16 weeks after infection
        4. HBeAg: associated with infectivity and disappears before jaundice
        5. anti-HBe: present in carriers, represents low infectivity
      4. Hepatitis C: no specific serologic tests
  3. Nursing interventions
    1. Promote adequate nutrition.
      1. Administer antiemetics as ordered, 30 minutes before meals to decrease occurrence of nausea and vomiting.
      2. Provide small, frequent meals of a high-carbohydrate, moderate- to high-protein, high-vitamin, high-calorie diet.
      3. Avoid very hot or very cold foods.
    2. Ensure rest/relaxation: plan schedule for rest and activity periods, organize nursing care to minimize interruption.
    3. Monitor/relieve pruritus (see Cirrhosis of the Liver).
    4. Administer corticosteroids as ordered.
    5. Institute isolation procedures as required; pay special attention to good hand-washing technique and adequate sanitation.
    6. In hepatitis A administer immune serum globulin (ISG) early to exposed individuals as ordered.
    7. In hepatitis B
      1. Screen blood donors for HBsAg.
      2. Use disposable needles and syringes.
      3. Instruct client/others to avoid sexual intercourse while disease is active.
      4. Administer ISG to exposed individuals as ordered.
      5. Administer hepatitis B immunoglobulin (HBIG) as ordered to provide temporary and passive immunity to exposed individuals.
      6. To produce active immunity, administer hepatitis B vaccine to those individuals at high risk.
    8. In non-A, non-B: use disposable needles and syringes; ensure adequate sanitation.
    9. Provide client teaching and discharge planning concerning
      1. Importance of avoiding alcohol
      2. Avoidance of persons with known infections
      3. Balance of activity and rest periods
      4. Importance of not donating blood
      5. Dietary modifications
      6. Recognition and reporting of signs of inadequate convalescence: anorexia, jaundice, increasing liver tenderness/discomfort
      7. Techniques/importance of good personal hygiene

Tuesday, May 20, 2008 | Labels: | 0 Comments  

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