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147 Cards in this Set
- Front
- Back
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The Liver
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-The largest organ in the body, weighing 3lbs
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The liver is located in
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the right epigastric region
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True/False
The liver is essential for life |
True
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About _____ of the blood supply comes from the hepatic artery
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1/4
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About _____ of the blood supply comes from the portal vein
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3/4
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The portal circulatory system brings blood to the liver from the
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-Stomach
-Intestines -Spleen -Pancreas |
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Blood enters the liver through the
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portal vein
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Functions of the liver
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-Metabolic function
-Bile synthesis -Storage -Mononuclear Phagocyte System |
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Metabolic Functions of the liver
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-Carbohydrate metabolism
-Protein metabolism -Fat Metabolism -Detoxification -Steroid metabolism |
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Extra glucose in the body is stored as glycogen in
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liver and skeletal muscles
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The liver is responsible for bile ______ and ______
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production and excretion
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The liver produces how much bile daily?
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1 liter
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Bile is stored in
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gallbladder
*about 45 ml |
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The liver stores
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-Glucose in the form of glycogen
-Vitamins (fat and water soluble) -Fatty acids -Minerals -Amino acids (Albumin and B-globulins) |
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The liver's Mononuclear Phagocyte System consists of
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Kupffer Cells
*line the sinusoids of the liver |
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Kupffer Cells phagocyte functions include
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-Breakdown of old RBCs, WBCs, bacteria, and other particles
-Breakdown of hemoglobin from old RBCs to bilirubin and biliverdin |
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Drug metabolism by the liver generally results in the ______ of activity of the medication
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loss of activity
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True/False
Certain oral medications absorbed by GI tract may be metabolized by liver to such a great extent (first-pass effect) that bioavailability is decreased |
True
*The greater the first-pass effect, the more drug that is metabolized by the liver |
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Ammonia is a byproduct of
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gluconeogenesis
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After ammonia is converted to urea it is excreted how?
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*
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How does the liver aid in blood clotting
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the liver synthesizes clotting factors
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Liver function tests include
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-Bile formation and excretion
-Protein metabolism (serum) -Hemostatic function -Serum enzymes -Lipid metabolism |
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Liver Bile Formation and Excretion values
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-Serum bilirubin
-Total bilirubin 0.2 -1.2 mg/dl -Direct 0.1-0.3 mg/dl -Indirect 0.1-1.0 mg/dl -Urinary bilirubin 0 or negative -Urinary urobilinogen 0.5-4mg/day |
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Liver protein metabolism (serum) values
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-Albumin 3.5-5 g/dl
-Globulin 2.0-3.5 g/dl -Total protein 6.4-8.3 g/dl -A/G ratio 1.5:1 - 2.5:1 -a-Fetoprotein <10 ng/ml -Ammonia 15-45 mcg N/dl |
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Ammonia
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15-45 mcg N/dl
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Significant values if the liver is not functioning well
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-Decrease in proteins
-Decrease in Osmotic pressure |
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Liver Hemostatic lab values
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-Prothrombin 11- 16 sec
-Vitamin K 0.1- 2.2 ng/ml |
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Liver Serum enzyme values
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-Alkaline phosphate (ALP) 38- 126 U/L (depending on method and age)
-Aspartate amino-transferase (AST) 10-30 U/L -Alanine aminotransferase (ALT) 10-40 U/L |
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If all serum enzymes are elevated typically indicates
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liver disorder
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If only a couple serum enzymes are elevated this may indicate problems with the
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pancreas
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If AST level is increased, this may indicate
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MI
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If AST and ALT are both elevated
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This indicates a problem with the liver rather than MI
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ALP is also present in the
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Bones
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IF ALP is increased it may indicate
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Metastasis in the bones
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Liver lipid metabolism values
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-Cholesterol (serum) <200 mg/dl
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Liver biopsy is done to
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obtain a specimen of liver tissue
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Liver biopsy is performed under ______ anesthesia
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local anesthesia
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Complications of liver biopsies
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-Pneumothorax
-Peritonitis -Hemorrhage |
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Before a liver biopsy is performed ________ must be obtained
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consent
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Cirrhosis of the liver is a
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chronic PROGRESSIVE disease
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Liver cirrhosis causes
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extensive degeneration and destruction of the liver cells
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True/False
Liver Cirrhosis is twice as common in men as women |
True
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_______ and ________ become obstructed with cirrhosis
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blood vessels and lymphatics
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Causes of Liver Cirrhosis
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-Long-term liver disease
-Excessive alcohol intake -Alcohol vs malnutrition -NAFLD (non alcoholic fatty liver disease) -Biliary causes -Cardiac cirrhosis |
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NAFLD is often caused by
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-Increase in BMI/Obesity
-High COH intake |
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Biliary causes of liver cirrhosis
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-Primary biliary cirrhosis (PBC): obstruction in the hepatic and common bile duct
-Primary sclerosing cholangitis |
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Cardiac Cirrhosis is caused by
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Right side of heart back flowing into the liver
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Increased Bilirubin can cause
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Jaundice in the sclera and skin
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Early s/s of liver cirrhosis
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-n/v
-Anorexia -Dyspepsia -Flatulence -Diarrhea or constipation -Abdominal pain -Fever -Slight weight loss -Enlargement of liver and spleen |
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If the spleen is palpable this is a sign of
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disease
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Late s/s of Liver Cirrhosis
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-Jaundice
-Peripheral edema -Ascities -Skin lesion -Hematologic disorders -Endocrine disturbances -Peripheral neuropathies -Liver size decreases & nodular |
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Jaundice associated with cirrhosis is caused by
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-Functional derangement of liver cells
-Compression of bile ducts by connective tissue growth -Decreased ability to conjugate and excrete bilirubin (hepatocellular jaundice) |
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Skin lesions associated with Cirrhosis
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-Spider angiomas (telangiectasia or spider nevi)
-Palmar erythema |
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Spider angiomas are typically located on
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-nose
-face -neck -palms |
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Spider angiomas and palmar erythema are attributed to
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an increase in circulating estrogen as a result of the damaged liver's inability to metabolize steroid hormones
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Hematologic problems associated with cirrhosis
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-Thrombocytopenia
-Leukopenia -Anemia -Coagulation disorders -Splenomegaly |
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Endocrine problems associated with cirrhosis
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-Inactivation of adrenocortical hormones, estrogen, and testosterone
-Hyperaldosteronism |
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Male endocrine problems associated with cirrhosis
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-Gynecomastia, loss of axillary and pubic hair, testicular atrophy, impotence, loss of libido
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Women endocrine problems associated with cirrhosis
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-Younger women: amenorrhea (no period)
-Older women: vaginal bleeding |
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A common finding of cirrhosis
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Peripheral neuropathy
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Peripheral neuropathies associated with cirrhosis may be related to
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-dietary deficiency
-folic acid -Cobalamin |
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Peripheral neuopathies may cause
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mixed nervous system symptoms
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Complications associated with liver cirrhosis
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-Portal hypertension
-Esophageal & Gastric Varices -Peripheral edema -Ascites -Hepatic encephalopathy (coma) -Hepatorenal syndrome |
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Hepatic portal hypertension causes
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blood vessels in the liver become obstructed/ occluded and increase pressure
-Increase pressure builds up and makes varices (colateral) causing bleeding |
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Ascites occurs as a result of
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portal hypertension pushing fluid into the abdomen
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Compensated Cirrhosis
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Patients without complications of their disease
i.e. stop drinking alcohol |
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Decompensated Cirrhosis
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Patients who have one or more complications of their disease
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Portal Hypertension
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-Compression and destruction of the portal and hepatic veins
*obstruction of normal blood flow |
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Medication for Portal Hypertension
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non-selective beta blocker
*Inderal |
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Esophageal Varices
(caused by cirrhosis) |
complex of tortuous veins at the lower end of the esophagus, enlarged and swolen
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Gastric Varices
(caused by cirrhosis) |
located in the upper portion (cardia, fundus) of the stomach
*May occur alone or along with esophageal varices |
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Medications for Gastric and Esophageal Varices
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-Vasopressin IV to minimize bleeding
-Vitamin K -FFP |
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Factors producing ulcerations
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-Alcohol ingestion
-Swallowing of poorly masticated food -ingestion of coarse food -acid regurgitation from the stomach -Straining during BM -coughing or sneezing -Lifting heavy objects |
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Ways to prevent ulceration bleeding
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-Give stool softener
-Give PPI -Give antitussive |
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If you are unsure if the patient's cirrhosis is compensated or uncompensated and the MD calls or insertion of an NG tube what should you do?
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Tell the MD that the patient has cirrhosis of the liver and bleeding may result due to insertion of the NG tube
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Ascites
(caused by cirrhosis) |
The accumulation of serous fluid in the peritoneal or abdominal cavity
*abdominal distention and weight gain |
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Causes of ascites
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-Lymphatic system unable to carry off the excess proteins and water
-Hypoalbuminemia -Hyperaldoseronism -Increased in antidiuretic hormone |
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RN implementation with ascities
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Measure in the same location (mark) and weigh daily to determine progression of ascites
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s/s of ascities
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-Dehydration (hypovolemia)
-Dry tongue and skin -Sunken eyeballs -Muscle weakness -Decreased in urinary output -HYPOKALEMIA |
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Hepatic Encephalopathy
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-A neuropsychiatric manifestation of liver damage
-Terminal complication of liver disease -Causes ammonia to enter the systemic circulation without liver detoxification |
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What happens with Hepatic Encephalopathy?
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Ammonia crosses the blood-brain barrier and produces neurotoxic manifestations
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During hepatic encephalopathy, the liver is unable to
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convert ammonia to urea
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True/False
Hepatic encephalopathy is curable |
False
*Hepatic encephalopathy is a TERMINAL complication of liver disease |
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S/S of Hepatic encephalopathy
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-Changes in neurologic and mental responsiveness
-sleep disturbances -lethargy -coma -Asterixis (flapping tremors) -Fetor hepaticus (musty, sweet odor of pt's breath) |
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Hepatorenal Syndrome
(caused by cirrhosis) |
Functional renal failure with azotemia, oliguria and intractable ascites
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True/False
Hepatorenal syndrome causes structural damage to the kidneys |
False
Hepatorenal syndrome DOES NOT cause structural damage to the kidneys |
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True/False
Hepatorenal syndrome can be reversed by liver transplantation |
True
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Lab Findings with Cirrhosis
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-Alkaline Phosphate, AST, ALT, GGT are initially elevated
-Decreased Cholesterol levels (because the liver cant make it) -Prothrombin time is prolonged |
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Lab findings in compensated or end-stage liver disease
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-Decreased AST and ALT levels may be normal
-Decreased protein -Decreased albumin -Increased serum bilirubin -Increased globulin levels |
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Nursing care for Ascites
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-Sodium restriction
-Diuretics -Fluid removal |
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Na+ restriction is required for pt's with ascites because
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Aldosterone
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RN intervention for increased pressure on diaphragm r/t ascites
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monitor pulse ox
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RX Diuretics for Ascites
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-Spironolactone (Aldactone)
-Amiloride (Midamor) -Triamterene (Dyenium) -Furosemide (Lasix) -Hydrochlorothiazide (Hydrodiuril) |
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Interventions for fluid removal associated with ascites
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-Paracentesis
-Peritoneovenous Shunt |
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RN interventions/cautions with paracentesis
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-Watch BP
-Give Albumin (due to removal of electrolytes) -Raise HOB |
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Goal for Esophageal and gastric varices
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-Avoid bleeding/hemorrhage
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Things to avoid with Esophageal and gastric varices
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-ASA
-Alcohol -irritating foods |
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Endoscopic Ligation for varices
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Banding of varices
*fewer complications than sclerotherapy |
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Balloon Tamponade for varices
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-Used for esophageal varices
-Controls hemorrhage by compression of varices -Uses Sengstaken-Blakemore tube |
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RN care for Hepatice Encephalopathy
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-# I GOAL: SAFETY b/c LOC
-Restrict protein intake in early stages -Lactulose -D/C sedatives, tranquilizers, analgesics -Phenergan (decrease anxiety) |
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Protein restriction during Hepatic Encephalopathy is due to
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protein is broken down to acid = ammonia. The liver cant change the ammonia to urea = Increase in ammonia
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Action of Lactulose
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-Minimizes ammonia in the gut through bowel evacuation
-Fecal flora are changed to organisms that do not produce ammonia from urea |
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When administering Lactulose the patient should
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have at lease 3 diarrhea stools to pass all of the ammonia
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Acute intervention for Hepatic Encephalopathy
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-Maintain safe environment
-Assess: *Level of responsiveness *Sensory and motor abnormalities *F&E imbalances *Acid Base balance *Effect treatment measures *Neurologic status q2h *Prevention of constipation (don't want stool in colon too long) *limit physical activity (neurological safety) *Control hypokalemia *Ensure proper nutrition |
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Nursing Assessment for Cirrhosis
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-Past health history
*Chronic alcoholism *Viral hepatitis -Physical exam -RX -Weight loss -Jaundice -Abdominal distention -n/v -Altered mentation -RUQ pain -Abnormal lab values |
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Nursing diagnosis for Cirrhosis
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-Imbalanced nutrition: Less than body requirements
-Impaired skin integrity -Ineffective breathing pattern -Excessive fluid volume -Dysfunctional family process: Alcoholism |
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Rx should be avoided with Cirrhosis
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-Tylenol
-Statins -INH -Cymbalta -Cava Cava |
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True/False
The older the cirrhosis patient, the lower the drug clearance |
True
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Health Promotion for Cirrhosis Patients
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-Treat alcoholism
-Identify hepatitis early -Stress importance of adequate nutrition -Identify biliary disease early and treat |
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Viral Hepatitis
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-Inflammation and necrosis of hepatic cells
-Bile flow is impaired -Necrosis occurs in a spotty pattern -Liver cells may regenerate during recovery period |
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Types of Viral Hepatitis
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-A (HAV)
-B (HBV) -C (HCV) -D (HDV) -E (HEV) |
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Hepatitis B,C,D are transmitted by
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blood products and body fluids
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Hepatitis A and E are transmitted by
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Oral/Fecal route
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The only way to determine the type of Hepatitis is by
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an antigen test
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Possible triggers of hepatitis
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-German measles
-Herpes |
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Hepatitis vaccines are only available for
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Hep A and B
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Hep B may develop into
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Hep D
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HAV
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-Also known as "infectious hepatitis"
-Often transmitted by poor sanitation -Incubation period of 15-50 days |
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HAV may occur with or without symptoms that are often _____ like
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Flu like
*preicteric phase: headache, anorexia, fever *Iceric phase: dark urine, jaundice of skin, sclera |
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HAV vaccine is recommended to
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-Travelers to locations of poor sanitation
-High risk groups -Homosexual men -IV drug users -Day care workers |
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RN management for HAV includes
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-Stressing good hygiene
-Environmental sanitation (fecal contamination) |
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HAV outcome
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-Usually mild with recovery
-Fatality rate less than 1% -No carrier state -No increased risk of chronic hepatitis, cirrhosis or hepatic cancer |
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HBV
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-Also know as "Serum hepatitis"
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Health care workers are at greatest risk for
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HBV
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HIgh risk groups for HBV
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-IV drug users (may develop down the road
-Homosexual activity -May occur with or without symptoms (rash) |
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HBV vaccine is used to promote
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Active immunity
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HBV vaccine is recommended for
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-HCP
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PAssive HBV immunity is provided through
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-Hepatitis B immune globulin (HBIG)
-Recommended for people exposed to HBV that have nor received the vaccine or have never had HBV |
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Rn Management for HBV
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-Proper nutrition
-Rest -Prevention of spread through body fluids |
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HBV patients have an increased risk for
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-Cirrhosis
-Chronic hepatitis -Hepatic cancer |
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True/False
Carrier state is possible with HBV |
True
*fatality 1-10% |
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HCV
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-Also known as non- A and non- C
-Clinical course similar to HBV -Chronic carrier state occurs frequently -Increase risk for chronic liver disease and cancer |
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Transmission of HCV is commonly done by
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-Blood transfusion
-exposure to blood contaminated equipment or drug paraphernalia -Sexual contact |
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Treatment for HCV
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-Interferon (reduces viral load and liver enzymes)
-Ribavirin |
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HCV accounts for ______% of all liver transplants in US
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30
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True/False
There is no treatment for Viral Hepatitis until it reaches the chronic phase |
True
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HDV
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-Only individuals with HBV at risk
-Sexual contact, drug use -Similar symptoms to HBV -More likely to develop cirrhosis |
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HEV
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-Similar to HAV
-Jaundice usually always present -Poisonous mushrooms -Rat poison |
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Incubation period for HAV
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15-50 days
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Incubation period for HBV
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1-6 months
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Incubation period for HCV
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15-160 days
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Incubation period for HEV
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15-65 days
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Toxic and Drug induced Hepatitis
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-Inflammatory condition caused by ingestion or inhalation of certain substances
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Inhalation substances that can cause hepatitis
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-Dry cleaning fluid
-Glue -Insecticides -Poisonous mushrooms -Rat poison |
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Drug induced hepatitis caused by
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-Tylenol
-ASA -Thorazine -INH -Valium |
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S/S of drug induced hepatitis
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-Similar to viral hepatitis
-GI and flu symptoms -Jaundice -Hepatomegaly *may take days or months to appear |
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Diet for Hepatitis
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- High glucose
- High calorie - Low protein - Low Na+ (ascites) - Low fat |
