Chapter 43

Assessment and Management of

Patients with Hepatic Disorders

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Review of Anatomy and Physiology

Largest gland of the body

Located in the upper right abdomen
A very vascular organ that receives blood from GI
tract via the portal vein and from the hepatic artery

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Liver and Biliary System

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Section of a Liver Lobule

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Metabolic Functions of the Liver
Glucose metabolism
Ammonia conversion ( produced by cells , mostly
liver to produce urea
Protein metabolism
Fat metabolism
Vitamin and iron storage
Bile formation ( carry waste, fat breakdown , dark brown color to
your feces
Bilirubin excretion( pigment form breakdown of RBC,pass
through the liver
Drug metabolism

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Question #1

Is the following statement true or false?

The majority of blood supply to the liver, which is poor

in nutrients, comes from the portal vein.

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Answer to Question #1

False

Rationale: The majority of blood supply to the liver,

which is rich in nutrients from the gastrointestinal
tract, comes from the portal vein.

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Liver Function Studies

Serum aminotransferase: AST, ALT, GGT, GGTP, LDH

Serum protein studies
Direct and indirect serum bilirubin, urine bilirubin,
and urine bilirubin and urobilinogen
Clotting factors
Serum alkaline phosphatase
Serum ammonia
Lipids
Refer to Table 43-1

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Liver Function Tests

Serum aminotransferases: indicators of injury to the

liver cells; useful in detecting hepatitis
Alanine aminotransferase (ALT): levels increase
primarily in liver disorders; used to monitor the
course of hepatitis, cirrhosis, the effects of
treatments that may be toxic to the liver
Aspartate aminotransferase (AST): not specific to
liver diseases; however, levels of AST may be
increased in cirrhosis, hepatitis, and liver cancer
Gamma-glutamyl transferase (GGT): levels are
associated with cholestasis; alcoholic liver disease

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Additional Diagnostic Studies

Liver biopsy
Ultrasonography
CT
MRI
Other

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Assessment of the Patient with
Alterations of the Liver

Health history
o Previous exposure to hepatotoxic substances or
infectious agents
o Travel, alcohol and drug use
o Lifestyle
Physical assessment
o Skin
o Cognitive status
o Palpation, percussion

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Hepatic Dysfunction

Acute or chronic, cirrhosis of the liver

Liver failure associated with alcohol use
Infection
Fatty liver disease
o Nonalcoholic fatty liver disease (NAFLD)
o Nonalcoholic steatohepatitis (NASH)

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Manifestations of Hepatic Dysfunction

Jaundice
Portal hypertension
Ascites and varices
Hepatic encephalopathy or coma
Nutritional deficiencies

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Jaundice

Yellow- or greenish-yellow sclera and skin caused by

increased serum bilirubin levels
Bilirubin level exceeds 2 mg/dL
Hemolytic, hepatocellular, obstructive
o Hereditary hyperbilirubinemia
Hepatocellular and obstructive jaundice are most
associated with liver disease

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Signs and Symptoms Associated with
Hepatocellular and Obstructive Jaundice

Hepatocellular( bilirubin Obstructive ( blocked

unable to leave the liver bile duct )
cells)  Dark orange-brown
 Mild or severely ill urine, clay-colored
stools
 Lack of appetite, nausea
or vomiting, weight loss
 Dyspepsia and
intolerance of fats,
 Malaise, fatigue, impaired digestion
weakness
 Pruritus
 Headache, chills, fever,
infection

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Portal Hypertension

Obstructed blood flow through the liver results in

increased pressure throughout the portal venous
system
Results in
o Ascites
o Esophageal varices

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Jaundice

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Ascites

Portal hypertension resulting in increased capillary

pressure and obstruction of venous blood flow
Vasodilatation of splanchnic circulation (blood flow to
the major abdominal organs)
Changes in the ability to metabolize aldosterone,
increasing fluid retention
Decreased synthesis of albumin, decreasing serum
osmotic pressure
Movement of albumin into the peritoneal cavity
Figure 43-5

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Assessment of Ascites

Record abdominal girth and weight daily

Patient may have striae, distended veins, and
umbilical hernia
Assess for fluid in abdominal cavity by percussion for
shifting dullness or by fluid wave
Monitor for potential fluid and electrolyte imbalances

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Treatment of Ascites

Low-sodium diet
Diuretics
Bed rest
Paracentesis
Administration of salt-poor albumin
Transjugular intrahepatic portosystemic shunt (TIPS)
Other methods: peritoneovenous

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Ascites

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Question #2

Which diuretic medication would most often be used

for a patient with ascites?
A. Actazolamide
B. Ammonium chloride
C. Furosemide
D. Spironolactone

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Answer to Question #2

D. Spironolactone
Rationale: Spironolactone is most often the first-line
therapy in patients with ascites from cirrhosis. Oral
diuretics such as furosemide may be added but should
be used cautiously. Ammonium chloride and
acetazolamide are contraindicated because of the
possibility of precipitating hepatic coma.

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Pathophysiology of Hepatic
Encephalopathy and Coma
Life-threatening complications: accumulation of
ammonia and other toxic metabolites in the blood
Two major alterations underlie its development in
acute and chronic liver disease
o Hepatic insufficiency: the inability of the liver to
detoxify toxic by-products of metabolism
o Portosystemic shunting: collateral vessels
develop allowing elements of the portal blood
(laden with potentially toxic substances usually
extracted by the liver) to enter the systemic
circulation
Early signs: mental changes and motor disturbances
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Assessment and Stages of Hepatic
Encephalopathy

Assessment
 EEG
 Changes in LOC
 Potential seizures
 Fetor hepaticus
 Monitor fluid, electrolyte, and ammonia levels
Stages: refer to Table 43-3

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Medical Management of Hepatic
Encephalopathy

Eliminate precipitating cause

Lactulose to reduce serum ammonia levels
IV glucose to minimize protein catabolism
Protein restriction
Reduction of ammonia from GI tract by gastric
suction, enemas, oral antibiotics
Discontinue sedatives, analgesics, and tranquilizers
Monitor or treat complications and infections

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Esophageal Varices

Occurs in 30% of patient with compensated cirrhosis

and 60% of patients with decompensated cirrhosis
First bleeding episode has a mortality rate of 10% to
30% depending on severity
Manifestations include hematemesis, melena,
general deterioration, and shock
Patients with cirrhosis should undergo screening
endoscopy every 2 to 3 years

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Treatment of Bleeding Varices #1

Treat for shock; administer oxygen

IV fluids, electrolytes, volume expanders, blood and
blood products
Vasopressin, somatostatin, octreotide to decrease
bleeding
Nitroglycerin in combination with vasopressin to
reduce coronary vasoconstriction
Propranolol and nadolol to decrease portal pressure;
used in combination with other treatment
Balloon tamponade

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Treatment of Bleeding Varices #2

Endoscopic sclerotherapy
Endoscopic variceal ligation (esophageal banding
therapy)
Transjugular intrahepatic portosystemic shunt
Additional therapies
Surgical management
o Surgical bypass procedures
o Devascularization and transection

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Nursing Management of Esophageal
Varices

Maintain safe environment; prevent injury, bleeding

and infection
Administer prescribed treatments and monitor for
potential complications
Encourage deep breathing and position changes
Education and support of patient and family

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Question #3

Is the following statement true or false?

Bleeding esophageal varices result in an increase in

renal perfusion.

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Answer to Question #3

False

Rationale: Bleeding esophageal varices do not result in

an increase in renal perfusion. Bleeding esophageal
varices result in a decrease in renal perfusion due to
loss of blood.

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Hepatitis

Viral hepatitis: a systemic viral infection that causes

necrosis and inflammation of liver cells with
characteristic symptoms and cellular and
biochemical changes
o A and E: fecal–oral route
o B and C: bloodborne
o D: only people with hepatitis B are at risk
o Hepatitis G and GB virus-C
Nonviral hepatitis: toxic and drug induced

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Hepatitis A

Spread by poor hand hygiene; fecal–oral

Incubation: between 2 and 6 weeks
Illness may last 4 to 8 weeks
Mortality rate is 0.5% for those younger than age 40
years and 1% to 2% for those older than age 40
years
Manifestations: mild flu-like symptoms, low-grade
fever, anorexia, later jaundice and dark urine,
indigestion and epigastric distress, enlargement of
liver and spleen

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Management of Hepatitis A

Prevention
o Good handwashing, safe water, and proper
sewage disposal
o Vaccine
o Refer to Chart 43-5
o Immunoglobulin for contacts to provide passive
immunity
Bed rest during acute stage
Nutritional support

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Hepatitis B

Transmitted through blood, saliva, semen, and

vaginal secretions; sexually transmitted; transmitted
to infant at the time of birth
A major worldwide cause of cirrhosis and liver
cancer
Risk factors: refer to Chart 43-7
Long incubation period: 1 to 6 months
Manifestations: insidious and variable; similar to
HAV, loss of appetite, dyspepsia, abdominal pain,
generalized aching, malaise, and weakness
Jaundice may or may not be evident

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Management of Hepatitis B

Medications for chronic hepatitis type B include

alpha interferon and antiviral agents: entecavir
(ETV) and tenofovir (TDF)
Bed rest and nutritional support
Vaccine: for persons at high risk, routine vaccination
of infants
o Passive immunization for those exposed
o Standard precautions and infection control
measures
o Screening of blood and blood products

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Hepatitis C

Transmitted by blood and sexual contract, including

needle sticks and sharing of needles
The most common bloodborne infection
A cause of one third of cases of liver cancer and the
most common reason for liver transplant
Risk factors: refer to Chart 43-8
Incubation period is variable: ranging from 15 to 160
days
Symptoms are usually mild
Chronic carrier state frequently occurs

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Management of Hepatitis C

Antiviral medications
Alcohol potentiates disease; medications that effect
the liver should be avoided
Prevention: public health programs to decrease
needle sharing among drug users
Screening of blood supply
Safety needles for health care workers

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Hepatitis D

Only persons with hepatitis B are at risk

Blood and sexual contact transmission
Use of IV or injection drugs, patients undergoing
hemodialysis, and recipients of multiple blood
transfusions
Likely to develop fulminant liver failure or chronic
active hepatitis and cirrhosis
Incubation period between 30 and 150 days
Interferon alfa is the only licensed drug available in
the treatment for HDV infection

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Hepatitis E

Transmitted by fecal–oral route, contaminated water

Incubation period: 15 to 65 days
Resembles hepatitis A; self-limiting, abrupt onset,
not chronic
Prevention: good hygiene, handwashing

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Question #4

Is the following statement true or false?

Only persons with hepatitis B are at risk for hepatitis
D.

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Answer to Question #4

True

Rationale: Only persons with hepatitis B are at risk for

hepatitis D. Hepatitis D is common among those who
use IV or injection drugs, patients undergoing
hemodialysis, and recipients of multiple blood
transfusions. Sexual contact with those who have
hepatitis B is considered to be an important mode of
transmission of hepatitis B and D.

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Other Liver Disorders

Nonviral hepatitis
o Toxic hepatitis
o Drug-induced hepatitis
Fulminant hepatic failure

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Hepatic Cirrhosis

Types
o Alcoholic: scar tissue characteristically surrounds
the portal areas
o Postnecrotic: broad bands of scar tissue
o Biliary: scarring occurs in the liver around the
bile ducts
Pathophysiology
Manifestations: liver enlargement, portal
obstruction, ascites, infection and peritonitis,
varices, GI varices, edema, vitamin deficiency,
anemia, mental deterioration
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Care of the Patient with Cirrhosis of the
Liver

Refer to Chart 43-10

Nursing interventions directed toward:
o Promoting rest
o Improving nutritional status
o Providing skin care
o Reducing risk of injury
o Monitoring and managing potential
complications

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Nursing Interventions for the Patient with
Cirrhosis of the Liver

Promoting rest
o Rest and supportive measures
o Positioning for respiratory efficiency
o Oxygen
o Planned mild exercise and rest periods
o Address nutritional status to improve strength
o Measures to prevent hazards of immobility

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Nursing Interventions for the Patient with
Cirrhosis of the Liver #1

Improving nutritional status

 I&O
 Encourage small frequent meals
 High-calorie diet, sodium restriction
 Protein modified or restricted if patient is at risk for
encephalopathy
 Supplemental vitamins, minerals, B complex, provide
water-soluble forms of fat-soluble vitamins if patient has
steatorrhea
 Consider patient preferences

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Nursing Interventions for the Patient with
Cirrhosis of the Liver #2

Providing skin care

o Frequent position changes
o Gentle skin care
o Reduce scratching related to pruritus
Reducing risk for injury
o Prevent falls, trauma related to risk for bleeding

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Collaborative Problems and Complications
of the Patient with Cirrhosis of the Liver

Bleeding and hemorrhage

Hepatic encephalopathy
Fluid volume excess

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Cancer of the Liver
Primary liver tumors
 Associated with hepatitis B and C
 Hepatocellular carcinoma (HCC)
Liver metastasis
 Few cancers originate in the liver
 Frequent site of metastatic cancer
Manifestations
 Dull persistent pain, RUQ, back, or epigastrium
 Weight loss, anemia, anorexia, weakness
 Jaundice, bile ducts occluded, ascites, or obstructed
portal veins
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Nonsurgical Management of Liver Cancer

Underlying cirrhosis, which is prevalent in patients

with liver cancer, increases risks of surgery
Major effect of nonsurgical therapy may be palliative
Radiation therapy
Chemotherapy
Percutaneous biliary drainage
Other nonsurgical treatments

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Surgical Management of Liver Cancer

Treatment of choice for HCC if confined to one lobe

and liver function is adequate
Liver has regenerative capacity
Types of surgery
o Lobectomy
o Cryosurgery
o Liver transplant

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Nursing Care of the Patient Undergoing a
Liver Transplantation

Preoperative nursing interventions:

o Support, education, and encouragement are
provided to help prepare psychologically for the
surgery
Postoperative nursing interventions:
o Monitor for infection, vascular complications,
respiratory and liver dysfunction, constant close
monitoring
Caregiver stress

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Patient Education for Liver Transplant

Education about long-term measures to promote

health
Adhere closely to the therapeutic regimen, with
special emphasis on administration, rationale, and
side effects of immunosuppressive agents
Education about the signs and symptoms that
indicate problems necessitating consultation with
the transplant team
Emphasize the importance of follow-up laboratory
tests and appointments with the transplant team

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