Cirrhosis and portal hypertension

CIRRHOSIS AND PORTAL HYPERTENSION
ADULT MED-SURG
A. End stage of chronic liver disease. Progressive, irreversible disorder , eventually leading to liver failure Functional liver tissue is destroyed and replaced by fibrous scartissueMetabolic functions of the liver are lost Bile statsis occurs due to constrictive bands Blood does not flow freely through the liver to inferior vena cava Increased pressure in portal venous system - congested veins resultII. CAUSESA. Alcoholic cirrhosis – most common cause1. Alcohol causes metabolic changes in liver2. Fatty infiltration of hepatocytes3. Inflammatory cells infiltrate the liver causing necrosis, fibrosis and destruction of functional liver tissue 4. Liver shrinks and develops a nodular appearance5. Malnutrition commonly accompanies alcoholic cirrhosisB. Billary Cirrhosis1. Obstructed bile damages and destroys liver cells2. Leads to inflammation, fibrosis and formation of regenerative nodulesC. Posthepatic Cirrhosis1. Results from chronic hepatitis B or C or unknown cause2. Liver is shrunken and nodular with cell loss and fibrosisIII. SIGNS AND SYMPTOMSA. Early – few symptoms1. Liver is usually enlarged and may be tender2. Dull ach in RUQ3. Weight loss, weakness and anorexia4. Bowel changes with diarrhea or constipationB. Late – related to liver cell failure and portal hypertension1. Malnutrition, muscle wasting Impaired nutrient metabolismImpaired fat absorption Decreased clotting factor synthesisIncreased platelet destruction by enlarged spleenImpaired vitamin K absorption and storage Impaired plasma protein synthesisIncreased pressure in portal venous system Impaired bilirubin metabolism and excretion http://www.dmacc.cc.ia.us/instructors/caklocke/cirrhosis.htm (1 of 5)14.03.2007 17:35:14 Accumulated metabolic toxinsImpaired ammonia metabolism and excretion MULTISYSTEM EFFECTS OF CIRRHOSIS
Agitation leading to lethargy, stupor, comaAsterixis (liver flap) flapping tremor of hands when arms are extended Bounding pulses, pulmonary hypertension,dysrhythmias Abdominal pain, anorexia, Nauses, Clay-coloredstools, peptic ulcers, GI bleeding, hemorrhoids Oligomenorrhea (female)(testicular atrophy (male) Jaundice, erythemai of palsm, spider angioma, decreased body hair, pruritis, ecchymoses, caput medusae (dilated veins around the umbilicus) leukocytopenia, increased susceptibility to infection IV. COMPLICATIONSA. Portal hypertension1. Normal blood flow returning to the heart from the abdominal organs collects in the portal veins and travels through the liver 2. Pressure increases in the portal vein due to restricted flow3. Collateral channels develop between the portal and systemic veins that supply the lower rectum and esophagus and the umbilical veins 4. Results in hemorrhoids, esophageal varices and caput medusae (dilated B. Splenomegaly1. Spleen enlarges due to portal hypertension and shunting of blood into splenic 2. Increased destruction of red and white blood cells and platelets3. Leads to anemia, leukopenia and thrombocytopeniaC. Ascites1. Accumulation of fluid in abdominal cavity2. Hypoalbuminemia – low serum albumin levelsD. Esophageal Varices1. Enlarged, thin-walled veins in the esophagus due to portal hypertension2. May bleed, rupture causing massive hemorrhageE. Hepatic Encephalopathy1. Accumulation of neurotoxins in the blood2. Ammonia accumulation – destroys brain cells http://www.dmacc.cc.ia.us/instructors/caklocke/cirrhosis.htm (2 of 5)14.03.2007 17:35:14 F. Hepatorenal Syndrome1. Renal failure with azotemia2. Sodium retention, oliguria, hypotensionV. TREATMENTA. Medications 1.Avoid known hepatotoxic drugs and alcohol (barbiturates, sedatives, hypnotics, and acetaminophen)2. Diuretics – reduce fluid retention and ascites Spironolactone – lasix3.Reduce nitrogenous load and lower serum ammonia levels Lactulose and neomycin. Reduce the number of ammonia forming organismsin the bowel and ammonium is excreted in the feces 4. Lower hepatic venous pressure- prevent rebleeding of esophageal varices Corgard, Imdur, Monoket5. Ferrous sulfate and folic acid – treat anemia6. Vitamin K – reduce risk of bleeding7. Antacids are prescribed as indicated8. Serax a benzodiazepine antianxiety/sedative drug, not metabolized by liver B. Dietary and fluid management1. Sodium intake is restricted to under 2 g/day2. Fluids are limited to 1500mL/day3. Adequate calories 75-100g of protein per day4. With encephalopathy is present, 60-80 g/day5. Vitamins and mineral supplements. Particularly B-complex6. Magnesium deficiency common in alcohol-induced cirrhosis7. TPN (total parenteral nutrition) may be initiated through a Central line Contains carbohydrates high concentration of dextrose), protein, e-lytesvitamins, minerals and fat emulsion.
New containers every 24 hours – procedure for checking similar to blood checks. Solutions are mixed specifically for patient based on lab value Always infused with pump Blood glucose levels carefully monitored and insulin may be administeredas needed. e-lytes also closely monitored and formula adjusted as needed High risk for infection due to disruption of skin barrier and highglucose solution. Monitor closely for S&S of infection C. Paracentesis1. Aspiration of fluid from peritoneal cavity to relieve respiratory distress2. Moderate withdrawal 500ml to 1L to reduce risk of fluid and electrolyte 3. 4-6L of fluid may be done Albumin intravenously during large Informed consentWeight prior to paracentesis Vital signs for baseline http://www.dmacc.cc.ia.us/instructors/caklocke/cirrhosis.htm (3 of 5)14.03.2007 17:35:14 Have client void immediately prior to test to avoid bladder puncturePosition seated, on side of bed or in chairAssess site for fluid leakage, change dressing prn D. Gastric Endoscopic1. Gastric lavage – saline improve visualization; decrease bleeding Nursing care during lavage Baseline assessment – VS, abdominal inspection, girth BS Pt teaching – gain cooperation during procedure Fowler’s or semi-fowlers position Verify placement - test 2. Varices may be sclerosed to reduce risk of recurrent bleeding3. Banding – small rubber bands are placed on varices to occlude blood flow4. Balloon tamponade – Sengstaken-blakemore tube and balloons are inflated to apply direct pressure on the bleeding varices ET tube inserted prior to support airway and reduce aspiration risk Short term measure onlyE. Transjugular intrahepatic portosystemic shunt (TIPS)1. Channel created through the liver tissue – shunt inserted to allow blood flow to 2. Relieves pressure in esophageal varices3. Stenosis and occlusion of shunt are frequent complications4. Increases the risk of developing hepatic encephalopathy5. Short term measureF. Surgery - liver transplantation Indicated for some clients with irreversible, progressive cirrhosis Placement confirmed by X-ray before use.
Triple lumen most common – administer meds, parenteral solutions, draw labs.
Review nursing care of Central Venous Catheter care Excess fluid volumeDisturbed thought processImpaired skin integrityImbalanced nutrition: less than body requirementsIneffective health maintenanceFatigue VII HOME CARE A. Teaching1. Avoid alcohol and other hepatotoxic drugs2. Diet and fluid intake restriction and recommendations3. Medications – timing, adverse effects 4. Bleeding precautions5. Manifestations of potential complications to be reported6. Skin care techniques to reduce pruritus and damage7. Ways to manage fatigue and conserve energy http://www.dmacc.cc.ia.us/instructors/caklocke/cirrhosis.htm (4 of 5)14.03.2007 17:35:14 1. Home health services, etc.
2. Local support groups3. Hospice if indicated http://www.dmacc.cc.ia.us/instructors/caklocke/cirrhosis.htm (5 of 5)14.03.2007 17:35:14

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