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Liver
1.
2. Out lines
• Definition
• Pathophysiology
• Clinical manifestations
• Complications
• Diagnostic measures
• Management
• Nursing process
3. liver failureliver failure
The liver is the largest internal organ of theThe liver is the largest internal organ of the
human body. The complexity of the liver'shuman body. The complexity of the liver's
role means that alterations in function canrole means that alterations in function can
cause multi system problemscause multi system problems
4. DefinitionDefinition
• It is a clinical syndrome characterized byIt is a clinical syndrome characterized by
severe impairment of liver functionsevere impairment of liver function
associated with hepatic encephalopathyassociated with hepatic encephalopathy
5. Pathophysiology and EtiologyPathophysiology and Etiology
• Viral hepatitis is the most common cause.Viral hepatitis is the most common cause.
• Drugs as acetaminophen, tetracyclineDrugs as acetaminophen, tetracycline
(Tetracyn), anesthetics (halothane),(Tetracyn), anesthetics (halothane),
amiodarone (Cordarone).amiodarone (Cordarone).
6. • Ischemia and hypoxia because of hepaticIschemia and hypoxia because of hepatic
vascular occlusionvascular occlusion
• Acute fatty liver of pregnancy,Acute fatty liver of pregnancy,
autoimmune hepatitisautoimmune hepatitis
• Hepatocellular carcinomaHepatocellular carcinoma
• welson's diseasewelson's disease
• Mushroom poisoningMushroom poisoning
7. • liver failure is characterized by rapid onsetliver failure is characterized by rapid onset
of severe liver dysfunction in someoneof severe liver dysfunction in someone
with no prior history of liver disease.with no prior history of liver disease.
Generally the disease runs its course overGenerally the disease runs its course over
8 weeks but it can last as long as 26 weeks8 weeks but it can last as long as 26 weeks
depending on the cause.depending on the cause.
8.
9. Clinical ManifestationsClinical Manifestations
• Malaise, anorexia, nausea, vomiting,Malaise, anorexia, nausea, vomiting,
fatigue.fatigue.
• Jaundice, especially mucous membranes.Jaundice, especially mucous membranes.
• Pruritus caused by bile salts deposited onPruritus caused by bile salts deposited on
skin.skin.
• Steatorrhea and diarrhea because ofSteatorrhea and diarrhea because of
decreased fat absorption.decreased fat absorption.
10. • Peripheral edema as the fluid moves fromPeripheral edema as the fluid moves from
the intravascular to the interstitial spaces,the intravascular to the interstitial spaces,
secondary to hypoproteinemia.secondary to hypoproteinemia.
• Ascites from hypoproteinemia or portalAscites from hypoproteinemia or portal
hypertension.hypertension.
• Easy bruising, petechiae, overt bleedingEasy bruising, petechiae, overt bleeding
because of clotting deficiency.because of clotting deficiency.
11. • Altered LOC, ranging from irritability andAltered LOC, ranging from irritability and
confusion to stupor, somnolence, andconfusion to stupor, somnolence, and
coma.coma.
• Change in deep tendon reflexes initiallyChange in deep tendon reflexes initially
hyperactive, become flaccid, asterixishyperactive, become flaccid, asterixis
(tremor).(tremor).
• Fetor hepaticus breathe odor of acetone.Fetor hepaticus breathe odor of acetone.
12. • Portal systemic encephalopathy, alsoPortal systemic encephalopathy, also
known as hepatic coma or hepaticknown as hepatic coma or hepatic
encephalopathy can occur in conjunctionencephalopathy can occur in conjunction
with cerebral edema.with cerebral edema.
• Cerebral edema is commonly the cause ofCerebral edema is commonly the cause of
death because of brain stem herniation ordeath because of brain stem herniation or
because of respiratory arrest.because of respiratory arrest.
13. Diagnostic EvaluationDiagnostic Evaluation
• Clinical manifestation resulting fromClinical manifestation resulting from
hepatic necrosis and fibrosishepatic necrosis and fibrosis
• Laboratory abnormalitiesLaboratory abnormalities
• Diagnostic studiesDiagnostic studies
16. Diagnostic studiesDiagnostic studies
• Liver biopsy may be indicated whenLiver biopsy may be indicated when
conditions such as autoimmuneconditions such as autoimmune
hepatitis, metastatic lever disease, andhepatitis, metastatic lever disease, and
lymphoma are suspectedlymphoma are suspected
• Ultrasound, CT, or MRI are helpfulUltrasound, CT, or MRI are helpful
17. ManagementManagement
• Lactulose: Oral or rectal administration toLactulose: Oral or rectal administration to
minimize formation of ammonia and otherminimize formation of ammonia and other
nitrogenous by-products in the bowel.nitrogenous by-products in the bowel.
• Neomycin: to suppress urea-splittingNeomycin: to suppress urea-splitting
enteric bacteria in the bowel and decreaseenteric bacteria in the bowel and decrease
ammonia formation.ammonia formation.
18. • Low-molecular-weight dextran or albuminLow-molecular-weight dextran or albumin
followed by a potassium-sparing diureticfollowed by a potassium-sparing diuretic
(spironolactone) to enhance fluid shift(spironolactone) to enhance fluid shift
from interstitial back to intravascularfrom interstitial back to intravascular
spaces which decrease edema and ascites.spaces which decrease edema and ascites.
• Mannitol I.V. for management of cerebralMannitol I.V. for management of cerebral
edema when indicated.edema when indicated.
19. • Antacids and histamine-2 (H2)Antacids and histamine-2 (H2)
antagonists to reduce the risk of bleedingantagonists to reduce the risk of bleeding
from stress ulcers.from stress ulcers.
• Restriction of dietary protein and sodiumRestriction of dietary protein and sodium
while maintaining adequate caloric intakewhile maintaining adequate caloric intake
with diet or hypertonic dextrose solutions.with diet or hypertonic dextrose solutions.
20. • Infusion of fresh frozen plasma toInfusion of fresh frozen plasma to
maintain PT; cryoprecipitate as needed.maintain PT; cryoprecipitate as needed.
• Supplemental vitamins (A, B complex, C,Supplemental vitamins (A, B complex, C,
and K) and folate.and K) and folate.
21. • Additional medical interventions,Additional medical interventions,
depending on the patient's condition, maydepending on the patient's condition, may
include abdominal paracentesis to removeinclude abdominal paracentesis to remove
fluid and relieve symptoms, gastric lavagefluid and relieve symptoms, gastric lavage
to control bleeding, hemodialysis toto control bleeding, hemodialysis to
remove toxins.remove toxins.
24. Nursing AssessmentNursing Assessment
• Obtain history of exposure to drugs,Obtain history of exposure to drugs,
chemicals, or toxins; exposure tochemicals, or toxins; exposure to
infectious hepatitis; and course of illness.infectious hepatitis; and course of illness.
• Assess respiratory status, breath, LOC,Assess respiratory status, breath, LOC,
and vital signs.and vital signs.
25. • Assess for ascites, edema, jaundice,Assess for ascites, edema, jaundice,
bleeding, asterixis, presence or absence ofbleeding, asterixis, presence or absence of
reflexes.reflexes.
• Assess results of arterial blood gas (ABG)Assess results of arterial blood gas (ABG)
tests, electrolytes, PT, and hemoglobintests, electrolytes, PT, and hemoglobin
level and hematocrit.level and hematocrit.
26. Nursing DiagnosesNursing Diagnoses
• Deficient Fluid Volume related toDeficient Fluid Volume related to
hypoproteinemia, peripheral edema,hypoproteinemia, peripheral edema,
ascitesascites
• Ineffective Breathing Pattern related toIneffective Breathing Pattern related to
anemia and decreased lung expansionanemia and decreased lung expansion
from ascitesfrom ascites
27. • Imbalanced Nutrition: Less Than BodyImbalanced Nutrition: Less Than Body
Requirements related to GI adverseRequirements related to GI adverse
effects and decreased absorption,effects and decreased absorption,
storage, and metabolism of nutrientsstorage, and metabolism of nutrients
• Risk for Injury related to encephalopathyRisk for Injury related to encephalopathy
28. • Risk for Impaired Skin Integrity related toRisk for Impaired Skin Integrity related to
malnutrition, deposition of bile salts,malnutrition, deposition of bile salts,
peripheral edema, decreased activityperipheral edema, decreased activity
• Risk for Infection related to alteredRisk for Infection related to altered
immune responseimmune response
29.
30. Maintaining Adequate Fluid VolumeMaintaining Adequate Fluid Volume
• Monitor vital signs frequently.Monitor vital signs frequently.
• Weigh patient daily and keep an accurateWeigh patient daily and keep an accurate
intake and output record; recordintake and output record; record
frequency and characteristics of stool.frequency and characteristics of stool.
• Measure and record abdominal girth daily.Measure and record abdominal girth daily.
31. • Assess and record peripheral edema.Assess and record peripheral edema.
• Restrict sodium and fluids; replaceRestrict sodium and fluids; replace
electrolytes as directed.electrolytes as directed.
• Administer low-molecular-weight dextranAdminister low-molecular-weight dextran
or albumin and diuretics as prescribed.or albumin and diuretics as prescribed.
• Assess for signs and symptoms ofAssess for signs and symptoms of
hemorrhage or bleeding.hemorrhage or bleeding.
32. Improving Respiratory StatusImproving Respiratory Status
• Monitor respiratory rate, depth, use ofMonitor respiratory rate, depth, use of
accessory muscles, nasal flaring, andaccessory muscles, nasal flaring, and
breath sounds.breath sounds.
• Evaluate ABG values, hemoglobin level,Evaluate ABG values, hemoglobin level,
and hematocrit.and hematocrit.
33. • Elevate head of the bed to lowerElevate head of the bed to lower
diaphragm and decrease respiratory effort.diaphragm and decrease respiratory effort.
• Turn patient frequently to prevent stasis ofTurn patient frequently to prevent stasis of
secretions.secretions.
• Administer oxygen therapy as directed.Administer oxygen therapy as directed.
34. Improving Nutritional StatusImproving Nutritional Status
• Enlist a nutrition specialist to helpEnlist a nutrition specialist to help
evaluate nutritional status and needs.evaluate nutritional status and needs.
• Encourage patient to eat in a sittingEncourage patient to eat in a sitting
position to decrease abdominal tendernessposition to decrease abdominal tenderness
and feeling of fullness.and feeling of fullness.
35. • Provide small, frequent meals or dietaryProvide small, frequent meals or dietary
supplements to conserve patient'ssupplements to conserve patient's
energy.energy.
• Provide mouth care if patient hasProvide mouth care if patient has
bleeding gums or fetor hepaticus.bleeding gums or fetor hepaticus.
36. • Restrict sodium intake and proteinRestrict sodium intake and protein
based on ammonia levels and symptomsbased on ammonia levels and symptoms
of encephalopathy.of encephalopathy.
• Provide enteral and parenteral feedingsProvide enteral and parenteral feedings
as needed.as needed.
37. Maintaining Skin IntegrityMaintaining Skin Integrity
• Inspect skin for alteration in integrity.Inspect skin for alteration in integrity.
• Provide good skin care.Provide good skin care.
• Bathe without soap and apply soothingBathe without soap and apply soothing
lotions.lotions.
• Keep patient's fingernails short to preventKeep patient's fingernails short to prevent
scratching from pruritus.scratching from pruritus.
38. • Administer medications as prescribed forAdminister medications as prescribed for
pruritus.pruritus.
• Assess for signs of bleeding from brokenAssess for signs of bleeding from broken
areas on the skin.areas on the skin.
• Turn patient frequently to preventTurn patient frequently to prevent
pressure ulcers.pressure ulcers.
• Avoid trauma and friction to the skin.Avoid trauma and friction to the skin.
39. Preventing InfectionPreventing Infection
• Be alert for signs of infection, such asBe alert for signs of infection, such as
fever, cloudy urine, abnormal breathfever, cloudy urine, abnormal breath
sounds.sounds.
40. • Use good hand-washing and asepticUse good hand-washing and aseptic
technique when caring for a break in thetechnique when caring for a break in the
skin or mucous membranes.skin or mucous membranes.
• Restrict visits with anyone who may haveRestrict visits with anyone who may have
an infection.an infection.
• Encourage the patient not to scratchEncourage the patient not to scratch
itching skin.itching skin.
41. Preventing InjuryPreventing Injury
• Maintain close observation, bed side railsMaintain close observation, bed side rails
up, and nurse call system within reach.up, and nurse call system within reach.
• Assist with ambulation as needed andAssist with ambulation as needed and
avoid obstructions to prevent falls.avoid obstructions to prevent falls.
42. • Have well-lit room and frequently reorientHave well-lit room and frequently reorient
patient.patient.
• Observe for subtle changes in behaviorObserve for subtle changes in behavior
(such as unkempt appearance), worsening(such as unkempt appearance), worsening
of sample of handwriting, and change inof sample of handwriting, and change in
sleeping pattern to detect increasingsleeping pattern to detect increasing
encephalopathy.encephalopathy.
43. Patient Education and HealthPatient Education and Health
MaintenanceMaintenance
• Teach patient and family to notify healthTeach patient and family to notify health
care provider of increased abdominalcare provider of increased abdominal
discomfort, bleeding, increased edema ordiscomfort, bleeding, increased edema or
ascites, hallucinations, or lapses inascites, hallucinations, or lapses in
consciousness.consciousness.
44. • Instruct to avoid activities that increaseInstruct to avoid activities that increase
the risk of bleeding: scratching, falling,the risk of bleeding: scratching, falling,
forceful nose blowing, aggressive toothforceful nose blowing, aggressive tooth
brushing, and use of straight-edged razor.brushing, and use of straight-edged razor.
45. • Advise limiting activities when fatiguedAdvise limiting activities when fatigued
and encourage use of frequent restand encourage use of frequent rest
periods.periods.
• Maintain close follow-up for laboratoryMaintain close follow-up for laboratory
testing and evaluation by health caretesting and evaluation by health care
provider.provider.
46. Evaluation: Expected OutcomesEvaluation: Expected Outcomes
• Blood pressure stable, urine outputBlood pressure stable, urine output
adequateadequate
• Respirations unlaboredRespirations unlabored
• Tolerates feedingTolerates feeding
• Skin intact without abrasionsSkin intact without abrasions
• No fever or signs of infectionNo fever or signs of infection
