lesson plan on acute liver failure

1. SUMANDEEP COLLEGE OF NURSING
PIPARIA, WAGHODIYA, VADODARA
PRACTICE TEACHING
ON
Acute liver failure
SUBMITTED TO- SUBMITTED BY-
MRS. SONAL PATEL NIKHIL VAISHNAV
ASSISTANT PROFESSOR M.Sc. NURSING 1STYEAR
SUMANDEEP COLLEGE OFNURSING MEDICALSURGICALNURSING

2. Name of the Student Teacher - Mr. Nikhil vaishnav
Course - M.Sc. Nursing
Subject - Medical Surgical Nursing
Topic - Acute liver failure
Year - B. Sc. Nursing 2nd Year
Method of the Teaching - Lecture Cum Discussion
Teaching Aids - PPT, Black board, video, Pamphlets, handouts.
Name of the Evaluator - Mrs. Sonal Patel
Date - 04/05/2017
Time - 3-4 p.m.

3. OBJECTIVE
General objective– At the end of my practice teaching class students will be having in-depth knowledge regarding acute liver failure.
Specific Objective:
At the end of the topic the student will be able to –
1. Introduce the topic of discussion.
2. Define acute liver failure.
3. Classify the Acute liver failure.
4. Enlist the causes and risk factors of acute liver failure.
5. Explain the Pathophysiology of acute liver failure.
6. List out of signs and symptoms of acute liver failure.
7. Enumerate the investigating measures of acute liver failure.
8. List the nursing diagnosis for acute liver failure.
9. Describe the medical and nursing management of acute liver failure.
10.Enlist the possible complication of acute liver failure.

4. Sr.
No
SPECIFIC
OBJECTIVE
TIME CONTENT TEACHING
LEARNING
ACTIVITY
A.V.
AIDS
EVALUATION
1
2
Introduction
about
anatomy and
physiology of
the liver
3 min ANATOMY OF THE LIVER:
The liver is the largest gland in the body, weighing between 1 and 2.3 kg . It is
situated in the upper part of abdominal cavity occupying the greater part of the
right hypochondriac region, part of the epigastric region. Its upper surfaces are
smooth and curved to fit the under surface of the diaphragm. Its posterior
surface is irregular in outline.
The liver is enclosed in a thin elastic capsule and incompletely covered by a
layer of peritoneum. Folds of peritoneum from supporting ligaments attaching
the liver to the inferior surface of the diaphragm . It is held in position partly
by these ligaments and partly by the pressure of the organs in the abdominal
cavity. The liver has four lobes. The two most obvious are the large right lobe
and the smaller , wedge shaped left lobe. The other two, the caudate and
quadrate lobes are areas on the posterior surfaces.
The portal fissure is the region on the posterior surface of liver where various
structures enter and leave the gland.
The portal vein enters, carrying blood from the stomach, spleen, pancreas and
large intestines. The hepatic artery enters , carrying arterial blood. Nerve
fibers, sympathetic and parasympathetic enter here. The right and left hepatic
ducts leave, carrying bile from the liver to the gall bladder.
BLOOD SUPPLY:
The hepatic artery and the portal vein take blood to the artery. Venous return
is by a variable number of hepatic veins that leaves the posterior surface.
STRUCTURE: The lobes of the liver are made up of tiny functional units,
called lobules. Liver lobules are hexagonal in outline and formed by
hepatocytes. Hepatocytes are arranged in pairs of columns radiating from a
central vein. Between two pairs of column of cells are sinusoids containing a
mixture of blood from the tiny branches of the portal vein and hepatic artery .
Amongst the cells lining sinusoids are kuffer cells whose function is to ingest
Discussion
PPT

5. and destroy worn out blood cells and any foreign particles present in the
blood.
Blood drains from the sinusoids into central veins. Lymphoid tissue and a
system of lymph vessels are also present in each module.
PHYSIOLOGY OF LIVER
Functions of liver: The liver is an extremely active organ. The functions of
the liver are as follows:
1. Carbohydrate metabolism: The liver has an important role in
maintaining plasma glucose levels. After a meal when level of glucose
rises, glucose is converted to glycogen under the influence of hormone
insulin. Later when glucose level falls, the hormone glucagon
stimulated conversion of glycogen into glucose again.
2. Fat metabolism: Stored fat can be converted to a form in which it can
be used by tissues to provide energy.
3. Protein metabolism: Deamination of amino acids. In this process
- Removes the nitrogenous portion from the amino acids not required for
the formation of new protein. Urea is formed from this nitrogenous
portion which is excreted in urine.
- Breaks down nucleic acids to form uric acid which is excreted in urine.
4. Synthesis of plasma proteins and most blood clotting factors from
amino acids.
5. Breakdown of erythrocytes and defence against microbes: This is
carried out by phagocytic hepatic macrophages (Kupffer cells) in the
sinusoids.
6. Detoxification of drugs and noxious substances: These include
ethanol (alcohol) and toxins produced by microbes.
7. Production of heat: The liver uses a considerable amount of energy,
has a high metabolic rate and produces a great deal of heat. It is the
main heat producing organ of the body.
8. Secretion of bile: The hepatocytes synthesize the constituents of bile
from the mixed arterial and venous blood in sinusoids. This includes
bile salts, bile pigments and cholesterol.
9. Storage: Liver stores glycogen , fat soluble vitamins: (A, D,E,K ),
Iron, copper, Vitamin B12 .
Lecture cum
discussion
PPT

6.  COMPOSITION OF BILE: About 500 ml of bile are secreted by the
liver daily. Bile consists of water, mucus, mineral salts, bile pigments
mainly bilirubin, bile salts which are mainly derived from the primary
bile acids , cholic acid and chenodeoxycholic acid and cholesterol .
- The bile acids, cholic and chenodeoxycholic acid, are synthesized by
hepatocytes from cholesterol, conjugated with either glycine or taurine,
then secreted into bile as sodium or potassium salts . In the small
intestine they emulsify fats, aiding their digestion. In the terminal
ileum most of the bile salts are reabsorbed and return to liver in the
portal vein.
- Bilirubin is one of the products of hemolysis of erythrocytes by
Kupffer cells in the liver and by other macrophages in the spleen and
bone; In its original form bilirubin is insoluble in water and is carried
in the blood bound to albumin. In hepatocytes it is conjugated with
glucuronic acids and becomes water soluble before being excreted in
bile . Bacteria in the intestine change the form the form of bilirubin and
most is excreted as stercobilin in the feces. A small amount is
reabsorbed and excreted in urine as urobilinogen.

7. 3
4
Define the
Acute liver
failure
Describe the
incidence of
acute liver
failure
5 min
INTRODUCTION
Liver is the second largest organ. The liver performs many essential functions
related to digestion, metabolism, immunity, and the storage of nutrients within
the body. These functions make the liver a vital organ without which the
tissues of the body would quickly die from lack of energy and nutrients.
Fortunately, the liver has an incredible capacity for regeneration of dead or
damaged tissues.
Liver failure is severe deterioration in liver function. Liver failure is caused by
a disorder or substance that damages the liver A large portion of the liver is
damaged . Liver failure may develop rapidly over days or weeks( acute) or
gradually over months or years( chronic) .
Acute liver failure is loss of liver function that occurs rapidly — in days or
weeks —usually in a person who has no pre-existing liver disease. Acute liver
failure is less common than chronic liver failure, which develops more slowly.
Acute liver failure, also known as fulminant hepatic failure, can cause serious
complications, including excessive bleeding and increasing pressure in the
brain. It's a medical emergency that requires hospitalization. Depending on the
cause, acute liver failure can sometimes be reversed with treatment. In many
situations, though, a liver transplant may be the only cure
Acute liver failure is an uncommon condition in which rapid deterioration of
liver function results in coagulopathy and alteration in the mental status(
encephalopathy ) of a previously healthy person. It indicates that liver has
sustained severe damage. Acute liver failure often affects young people and
carries a very high mortality. Acute liver failure (ALF) (also called fulminant
hepatic failure) is a rare condition characterized by the abrupt onset of severe
liver injury.
Acute liver failure is sub divided into fulminant hepatic failure and sub
Lecture cum
discussion
Lecture cum
discussion
PPT
PPT
What do you
mean by Acute
liver failure ?

8. 5
.
Describe the
causes of
acute liver
failure
10 min
fulminant hepatic failure. Fulminant hepatic failure requires onset of
encephalopathy within 8 weeks and sub fulminant hepatic failure describes
onset of encephalopathy after 8 weeks but before 26 weeks.
Acute liver failure is a rare but life-threatening critical illness that occurs most
often in patients who do not have preexisting liver disease. With an incidence
of fewer than 10 cases per million persons per year in the developed world.
There are nearly 2,000 cases of acute liver failures each year in the United
States, and it accounts for 6% of all deaths due to liver disease. It is more
common in women than in men, and more common in white people than in
other races.
Acute liver failure occurs when liver cells are damaged significantly and are
no longer able to function. There are numerous causes of acute liver failure but
major causes are acetaminophen overdose and viral hepatitis. The etiological
factors of acute liver failure as follows:
1. Viral hepatitis:
Viral hepatitis may lead to hepatic failure. Hepatitis A and B account for
most of these cases. In the developing world, acute hepatitis B virus (HBV)
infection dominates as a cause of fulminant hepatic failure because of the high
prevalence of the disease. Hepatitis C rarely causes Fulminant hepatic failure.
Atypical causes of viral hepatitis and fulminant hepatic failure include the
What all are the
causes of the
acute liver
failure?

9. 6.
List down the
sign and
symptom of
the Acute
liver failure.
3 min
following: Cytomegalovirus, Herpes simplex virus, paramyxovirus
Epstein-Barr virus.
2. Drug induced hepatotoxicity: Many drugs (both prescription and illicit)
are implicated in the development of fulminant hepatic failure.
Acetaminophen is the main drug for these type of hepatotoxicity.
Acetaminophen (also known as paracetamol and N-acetyl-p-aminophenol
[APAP]) may lead to liver failure as a result of intentional or accidental
overdose.
Some kind of prescribed medicines are also associated with the
idiosyncratic hypersensitivity reaction. It includes, antibiotics,
antidepressants, anesthetic agents, Salicylates (ingestion of these agents may
result in Reye syndrome)
Illicit drugs have been associated with hepatic failure such as cocaine etc.
Herbal or alternative medicines that have been associated with idiosyncratic
hypersensitivity reactions include Ginseng
Pennyroyal oil
3. Toxin related hepatotoxicity:
Some toxins are related with hepatoxicity includes: Amanita phalloides,
mushroom toxin, Cyanobacteria toxin , Organic solvents (eg, carbon
tetrachloride). Yellow phosphorus.
4. Vascular causes: Ischemic hepatitis, hepatic vein thrombosis (Budd chairi
syndrome) , portal vein thrombosis.
5. Metabolic causes ; including Alpha1-antitrypsin deficiency, Fructose
intolerance, Galactosemia ,Reye syndrome , Wilson disease.
6. Malignancies: includes primary liver tumor( hepatocellular carcinoma),
secondary tumor includes hepatic metastasis or breast, lung cancer .
- Hepatic encephalopathy (mental confusion, difficulty concentrating
Lecture
ppt
Which are the
symptoms of the
Acute liver
failure?

10. 7
Enumerate the
investigating
measures of
Acute liver
failure
5 min
and disorientation)
- Sudden jaundice (yellowing of the whites of the eyes and skin)
- Pain and tenderness in the upper right side of the stomach
- Nausea
- Vomiting
- Ascites (accumulation of fluid in the stomach)
- Edema (accumulation of fluid in the legs, ankles and feet)
- Feeling ill (Malaise).
- Drowsiness
- Muscle tremors
- Diarrhea
- Bleeding easily
- Cerebral edema
- Coma
- Brain herniation.
- Hypotension.
- Tachycardia.
- Hematemesis.
- Melena
Diagnostic evaluation of acute liver failure focused to identify the cause of
liver dysfunction. It consists of :
- History collection.
- Physical examination.
- CBC.
Lecture cum
discussion
Lecture
Chalk
and
board
PPT
PPT
Which are the
diagnosis
evaluations of the
acute liver
failure?

11. 8
Describe the
medical
management
of Acute liver
failure.
5 min - Prothrombin time.
- SGOT, SGPT.
- Serum billirubin level, Serum ammonia level.
- ABG.
- Serum Creatinine level, Serum free copper and Ceruloplasmin level.
- Blood cultures: For patients with suspected infection.
- Viral serology: hepatitis A virus immunoglobulin M (IgM), hepatitis
B surface antigen (HBsAg), hepatitis B virus anticore IgM
- Drug screening: Patients who are intravenous drug abusers.
- Autoimmune markers: Autoimmune markers (for autoimmune
hepatitis diagnosis): Antinuclear antibody (ANA), anti-smooth muscle
antibody (ASMA), and immunoglobulin levels.
- Electroencephalography
- Intracranial pressure monitoring.
- Percutaneous (contraindicated in presence of coagulopathy) or
transjugular liver biopsy.
Treatment of acute liver failure consists of Drugs and liver transplantation.
Pharmacological management includes certain antidotes to reverse the effects
of ALF and various medications to reduce ICP. Antidotes neutralize toxic
agents or counteract any form of poisoning. Drugs used in Acute liver failure
are:
1. Penicillin G: Intravenous Penicillin G is the drug of choice for the
treatment of Mushroom Poisoning from Amanita Phalloides.
2. Activated Charcoal: Patients who have recently ingested A. Phalloides
activated charcoal may bind the toxin and prevent absorption.
3. N-Acectylcycteine: It is the drug of choice in acetaminophen overdose.
4. Osmotic diuretics: Intracranial hypertension in acute liver failure managed
by osmotic diuretics such as mannitol. Mannitol decreases cerebral edema.
What is the
treatment of
Acute liver
failure?

12. 9.
10
List down the
complications
of the acute
liver failure
Describe the
Nursing
management
3 min
5. Barbiturate: agents such as pentobarbital are used when severe intracranial
hypertension does not respond to any measures.
6. Benzodiazepine: Midazolam is used for sedation in mechanically ventilated
patients.
7. Anesthetic agents: Propofol is a sedative hypnotic used to reduce cerebral
blood flow.
 For neurological complications the head of the patient should be
elevated to 30 degree , electrolyte, blood glucose, blood gases and
neurologic status monitored regularly.
 C.V.S. complications Hypotension should be treated with fluids.
 Pulmonary complications mechanical ventilation may be required.
 For coagulopathy/ GIT bleeding vitamin K can be given to abnormal
Prothrombin time.
 Liver transplantation:
When acute liver failure can't be reversed, the only treatment may be a
liver transplant. During a liver transplant, a surgeon removes patient’s
damaged liver and replaces it with a healthy liver from a donor. The
advent of transplantation has changed survival from as low as 15% in
the pretransplant era to more than 60% today. Liver transplantation is
indicated for many patients with ALF, and survival rates of 56–90%
can be achieved. In addition to transplantation, better critical care and
the trend toward more benign causes, such as acetaminophen, all
contribute to improved survival rates.
Complications of the acute liver failure are as follows:
1) Kidney failure: As a result of acetaminophen poisoning which
damages both liver and kidney.
2) Excessive fluid in the brain (cerebral edema): Excessive fluid causes
pressure to build in brain, which can displace brain tissue outside of
Discussion
Discussion
What all are the
complications of
acute liver
failure?

13. 11
of the acute
liver failure?
Describe
Nursing
interventions
of the acute
liver failure?
Describe the
preventive
3 min
2 min
the space. Cerebral edema can also deprive brain of oxygen.
3) Bleeding and bleeding disorders: Liver is not able to produce
sufficient amount of clotting factors, which help blood to clot.
4) Infections: People with acute liver failure are at increased risk of
developing a variety of infections particularly in the blood and in the
respiratory and urinary tracts.
 Nursing Diagnosis:
- Increased risk of dehydration, electrolytes and metabolic disturbances
related to liver damage.
- Increased risk of secondary infections due to impaired immune state ,
related to liver dysfunction.
- Increased risk of hematological complications related to liver
dysfunction.
- Changes in neurological state( Encephalopathy) due to liver
insufficiency.
- Increased risk of hematological complications related to liver
dysfunction.
- Anxiety related to the symptoms of disease and fear of the unknown.
 Interventions:
- Assess, report and record signs and symptoms and reactions to the
treatment.
- Monitor fluids input and output closely, observe signs of dehydration,
secondary infections, neurological disturbances, edema and jaundice.
- Provide adequate diet with high proteins, carbohydrates and vitamins (
carefully in encephalopathy) .
- Administer antibiotics, antiemetic, vitamins and other medications as
prescribed, monitor for side effects.
- Monitor for signs of possible bleeding.
- Provide prescribed diet, rest and comfort measures.
- Provide emotional support to client and his family , explain all

14. 12.
.
measures of
Acute live .
Describe the
prognosis of
procedure to decrease anxiety and to obtain cooperation.
Prevention of acute liver failure are as follows:
 Tell doctor about all medicines. Even over-the-counter and herbal
medicines can interfere with prescription drugs patient is taking.
 Drink alcohol in moderation, if at all. Limit the amount of alcohol .drink to
no more than one drink a day for women of all ages and men older than 65
and no more than two drinks a day for younger men.
 Avoid risky behavior: If someone is using illicit drugs he should get help.
Don't share needles. Use condoms during sex. . Don't smoke.
 Get vaccinated: If someone is at increased risk of contracting hepatitis, if
he has been infected with any form of the hepatitis virus he should get
himself vaccinated.
 Avoid contact with other people's blood and body fluids: Accidental
needle sticks or improper cleanup of blood or body fluids can spread
hepatitis viruses. Sharing razor blades or toothbrushes can also spread
infection.
 Don't eat wild mushrooms: It can be difficult to distinguish an edible
mushroom from a poisonous one.
 Take care with aerosol sprays: When you use an aerosol cleaner, make
sure the room is ventilated, or wear a mask. Take similar protective
measures when spraying insecticides, fungicides, paint and other toxic
chemicals. Follow manufacturers' instructions.
 Watch what gets on your skin: When using insecticides and other toxic

15. the acute liver chemicals, cover your skin with gloves, long sleeves, a hat and a mask.
 Maintain a healthy weight: Obesity can cause a condition called
nonalcoholic fatty liver disease, which may include fatty liver, hepatitis
and cirrhosis.
Historically mortality has been high, being in excess of 80%..In recent years
the advent of liver transplantation and multidisciplinary intensive care support
has improved survival significantly. At present overall short-term survival
with transplant is more than 65% .

16. 16
Problem/ Population Intervention/indicator Comparison/control Outcome

17. 17
Abstract