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Cirrhosis Dx
- Physical Exam
- LFT's= elev in the aminotransferases
- - AST (SGOT), ALT (SGPT), GGT
- - 70% of the liver is not functioning, damage release enzymes
- Labs
- - dec albumin, total protein
- - dec cholesterol- alter fat metabolism
- - elev PT and PTT- not clotting factos
- - elev bili- bc of dec excretion
- - eleva ammonia
- - elev Alk. phosp- found in the liver Kupffer cells
-
Cirrhosis other dx
- Liver US
- Liver scan- size, blood flood
- aspiration of ascites fluids- paracentesis
- liver biopsy- confirm dx
- - see brunner
- before:
- - 1. coag labs
- - 2 CBC
- - 3 VS
- After:
- assess
- vs, o2 stat
- pain
- site- bleeding
- avoiding coughing or straining
- turn pt on right side to help put pressure- reduce bleeding
- no heavy lifting for a week
-
other cirrhosis dx
child pugh classification
- prognostic indicator
- predicting outcomes of pt with liver disease
-
cirrhosis
nx dx
prioritize
-
Cirrohosis treatment
- Rest****
- - encourages regeneration of the liver
- - decr metabolic demands
- - HOB up- dyspenia
- - assess skin d/t edema, changes in skin mentation
- oxygen therapy
- IS/DB
-
Cirrhosis
nutrition
- with no complications: high calorie, high CHO, mod-low fat
- protein- 1-1.5 grams: problems low protein no problems mod protein
- - bc low protein watch for malnutrition
- - needs are based off of s/s
- *** sodium- 2G/d or 250-300mg/d if severe ascites
- vitamins: MVI, thiamine, folate
- fluids: may have fluid restriction (balancing act) w/ascites
- intervention: altered nutrition
-
High Na sources
- canned soup, vegatable
- salted snacks, nuts
- smoked meats, fish
- crackers, bread
- olives, pickles
- ketchup
- OTC meds ie antacids
- teach pt to read labels
-
what to do w/ascites
- assess fluid and electrolyte status
- Na restriction- becareful with malnutrition
- Strict I&O, qd wts and girth- mark the measurements for the right places
- hydration status
-
Ascites meds
- SPA (salt poor albumin)- inc colloid oncotic pressure: temporary works while in the blood
- - s/e FVE- holding on
- Beta Blocker
- - decr pressure in portal vein- bc it vasodilates
- - hypotension, H/A, dizziness, bradycardia
- directics- spironolactone w or w/out furosemide (blocks aldosterone)
- - monitor electrolytes
- - furosemide- is a loop diurectic (strongest one)
- - one holds on to k and the other lets it go
- - used for ascites
- - 90% effective
-
paracentesis
- bedside, local anesthesia
- fluid withdrawn with a needle
- baseline VS, IV access, girth, coags
- pt instructed to void prior
- position upright
- monitor VS during procedure and monitor hypovolemia
- this could be to dx or to tx
- temporary measure with tx
- sometimes use a foley cath to help drain
- make sure u don't pull out too fast- sometimes they take some fluid and then clamp it to help it with shifting
-
paracentesis- post
- check VS freq- q 15 1 hr, q 30 x2hr, q 1 x2 hrs
- position on right side for several hrs- to seal it
- compare abd girth pre and post
- bandaid to site clean and dry 3-5 d
- watch site for bleeding
- risk- hypovolemia, infection
- post teaching: no heavy lifting, straining, slow position changes d/t loss of volume
- normal to leak a lil- use 2x2 or 4x4
-
peritovenous shunt
- severe ascites: nothing else worked
- LaVeen shunt- surgically placed
- one end in the periteneus, other in jugular vein or SVC
- 1 way valve prevents back flow
- - valve opens with pressure
- incr abd pressure pushes fluid from abd into venous system- get fluid back in the blood
- palliative for ascites****
- risk thrombosis (whenever u add something foriegn in the body), infection, occulsion, FVO
- it has to interfer with life like pain, SOB
-
Shunting procedures
- TIPS= transjugular intrahepatic portosystemic shunt
- - severe ascites or bleeding varices
- redirects portal blood flow
- - shunt btw portal vein and portal artery
- decr portal pressure and pressure at varices
- c/o; sepsis bleeding, thrombosis, organ failure
- encephalopathy
- only fair long term success
-
Esophageal varices
- bleeding may be life threatening
- dx/tx by endoscopy
- - sclerotherapy, ligation
- prevention
- - avoidance of irritants- even big pill
- - beta blocker: helps with bleeding, dec portal pressure but becareful bc it can hyperprefuse liver and cause encephalopath
-
Esophageal varices
Sengstaken- Blakemore tube
- for severe bleeding uncontrolled by other measures
- balloon tampanade
- esophageal balloon- cork
- gastric balloon- cork, anchor- stabilizer
- *** airway***
- like an NG tube inserted in nose
- assess for respiratory distress
- keep scissors at bedside****
- if gastric balloon starts to leake- the will go up- cut esophageal balloon to deflate and pull out
-
Sengstaken-Blakemore tube
nursing care
- careful assessment of airway
- blackmore- deflate esophageal balloon q 8-12h, gastric balloon always inflated- u want to deflate to decr risk of pressure ulcers and the other one stays inflated to help anchor it
- scissors at bedside
-
Esophageal varices meds
- stabilize pt (airway, iv access)
- Vasopressin- DOC
- - splenic vasoconstriction- dec portal pressure, dec splenic congestion
- - se: chest pain, HA, arrithymias (VS, HR)
- ocetrotide (sandostatin)- same as above
- - dec portal htn and pressure
- - se: HA
- nitroglyerin
- - dilate portal vein
- - se: dec BP, HA
- beta blocker
- PRBC, FFP (clotting)
- Vitamin K not IM
- H2, PPI- dec acid
- - risk for bleeding- HE
- Lactulose, Neomycin, rifaximin- dec risk for H/E
- antiobiotics- preemptive
- - flagyl and cipro- broad spectrum, intra abdominal site- gets in there
-
Esopha varices
nursing responsibilities
- similar to with those with GIB
- HOB eleb
- NS lavage- put in saline and suction it out
-
Hepatic Enceph
- potentially life threatening
- goal: reduce NH3, formation
- avoid constipation and straining
- Assess neurologic s/s
- - escalating NH3 level threaten CNS function
- assess ammonia levels
- careful adm: sedative, analgesics
-
HE
meds
- Lactulose
- - NH3 attracted to acid environment, produces stools, dec bacterial flora
- - this creates acid environment in the GI- ammonia is attracted to acid
- - goal 2-3 soft stools 24 hrs
- - becareful of dehydration
- - no constant loose stools
- Neomycin
- - dec bacterial flora, NH3 production
- - works only in GI tract
- - SE
- Rifaximin
- - MOA- unknown
- - fever, GI, H/A
-
HE
nutrition
- protein restriction (if acute)
- 1.2-1.5g/Kg/d
- dairy, vegetable protein better tolerated than meat protein
- high CHO foods, encourage to maintain glucose, spare protein
- limit high protein foods in diet
- small freq meals
-
Liver transplant
- last resort
- recurring encephalopathy
- end stage liver disease
- availability a major obstacle
- incr success with living donors
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