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Copy of Liver Cirrhosis

Nursing 250
by

Barbara Rhine

on 29 March 2014

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Transcript of Copy of Liver Cirrhosis

Scenario:
32 yr old female
Grandmother brought her into ER with c/o being fatigue, confused, extremly weak, more yellow, and bigger belly.
Drinking history dates back to age 21.
Dx w/ Alcoholic Hepatitis in April 2010.
Started AA classes in August 2010.
Dx w/Alcoholic Liver Cirrhosis in 2011.
Pt made staff aware she had been secretly binge drinking again.
Has been considered NOT a transplant patient in a number of facilities.
Also the mother of two children.

Primary Dx:
Hepatic Failure with
Hepatic Encephalopathy
Pathophysiology:
Alcohol has toxic affects on the liver.
Hepatocytes become infammed and
damaged.
Liver functions such as storing,
metabolizing, and excreting is impaired.
Nodules form and the liver becomes
sclerotic.
Portal hypertension arises and causes a
number of complications.
Blood is shunted to other areas and
more complications occur.
Abnormal Assessment Findings
Glasgow Coma scale of 12, confusion, slurred speech, weak and drowsy.
Dyspnea at rest, bilateral crackles, and
resp rates up to 26 bpm.
+1 bilateral pitting edema in legs, +1 pedal pulses
Ascites, 10 lbs weight gain in the last week, loose stools, n/v, abdominal pain, and decrease in appetite.
Cloudy and rusty colored urine.
Jaundice, ecchymosis, and striae.

HE
Increase Ammonia Levels
Pressure on the diaphragm
3 L NC, HOB > 30,
Albuterol tx q 6 h
Shunting of blood
TEDS, SCDS
Platelet precautions
Fluid shift from the portal
hypertension and also
liver loses ability to make
enough albumin
Aldactone
NG Tube Feeding
Zofran
Parcentesis on day 1, removal of almost 4 Liters of yellow fluid
Lactulose
Peri care
Internal Rectal Catheter
uti
Ancef
Nursing Diagnosis:
P: Fluid Volume Excess
R: Increase pressure within the hepatic
circulation from liver cell damage.
C: +1 bilateral pitting edema in the legs,
bilateral crackles auscultated, weight
gain of 10 lbs within the last week.
Goal:
The patient will have a decrease in fluid volume as evidence by no signs of increasing edema, a decrease of 2-5 lbs in weight, and no crackles auscultated by day 2 of clinical (Jan. 28th, 2012).
Nursing Interventions:
The nurse will assess for fluid volume excess by monitoring daily weight, looking for edema, and listening to breath sounds q 8 hours.
The nurse will notify the physician of any abnormal lab values due to increase fluid volume (Na+, K+, Hgb, HCT).
The nurse will teach the pt why ascites is ocurring and ways to decrease fluid volume.

Evaluation:
Goal was met! Edema was measured and there was no new signs of edema noted or no new weight gain. Breath sounds were cleared by day two. The physician was notified of lab values and PRBCs were given for low HGb levels, pt was also placed on tele for K+ levels. Pt and family understood the teaching about ascites.
Nursing Diagnosis:
P: Altered Thought Process
R: A buildup of wastes in the
brain from impaired
excreting function of the
liver.
C: Ammonia level of 71,
Glasgow of 12,
and slurred speech.

Goal:
The pt will have an increase in thought process as evidence by a Glasgow scale of 15, clear speech, and a decrease in ammonia levels by day 2 of clinical (Jan. 28th, 2012).
Nursing Interventions:
The nurse will complete neuro checks q 2 hrs.
The nurse will collaborate with the physician of ammonia levels.
The nurse will teach the pt and family that Lactulose will be given to decrease ammonia but causes loose stools.
Evaluation:
The goal was partially met! Ammonia levels declined, the physician was aware, and the pt was taught about Lactulose, however, the pt was only having a very slight change of LOC (pt was talking more and indicated what she wanted but still had slurred speech.
These two Nursing Diagnosis are reflective
of two of the most common complications of liver cirrhosis. Both occur from the damage hepatocytes and the portal hypertension that arises.
What I learned?
As provider of care: good
assessment skills are crucial.
As manager of care: collaborate
with the physician on labs, assessment
findings, and pt requests.
As member of the discipline: follow your facilities codes of ethics and always be a pt advocate.
Abnormal Labs:
Medications:
Lab: Day 1 Day 2
WBC 19.07 25.00
RBC 2.51 2.19
Hgb 8.0 6.7
HCT 24.0 20.8
PLT 91 106
PT 22.5 22.9
INR 2.0 2.1
Ammonia 71 53
Albumin 1.5
AST 113 109
ALT 7 9
Bilirubin 7.7 7.2
These levels were high due to a UTI the pt had. Ancef an antibiotic was given.
The spleen is often affected in liver cirrhosis, causing Rbcs and platelets to be used up more quickly, and therefore leading to anemia in these patients. The patient was transfused with 1 Unit of Prbcs and placed in Platelet precautions.
The liver metabolizes alcohol as ....
Our liver normally breaks substances down to a water soluble form making it easier to excrete.
Alcohol is already water soluble so easily travels throughout the body and damages on the way.
Acetyaldehyde accumulates after excessive intake of alcohol and along with dehydration is responsible for 'hangover'.
Fatty acids accumulate in liver cells and also deposit around liver capillaries reducing blood flow and ultimately killing the cells (necrosis).
This leads to the deposition of collagen (fibrosis) and can advance to cirrhosis.



These are prolonged for the fact that the liver is not able to make clotting factors. IV Vitamin K was given as well as 2 Units of Fresh Frozen Plasma.
These levels are increased because the liver is not able to metabolize proteins such as ammonia. Ammonia is not being excreted as urea and builds up in the blood which can then cross into the brain. Lactulose was given.
These are the basic Liver Function Tests used to dx liver disease. Since the liver cells are damaged and hepatic circulation is being blocked these levels are off. Treating the complications that arise can only be completed, the pt needs a transplant.
Albuterol: Bronchodilator--> SOB/Dyspnea. Pt was having an easier time breathing. RN can evaluate by auscultating lungs sounds, monitoring Ox sats and labs (Hgb, Hct), and assessing respiratory rate.
Aldactone: K+ sparing diuretic --> Ascites & edema. Pt had a decrease in edema, decrease in wt, and no increases in ascites. RN can evaluate by assessing wt, adb girth, edema, I&O, labs (K+, Na+, BUN, CRT), and UO.
Ancef: Antibiotic--> UTI. Pt had no burning sensation, urine color from dark amber to yellow and cloudy. RN can evaluate effectiveness by monitoring WBCs, pt temp, I & O, and assessing urine color and consistency.
Humilin R: Regular Insulin/Antidiabetic--> Liver cirrhosis pts do not store enough or any insulin and therefore are hyperglycemic. Pt response was that she had wnl blood glucose levels and no s/s of hyperglycemia or hypoglycemia. RN can evaluate by monitoring BGL and giving Insulin subq based on sliding scale.
Lactulose: Laxative--> Increase ammonia levels. Pt response was having lots of loose stools and becoming more oriented throughout the day. RN can evaluate effectiveness by doing neuro checks q 2 hrs, monitoring I&O, and ammonia lab values.
Merrem: Anti-Infective--> Abdominal infections (peritonitis). Pt continued to have abdominal pain but no s/s of peritonitis. RN can evaluate by monitoring temp, WBC levels, and the paracentesis site.
Morphine: Opoid /Analgesic--> Pain. Pt continued to have abdominal pain throughout the shift. RN can evaluate by accessing pain q 4 hours.
Mycostatin (powder): Antifungal--> skin breakdown under breasts and coccyx. Pt response was that the reddness was decreasing and no c/o pain in these areas. Rn can evaluate by accessing the areas q 8 hours and applying the powder after cleaning the skin.
Sandostatin: Anti-diarrheal--> Loose stools from Lactulose. Pt continued to have diarrheal episodes, internal rectal catheter in place. RN can evaluate by accessing the amount of output from the catheter q 4 hours.
Zofran: Anitemetic--> N/V. Pt had no signs of n/v after receiving. Rn can evaluate by assessing pt for n/v q 4 hours.

Alcohol is....
The leading cause of liver cirrhosis.
Affects depend on the amount consumed.
Occurs in men more often than women.
Men need to consume 80 grams of alcohol a day to develop Alcoholic Liver Disease. That is a 6 pack of beer or a liter of wine.
Women are more vulnerable and only need 20 grams per day.
Lactulose
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