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1) Glucose metabolism 2) Produces most of the body's clotting factors in the blood 3) Ammonia conversion to urea 4) Fat metabolism 5) Vitamin and iron storage and absorption 6) Drug and hormone metabolism 7) Kupfer cells phagocytize the blood and filter it 8) Protein metabolism 9). Bile formation

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Main functions of the liver

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Because most of the body's clotting factors are made by the liver

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Why does damage to the liver pose a bleeding risk?

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Elevated ammonia levels

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What is the most significant indication of liver damage?

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When the liver is not working properly lipids can accumulate in the hepatocytes causing the fatty liver.

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How can decrease in liver function cause fatty liver?

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Fat-soluble vitamins (ADEK)

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What type of vitamins are stored in liver?

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1) Carbohydrate ***2) Protein (b/c of ammonia) 3) Fat and steroids

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Considering all of the metabolic functions of the liver which one would have the most immediate effect on mental functioning?

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1). Glucose metabolism (Regulation of the blood glucose concentration) 2) Fat metabolism (Broken down to make energy and ketones and cholesterol) 3) Drug and hormone metabolism (Biotransformation into water-soluble forms, Detoxifies or inactivates) 4) Protein metabolism (Makes plasma proteins, albumin, clotting factors and prothrombin)

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Name the four metabolic functions of the liver

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Compression and destruction of the portal and hepatic veins and sinusoids lead to obstruction in blood flow through the portal system which leads to portal hypertension.

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Explain the portal venous system and portal hypertension.

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Elevated AST, ALT, LDH Elevated alkaline phosphates Elevated PT and INR Elevated cholesterol Decreased glucose (Hypoglycemia) Decreased platelet count RBC, and WBCs (Pancytopenia) Decreased albumin

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Lab test abnormalities related to liver dysfunction

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Elevated AST, ALT, LDH

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What lab test abnormalities are usually found with liver damage related to alcohol abuse?

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Elevated alkaline phosphates

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What lab test abnormalities are usually found with liver damage related to biliary obstruction?

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Intermittent mild fever Skin changes, purpura Spontaneous epistaxis (Nosebleed) Ankle edema G.I. upset Steatorrhea Bad breath Enlarged liver and spleen Portal hypertension Rectal varices that look like hemorrhoids Ascites Jaundice Weakness, Muscle wasting Weight-loss Clubbing and white fingernails Hypotension Sparse body hair Gonadal atrophy peripheral neuropathy

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Clinical manifestations of liver disease and failure

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Chronic condition, dense, fibrous, degenerative changes and loss of function of liver Cells are damaged and scar tissue forms Liver cells attempt to regenerate, Regeneration process is disorganized, Abnormal blood vessel in bile duct formation, the new fibrous connective tissue distorts liver's normal structure and impeding blood flow, Poor cellular nutrition and hypoxia results

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Pathophysiology of Cirrhosis

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Right-sided "fullness" and pressure

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What is a common complaint and manifestation of cirrhosis?

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1) Alcoholic (Most common type, accumulation of fat in the liver cells) 2) Post necrotic (Complication of chronic hepatitis, Broad scar tissue forms within the liver) 3) Biliary obstruction (Cystic fibrosis can cause this, Scarring around bile duct) 4) Cardiac ( Due to long-standing severe right heart failure)

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Four major types of cirrhosis

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Biliary cirrhosis

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Jaundice is the main feature of what type of cirrhosis?

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1). Hemolytic (increased desctruction of red blood cells by the spleen) 2) Hepatocellular (Inability of damaged liver cells to clear normal amount of bilirubin from blood) 3) Obstructive Jaundice (Blockage of the bile duct by gallstones, inflammation, tumor or enlarged organ, or bile stasis) 4) Hereditary hyperbilirubinemia

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Causes of jaundice

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These are due to inability of metabolizing steroid hormones with increasing circulating estrogen. -Spider angiomas -Palmer erythema (Redness that blanches with pressure)

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Manifestations of cirrhosis on the skin.

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Due to the enlargement of the spleen from backup of blood from portal vein into the spleen leading to overactivity and removal of blood cells from circulation. -Thrombocytopenia (decreased platelets): 90% of the circulating platelet mass can be temporarily removed by spleen -Leukopenia (decreased WBCs) - Anemia -Coagulation problems due to the liver's inability to produce prothrombin and clotting factors

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Manifestations of cirrhosis in the blood

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-Prevention of infection by avoiding crowds AND vaccinations for flu, pneumonia and hepatitis -Nutritional therapy: high calorie a d carbohydrate, steady protein, low-sodium diet with ascites and edema, supplement vitamins -Immediate and total abstinence from alcohol

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Collaborative care and lifestyle changes with liver cirrhosis

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Portal hypertension and esophageal varices

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#1 complication of cirrhosis

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Enlarged spleen Large collateral veins Ascites Systemic hypertension Varicosities Hemorrhoids

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Manifestations of portal hypertension on body

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Esophageal varices 30 to 50% die within six weeks of first bleeding episode Complex of torturous veins at lower end of esophagus These torturous veins contain little elastic tissue and are quite fragile, tend to distend and bleed easily.

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What is the most life threatening complication of cirrhosis?

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When the liver does not convert ammonia to urea and ammonia is released back into the blood. This ammonia coming out of the liver cannot be used.

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Liver shunting

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Alcohol ingestion Swallowing poorly chewed food Acid regurgitation from the stomach Increased abdominal pressure due to vomiting, sneezing, coughing, and lifting heavy objects

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What leads to esophageal varices being irritated and rupturing?

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Melena (Black tarry poop) Hematemesis (Blood in vomit) Bleeding may range from oozing slowly or massive hemorrhage Signs and symptoms of shock may appear

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Signs and symptoms of ruptured and bleeding esophageal varices.

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1) Imbalanced nutrition, less than body requirements related to anorexia 2) Activity intolerance related to muscle weakness 3) Fluid and electrolyte imbalances related to portal hypertension 4) Ineffective tissue perfusion related to hematemesis and melena 5) Anxiety related to hematemesis and melena 6) Ineffective breathing pattern related to decreased lung expansion 7) Impaired verbal communication related to neurological disturbances 8) Risk for injury related to uncontrolled movements 9) Self-care deficit related to a state of coma

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Priority nursing diagnoses associated with liver cirrhosis

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1) Avoidance of bleeding (Avoid alcohol and irritating foods, Control cough, Screening for varices with upper endoscopy) 2) Main priority during acute bleeding event is to PROTECT AIRWAY 3) Active bleeding is a medical emergency and requires aggressive intervention

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Treatment goals of esophageal varices

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-Beta blockers, nitrates, propanolol (Indural): Reduce portal hypertension in pressure within the varices -Prophylactic antibiotic treatments: Used in active bleeding to prevent infectious complications and reduce mortality

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Drug therapy: prevention of esophageal varices

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1). Storage 2) Protection 3) Metabolism

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Three major functional categories of the liver

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Has the ability to regenerate Has a fibrous capsule of four lobes Lobules are the functional units of the liver Hepatocytes arose of hepatic cells arranged around a vein Sinusoids are capillaries between rows of hepatocytes Sinusoids are lined with Kupfer cells (Patrol and remove bacteria and toxins from blood)

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Anatomy of the liver

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-Octrecide (Sandostatin): Inhibits the release of glucagon (vasodilator hormone), Decreases visceral blood flow -Vasopressin: Causes vasoconstriction in all vascular beds, dangerous with CAD

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Drug therapy: Treating active bleeding esophageal varices

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-Sclerotherapy: Sclerosing agent used to thrombose and obliterate the distended veins (Not common anymore) -Ligation or banding (more common) Small clips of rubber bands slipped around base of the varix.

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Endoscopic therapies for esophageal varices to treat active bleeding or prevent bleeding

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Balloon tapenade: Use this unable to control bleeding with endoscopic procedures and medications Controls hemorrhage by direct mechanical compression of the varices Risks: Aspiration, esophageal rupture, re-bleeding after deflation

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Emergency measures treating esophageal varices

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1) Ensure patent airway (oxygen therapy) 2) Large bore IV access 3) Treatment of shock (Rapid bolus IV fluids, Administration of blood products) 4) Administer vitamin K 5) H2 blocker 6) Celine lavage to remove blood from stomach (Prevents degrading to ammonia) 7) Laxilose and neomycin to prevent hepatic encephalopathy (Binds to ammonia and then you poop it out) 8) Patients are NPO when there are esophageal varices

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Nursing care measures of the patient with bleeding esophageal varices

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Hepatic encephalopathy (The occurrence of confusion and altered level of consciousness as a result of liver failure. Advanced stages is called hepatic coma.)

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What is the most common complication of esophageal varices?

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1) Monitor the patient's condition frequently including emotional responses and cognitive status. 2) Monitor treatments including tube care and GI suction 3) Oral care 4) Ensure quiet, calm environment and reassuring manner 5) Implement measures to reduce anxiety and agitation 6) Teaching and support of patient and family

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Nursing management and monitoring of the patient with bleeding esophageal varices

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1) Pork chops, broccoli 2) Steak, baked potato ***3) Soup and lima beans 4) Club sandwich and potato chips

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Which of the following menu choices would be appropriate for patient that was hospitalized with esophageal varices?

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Serum ammonia levels

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A patient with cirrhosis has an episode of bleeding esophageal varices that is controlled with hygroscopic sclerotherapy. To detect the most serious complication of the bleeding episode, it is most important for the nurse to monitor which lab value?

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Peripheral edema and ascites -Edema results from decrease oncotic pressure from impaired liver synthesis of albumen, increased pressure from portal hypertension and hyperaldosteronism with sodium and water retention. -Ascites results from portal hypertension and movement of albumin into the peritoneal cavity. **Important to remember that ascites can impair breathing!!

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#2 Complication of cirrhosis

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Abdominal distention weight gain Signs and symptoms of the dehydration: Dry tongue and skin, sunken eyeballs, muscle weakness, hypokalemia (due to aldosterone and diuretics) * This patient can be given a potassium-sparing diuretic instead of Lasix

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Manifestations of edema and ascites

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Spontaneous bacterial peritonitis Bacteremia due to translocation of intestinal flora Diagnosed by paracentesis and fluid analysis Treated with antibiotics

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All patients with ascites have the potential to develop what?

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1) Sodium restriction 2) Diuretics : Usually given potassium sparing such as spironolactone, May be combined with loop diuretics if there is a poor response but potassium must be monitored 3) Fluid removal of ascites by paracentesis: Needle puncture intra-abdominal cavity for patients with impaired respiratory function or abdominal pain

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Treatment of ascites and edema

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1) Accurate I&O's, daily weights, abdominal girth 2) Position the patient upright to maximize respiratory ability 3) Meticulous skin care: Special air mattress, turn every two hours, elevate legs 4) Monitor labs such as electrolytes, PT, PTT and platelets 5) Prepare patient for paracentesis: Empty bladder because you don't want to accidentally puncture, Position upright, monitor pos-paracentesis for hypovolemia and change in mental status

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Nursing management for ascites and edema

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Increased urine output

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The patient with cirrhosis receives 100 ML of 25% albumin. Which finding the best indicate that therapy has achieve the desired outcome?

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Hepatic and portal system encephalopathy: Disorder of protein metabolism and excretion Seizure and coma High mortality rate Terminal complication *Liver damage causes ammonia to enter systemic circulation fails to convert ammonia to urea Neuro-psychiatric manifestation

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#3 Complications of cirrhosis

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Mental status change Maybe sudden due to increased ammonia secondary to read or gradual onset * This is a common complication of bleeding varices and shunting procedures

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Signs and symptoms of hepatic encephalopathy

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1) Goal is to reduce ammonia formation 2) Protein restriction (Controversial) 3) Lactulose given (Traps ammonia in gut and laxative expels ammonia from colon, PO or retention enema) 4) Neomycin given (Reduces intestinal flora which promotes ammonia formation, oto and renal toxic) 5) Patient education to assure compliance 6) Treat precipitating causes such as G.I. hemorrhage, infections, and electrolyte imbalances.

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Treatment of hepatic encephalopathy

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1. Monitor the number of stools the patient has per day. 2) Check the consistency of the stools ****3) Perform frequent neuro checks

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How would the nurse monitor for the long-term effectiveness of lactulose therapy?

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Hepatorenal syndrome: Serious complication with complex etiology Portal hypertension and liver decompensation results in systemic vasodilation and decreased arterial blood flow. This results in renal vasoconstriction and then renal failure occurs. *This complication often follows diuretic therapy, G.I. bleed, spontaneous peritonitis, or paracentesis

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#4 Complications of cirrhosis

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-Azotemia: increased BUN and high levels of nitrogen containing compounds such as urea and creatinine -Intractable ascites -No structural abnormalities of the kidneys -May need to be treated with dialysis -With liver transplantation renal function returns

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Signs and symptoms of hepatorenal syndrome

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1) General: Activity intolerance and fatigue, Malnutrition risk for skin breakdown, risk for bleeding or injury, knowledge deficit, sense of guilt, possible infection, electrolyte disturbances 2) Esophageal varices: Possible hemorrhage, shock, risk of aspiration 3) Ascites: Ineffective breathing, shortness of breath, fluid imbalance and skin breakdown 4) Hepatic encephalopathy: Confusion, mental status change, injury risk and noncompliance 5). Hepatorenal syndrome

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Potential patient problems with hepatorenal syndrome

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1) Avoid hot water baths 2) Cool compresses and cool bath 3) Add menthol or camphor to the bath 4) Gentle pressure 5) Reduce stress

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Nursing management of pruritis related to cirrhosis

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1) Increased participation in activities 2) Improved nutritional status 3) Improve skin integrity 4) Maintain proper fluid volume balance 5) Decreased potential for injury 6) Improved mental status 7) Absence of complications: Refer liver disorder patients to American liver foundation, refer alcoholics to AA

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***Goals and outcomes for patients with cirrhosis

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High % of people with cirrhosis of the liver or any chronic liver disease such as hepatitis develop liver cancer. -Malignant cells cause liver to be enlarged and misshapen -Hemorrhage and necrosis in the liver is common -Lesions singular or numerous and nodular or diffusely spread over the entire liver -This cancer may infiltrate other organs such as GB, peritoneum or diaphragm; commonly metastasizes to the lungs

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Pathophysiology of liver cancer

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This type of cancer is difficult to diagnose because early stages look much like cirrhosis. -Hepatomegaly, weight-loss, peripheral edema, ascites, portal hypertension -Dull abdominal pain in epigastric or RUQ -Jaundice, anorexia, extreme weakness -Pts. frequently have pulmonary emboli

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Signs and symptoms of liver cancer

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Liver scan CT scan MRI Arteriography ERCP Liver biopsy: danger of bleeding

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Diagnostic tests used to diagnose liver cancer

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Alfa- fetoprotein produced by malignant tumor cells Helps distinguish primary cancer from metastatic cancer

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Tumor markers for liver cancer

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Mostly palliative -Surgical excision lobectomy sometimes performed tumor is localized to one portion of the liver (20%) Surgical excision offers the best chance of a cure -Liver resection -Radiofrequency ablation: Hyper heating the liver tumors -Cryosurgery: Freezing tumors -PEI (Percutaneous ethanol injection): Inject alcohol to dehydrate tumor, outpatient procedure -Chemotherapy

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Treatment of liver cancer

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-Congenital biliary abnormality -Inborn errors of metabolism -Primary hepatic malignancy - Chronic end-stage liver disease -Chronic viral hepatitis (#1 reason) Types of liver transplant: Cadaveric and living donor

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Indications for liver transplantation

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Severe cardiac or respiratory disease Active alcohol or substance abuse Metastases Severe psychological impairment or inability to follow posttransplant instructions

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People who are not considered for liver transplant

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-Infection -Reoccurrence of hepatitis (20-30 %) even with antiviral therapy leads often to cirrhosis of transplanted liver by 5th year -Rejection (Not a common problem with liver)

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Post operative complications of liver transplants

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-Alcoholism is a chronic, progressive, fatal disease if left untreated -Numerous factors lead to development such as genetic, biological, psychosocial, cultural, environmental -Has numerous effects on individual and family both physical and psychological -Individuals cannot quit without extensive rehab and help (AA) -Nurses must explore their own feelings and attitudes and tx patients without bias or prejudice

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Pathophysiology of alcoholism

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1) Give analgesics as ordered and encourage the patient to identify care measures that promote comfort 2) Provide patient with a special diet restricts sodium and prohibits alcohol 3) To increase venous return and prevent edema, elevate the patient's legs whenever possible 4) Keep the patient's fever down 5) Provide good skin care 6) Turn the patient frequently to prevent pressure ulcers 7) Monitor the patient for fluid retention and ascites 8) Monetary respiratory function 9) Explain treatments and help find palliative and hospice care if needed

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Nursing interventions for liver cancer

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1) Temperature 2) HR 3) Respirations 4) BP 5) Nausea and vomiting 6) Tremors (Arms extended, fingers spread) 7) Observable sweating or flushing of face 8) Tactile disturbances such as itching or numbness 9) Headaches 10) Auditory disturbances 11) Visual disturbances 12) Hallucinations 13) Disorientation 14) Ability to make eye contact and be present 15) Anxiety and agitation 16) Thought disturbances 17) Convulsions

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Nursing assessments for alcohol withdrawal (WAS)

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