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56 Cards in this Set

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What cell in the liver conjugates bile?
Hepatocytes
What cells in the liver help prevent infections and how do they do that?
Answer: Kupffer cells

Rationale: Kupffer cells phagotize 99% of microbes that pass into the liver.
What are the functions of the liver?
Answer:
1) carbohydrate metabolism
2) Synthesis of amino acids
3) Production and secretion of bile
4) Metabolism of bilirubin
5) Detoxification of blood
6) Inactivats steroid hormones
7)Inactivates Aldosterone
8)Stores vitamins and minerals
9) Drainage of blood from GI tract
What happens if carbohydrate metabolism fx. fails?
Answer: Hypoglycemia and decreased energy.

Rationale: Carbohydrate metabolism keeps blood glucose levels steady.
What happens if synthesis of albumin fails?
Answer: Edema, ascities can occur and deplete circulating volume.

Rationale: Albumin maintains colloid osmotic pressure (keeps fluid in the vessels). Albumin is only made in the liver.
Your patient with liver failure has a prolonged PT/PTT, why is this significant?
Answer: A prolonged PT/PTT means that the liver is not synthesizing clotting factors. Bleeding tendencies/hemorrhage can occur. Upper GI bleeding is most common.
Why is a person with liver failure at risk for decreased healing and at a high risk for infections?
Answer: The liver is in charge of synthesizing immunoglobulins.
Eventhough the liver regenerates, the new tissue is not like the original tissue. The new tissue is very fibrotic. Why is this of concern?
Answer: Fibrotic tissue can occulde vessesls and result in not enough flow for bile or blood.Bile flows from the lover to gallbladder to duodenum.

Obstruction of flow causes:
1) decreased fat absorption
2) decreased Vit K absorption leading to bleeding/hemorrhage
Ammonia is a product of what?
Answer: Made by bacteria in the gut and from protein.
What does the liver convert Ammonia (NH3) to?
Answer: Ammonia (NH3) is converted to urea, which is excreted in the urine.
What happens if the liver fails to convert NH3 to urea?
Answer:
1) Hepatic encepholopathy: b/c of accumulation of NH3 in the blood stream.

2) Changes in LOC, memoey, coordination-- progression to a coma.
What is the condition known as hepatic encepholopathy?
when the liver cannot properly metabolize and and turn poisons into harmless substances in the body, these poisons build up in the bloodstream. One substance believed to be particularly harmful to the central nervous system is ammonia, which is produced by the body when proteins are digested. Ammonia is normally made harmless by the liver. Many other substances may also accumulate in the body if the liver is not working well. They add to the damage done to the nervous system.
What happens if the liver fails to inactivates estrogen, progesterone, and testosterone?
Answer: Increased hormone levels can cause
1) gynecomastia and testicular atrophy

2) Spider angiomata, palmar erythema

3) Altered hair distribution

4) Amenorrhea
What does Aldosterone do?
Excrete sodium and water
What happens if the liver fails to inactivate aldosterone?
Answer:
1) Sodium and water retention causing edema/ascities
2) Increased potassium and hydrogen ion excretion causing hypokalemia and alkalosis.
Why is it important about the fx. of the liver storing vitamins and minerals?
For RBC production and iron stores?
What happens when the liver fails to store vitamins and minerals?
Answer:
1) Anemia
2) Decreasing energy/weakness/fatigue
What happens if the liver fails to drain blood from GI tract?
Answer:
1) Altered GI fx.
2) N/v
3) Anorexia, indigestion
4) flatulence, constipation
Diagnostic Testing

In liver failure, what laboratory tests would you expect to elevated?
1) ALT
2) AST
3) LDH
4) Alkaline phosphatase
5) Bilirubin (dep on degree of obstruction)
6) PT/PTT
7) Ammonia
In liver failure, what laboratory tests would you expect to decreased?
1) Albumin
2) Total protein
What is the most common complication of a liver biopsy?
Answer: hemorrhage
What is cirrhosis?
Answer: Chronic progressive diffuse fibrosis of liver with nodule formation

1) Structural damage
2) Secondary obstruction within liver
What is the most common cirrhosis in the US?
Answer: Portal (Laennec's or alcoholic)

-15% of all alcoholics develop cirrhosis
-75% of all cases in US
What is the most common cirrhosis worldwide?
Answer: Postnecrotic (hepatoxins)

a. following viral hepatitis or exposure to other hepatotoxins (drugs, chemicals)
Whatis the single most important factor contributing to the development of ascities?
Accumulation of fluid in the peritoneal cavity. [ascities]

Causes
1) Portal hypertension: b/c of obstruction of blood flow. High portal venous pressure results in development of collateral circulation by neighboring low pressure veins in attempt to link the portal and systemic venous system.

Common areas where the collateral pathways form are in the lower esophagus and stomach, abdominal wall, parietal peritoneum and the rectum.

These dulated vessels are called esophageal varices, caput medusae (paraumbilical varicies), and rectal varicies (hemorrhoids)
Besides portal hypertension what are some other contributing factors to ascities?
1) Hypoalbuminemia: b/c decreased albumin synthesis by the liver and loss of plasma proteins into ascitic fluid reduces osmitic pressure within the vascular compartment.

2) Hyperaldosteronism- depletion of circulating blood volume do to recrease in colloid osmotic pressure stimulates secretion of aldosterone from adrenal cortex.

This leads to: retntion of Na and H20. The liver is unable to metabolize aldosterone. ASH is also secreted in response to the depleted circulating blood volume....

Which results in: increased renal tubular water reorption.

THUS: Sodium and water resorption and retention contine, providing more fluid and INCREASED ascities.
When is treatment indicated for ascites?
Answer: When it interferes with respiration, causes impairment of tissue integrity or interferes with mobility.
How would you support respiratory function?
Answer: Encourage deep breathing exercises to prevent atelectasis.
You are a nurse with a patient with ascities r/t renal failure. What diuretic is given and what must it be given with?
Answer: The diuretic spironolactone (Aldactone) is given.

This medication is a aldosterone antagonist (remember the liver innhibits aldosterone)!

Aldactone is always given with albumin IV.
Why is Aldactone always given with albumin?
Answer: Albumin helps pull fluid into vascular space so that whenyou give the diuretic it will go OUT.

Note: Remember the liver is responsible for the synthesis of albumin, so if the liver is not working correctly the body will need additional albumin because the liver may not be making enough if any at all.

FYI: monitor fluid balance-- VS watch for hyportensiveness and hypovolemic shock.
What medical procedure is done to remove fluid from the abdomen and when is an indicator to have it done?
Answer: A paracentesis is done to remove fluid from the abdomen. This is done if the patient is having difficulty breathing and breathing is uncomfortable.

COMFORT MEASURE, the fluid will always come back.
What is a peritoneal venous shunt (LeVeen or Denver)used for?
Answer: A PVS provides a method of reinfusing ascetic fluid into the systemic circulation.

This is done as a comfort measure.
A patient that has a peritoneal venous shunt (LeVeen or Denver) is at risk for what? And what should you monitor for?
Answer: This patient is at risk for overload. The process works quickly.

Fluid moves from the abdomen to the SVC during pressure changes that occur with inspiration.

Note: Listen to heart and breath sounds.
What are some other complications that the nurse should monitor for a patient who has a peritoneal shunt?
Answer: DIC, CHF, SHUNT clotting.
A patient is having uncontrolled or recurrent variceal bleeding. What interventions may be done to control the bleeding?
Answer: Transjugular Intrahepatic Portosystemic Shunt (TIPS)
What is a Transjugular Intrahepatic Portosystemic Shunt?
Answer: A stent is placed in the liver to connect portal and hepatic veins.

Thus...blood bypasses the liver on the way back to the heart)
What are the possible complications of TIPS?
Answer: Stenosis and encephalopathy.

Blood bypasses liver = no detoxification and thus contributes to encephalopathy.
Portal hypertension causes esophageal varicies. What is the most dangerous consequence of esophageal varicies?
Answer: Bleeding frequent, abrupt, and massive.
What is the main therapuetic goal in working with a patinet that has esophageal varicies?
Answer: Prevention of bleeding and hemorrhage.
What is imporatant to teach a patient who has esophageal varicies?
Answer: It is important to teach the patient to avoid: 1)coughing and sneezing
2)valsalva
3)exercise that raises intra-abdominal pressure
4) Rough food
5) ETOH
6) GI irritants
You have a patient that has esophageal varicies, and is actively bleeding. What do you expect to be done to manage the bleeding?
Answer:
I. Replacement of fluid (LR's) and blood
II. Fresh whole blood is best
III. Administer Vasopression with Nitroglycerine.
IV. Gastric lavage with cold saline intil it returns clear or in preparation for endoscopy (constricts blood vessels)
Why is is important to give vasopressin and nitroglycerine together when treating an esophageal varice bleed?
Answer: Vasopressin is a very powerful vesso-constrictor.

Thus it can cause coronary arteries to constrict resulting in angina.

This is why nitroglycerine is given to compensate for the powerful vasoconstrictor to ensure adequate perfusion in the body.
In order to prevent hepatic encephalopathy from breakdown of blood and the release of ammonia in the intestine, what medication is given?
Answer: Neomycin
Your patient has an esophageal tamponade/ballon tampnade. The balloon ruptures with traction on, what nursing intervention should be done?
Answer: Deflate all balloons and remove to prevent airway obstruction, it can cover the trachea and cause respiratory distress.
You are taking care of a patient with a balloon tamponade how often should the balloon pressures be recorded? And what else should be monitored?
Answer: Record balloon pressures every hour. Monitor vital signs closely and oxygen saturation.

Note: Mouth/nose care and suction because secretions pool above the balloon.
What purpose does a portacaval shunt have?
Answer: A portacaval shunt serves as a means to divert portal blood around ht eliver to lower portal pressure.
Your patient has a portacaval shunt, what is this patient at an increased risk for?
Answer: This patient is at increased risk for HEPATIC ENCEPHALOPATHY because of the decrease NH3 (ammonia) detoxification (thus build up of NH3)

This shunt also decreases cleaning of the blood.
Your patient that has a portacaval shunt is experiencing disturbances in conscoiusness, behavior, and neurologic abnormalities. What syndrome does this patient most likely have?
Answer: Hepatic encephalopahy.
What would you suspect would be the cause of hepatic encephalopathy?
Answer: GI bleeding--> blood contains protein, and when this protein is broken down by intestinal bacteria excess ammonia is released and absorbed. Thus increase in ammonia levels are toxic to the CNS.

Remember: Ammonia is a product of protein being broken down.

So...increased dietary protein may cause encephalopathy.
Besides from GI bleeding and an increased dietary protein what else may precipitate encephalopathy?
Answer:
1) Electrolyte disturbances- hypokalemia
2) Hypoxia-- increases acute toxicity of ammonia
3) CNS depressants -- cannot be detoxified by the liver--> results in high serum levels of drugs causing increased cerebral depression.
4) Acute infections- result in tissue breakdown (protein), thus inreasing nitrogenous load.
5) Constipation results in increased absorption of ammonia and mercaptans.
What corresponds with an inrease in ammonia (NH3)?
Answer: EEG

A dec. LOC can also occur but the level at which it occurs at depends on each person.
A patient with known liver disease is experiencing axterixis (flapping tremor of the hands when extended), Fetor Hepaticus (musty odor of the breath), and has a decline in coordination as observed with the patient's handwriting what is this change due to?
Answer: Hepatic encephalopathy.
Your patient has been diagnosed with hepatic encephalopathy, what medication do you expect to be given to decrease ammonia levels?
Answer: Lactulose: to lower NH3 levels by acting as a laxative. NH3 is passed through the stool.
Your patient has hepatic encephalopathy, and has been receiving Neomycin for a prolonged period of time, your patient has renal insufficiency. What is an important effect to watch for in patients who have prolonged use of Neomycin?
Answer: Ototoxicity and nephrotoxocity.
Because CNS depressants cannot be used with a patient with hepatic encephalotoxicity because it cannot be detoxified by the liver and results in high serum levels of drugs causeing increased cerebral depression, what medication can be used for sedation?
Answer: Phenobarbital or Librium.
What is the unexplained progressive renal failure occurring in patients with cirrhosis and ascites in the absence of other known causes of renal failure; indicates a poor prognosis?
Answer: Hepatorenal syndrome