Assessment

and
Management
of Patients
With Hepatic
Disorders

Kenneth M. Sabido, RN, MN

 INTRODUCTIO
N
• The liver, the largest gland of the body and a
major organ, can be considered a chemical
factory that manufactures, stores, alters, and
excretes many substances involved in
metabolism.

• The liver is especially important in the

regulation of glucose and protein metabolism.
• The liver manufactures and secretes bile,
which has a major role in the digestion and
absorption of fats in the GI tract.
• The liver removes waste products from the
bloodstream and secretes them into the bile.
• Liver function is complex, and
hepatic dysfunction affects all body
systems.
• Liver disorders are common and
may result from a virus, obesity,
and insulin resistance, or exposure
to toxic substances, such as
alcohol, or tumors.
ASSESSM • HEALTH HISTORY
• Exposure to
• PHYSICAL ASSESSMENT
• Assess for skin
ENT hepatotoxic substance
or infectious agents
abnormalities (Jaundice,
Spider angioma)
• Occupation • Unilateral/bilateral
• Recreational and gynecomastia and Testicular
travel history atrophy (males)
• Alcohol and drug use • Cognitive status (recall,
(IV or injection drugs) memory, abstract thinking)
• Lifestyle behavior • Neurologic Status
• Past medical history • General tremor,
(liver disease) • Asterixis (seen in stage II
• Family history encephalopathy)
• Weakness
• Slurred speech
• Ascites (percussion, fluid
wave test)
• Tenderness (Palpation,
ballottement technique)
 DIAGNOSTIC
EVALUATION
• Liver Function Test
• Serum aminotransferases
• Alanine aminotransferase
(ALT),
• Aspartate aminotransferase
(AST),
• Gamma-glutamyl transferase
(GGT)
• Liver Biopsy
• OTHER DIAGNOSTIC TESTS
• Ultrasonography,
• Computed tomography (CT) scans,
• Magnetic resonance imaging (MRI)
• Laparoscopy
• Endoscopy
HEPATIC
DYSFUNCTION
Results from the damage to the liver’s
parenchymal cells

CAUSE OF HEPATIC DYSFUNCTION ;

1. directly from primary liver diseases, or
2. indirectly from either obstruction of bile
flow or
3. derangements of hepatic circulation.

Liver dysfunction may be acute or chronic

CHRONIC LIVER DYSFUNCTION – are more

common
 Bacteria, Virus, Anoxia, Metabolic disorders, Toxins, Medications, Nutritional
Deficiencies and Hypersensitivity states

Derangements of hepatic
Primary liver diseases Obstruction of bile flow
circulation.

Damage to the liver’s

parenchymal cells

Hepatic dysfunction

Chronic injury of
hepatocytes

Fibrosis or scaring Cirrhosis

 • Pallor
Physical signs of Liver Dysfunction
• Jaundice (skin, mucosa and
sclerae)
• Muscle Atrophy
• Edema
• Skin excoriation
• Petechiae
• Ecchymotic area (bruises)
• Unilateral/bilateral gynecomastia
and Testicular atrophy (males)
• Alteration in Cognitive status
• Alteration in Neurologic Status
• General tremor
• Asterixis
• Weakness
CLINICAL MANIFESTATION OF LIVER DISEASE
1. Jaundice
Types of Jaundice
A. Hemolytic jaundice
B. Hepatocellular jaundice
C. Obstructive jaundice
D. Jaundice due to hereditary hyperbilirubinemia
2. Portal hypertension
3. Ascites (consequence of Portal hypertension)
• Increased abdominal girth and rapid weight gain, SOB, striae and
distended veins, F&E imbalance
4. Varices (consequence of Portal hypertension)
• hematemesis, melena, or general deterioration in mental or
physical status
5. Nutritional deficiencies
6. Hepatic encephalopathy or coma
• mental status changes and motor disturbances(constructional
apraxia), alteration in mood and sleep pattern
MEDICAL PROBLEM PHARMACOLOGICAL MANAGEMENT
MANAGEME Ascites diuretes (Spinorolactone)

NT Esophageal Varices
(bleeding)
Octreotide (Sandostatin), Vasopressin (Pitressin), Beta-
blocking agents (Propanolol)
Hepatic Lactulose (Cephulac), Glucose, Antibiotics Neomycin,
Encephalopathy and metronidazole (Flagyl), and rifaximin (Xifaxan)
Coma

PROBLEM SURGICAL PROCEDURE

Ascites Paracentesis, Transjugular intrahepatic portosystemic
shunt (TIPS),
Insertion of a peritoneovenous shunt

Esophageal Varices no ideal surgical mgt. Balloon Tamponade, endoscopic

(bleeding) sclerotherapy, Endoscopic Variceal Ligation (Esophageal
Banding Therapy), TIPS, splenorenal, mesocaval, and
portacaval venous shunt, , Surgical Bypass Procedures,
Devascularization and Transection
 NURSING MANAGEMENT
PROBLEM NURSING RESPONSIBILITIES

Ascites Measure I&O, abdominal girth, and daily weight, monitor RR

Monitor serum ammonia, creatinine, and electrolyte levels to assess electrolyte
balance, response to therapy, and indications of hepatic encephalopathy

Esophageal Varices Monitor physical condition, Monitor and record VS, Assess nutritional and nuerological
(bleeding) status, Closely monitor BP,
The nurse provides support and explanations about medical and nursing interventions
to prepare both the patient and the family, because these procedures can be difficult
to undergo and observe.

Hepatic Neurologic status is assessed frequently. Mental status is monitored by keeping a daily
Encephalopathy and record of handwriting and arithmetic performance. I&O and body weight daily. VS q4
Coma Serum ammonia level is monitored daily, Provides safe environment and prevent
injury.
VIRAL HEPATITIS
Viral hepatitis
• is a systemic, viral infection in which
necrosis and inflammation of liver
cells produce a characteristic cluster
of clinical, biochemical, and cellular
changes.
• Hepatitis is easily transmitted and
causes high morbidity and
prolonged loss of time from school
or employment. Acute viral hepatitis
affects 0.5% to 1% of people in the • 5 definitive types of viral hepatitis that
United States each year. cause liver disease have been
• hepatitis A, B, C, D, and E. identified:
 Hepatitis A Hepatitis B Hepatitis C Hepatitis D Hepatitis E

ASSESSMENT AND Physical exam Physical exam Physical exam Physical exam Physical exam
DIAGNOSTIC Liver and spleen are HBV antigen Anti-HCV Anti-HDV Anti-HEV
moderately enlarged HBcAg Serum Bilirubin Serum Bilirubin Serum Bilirubin
HAV antigen may be HBsAg Liver Biopsy Liver Biopsy Liver Biopsy
found in the stool HBeAg
HBxAg

PREVENTION General precaution use of disposable Blood screening Blood screening Improved hygiene
Hand hygiene syringes, needles, and Sterile needles for Sterile needles for Food sanitation
Safe water supplies lancets and the drug injections drug injections Practice safe sex
Proper sewage introduction of Sanitary health care
disposal needleless IV settings
HAV vaccination administration
systems
HBV vaccination
Wearing gloves
Improved hygiene
Blood screening

MEDICAL Bed rest and -entecavir (ETV) and Direct-acting antiviral Chronic Hepatitis D Chronic hepatitis E
MANAGEMENT nutritious diet (SFF) tenofovir (TDF)-oral agents (with or can be treated with benefit from using
Gradual ambulation nucleoside analogs without pegylated- interferon alfa ribavin, an antiviral
interferon) drug

NURSING Assist with px and identifies psychosocial Use standard Use standard Advice Good hygiene
MANAGEMENT family coping, issues and concerns, precaution precaution Proper handwashing
Educate to seek Use standard Educate in mode of Educate in mode of
health care precaution transmission transmission
Use needleless system Use needleless system Use needleless system
NONVIRAL HEPATITIS
• Certain chemicals have toxic effects on the liver and produce acute liver cell necrosis or
toxic hepatitis when inhaled, injected parenterally, or taken by mouth.
• Some chemicals commonly implicated in this disease include carbon tetrachloride and
phosphorus.
• Drug-induced hepatitis is similar to acute viral hepatitis, but parenchymal destruction tends
to be more extensive.
• Medications that can lead to hepatitis include
• isoniazid (Nydrazid);
• halothane (Fluothane);
• acetaminophen;
• methyldopa (Aldomet); and
• certain antibiotics,
• antimetabolites, and
• anesthetic agents.
 NOVIRAL Hepatitis
Toxic Hepatitis Drug induced Hepatitis
DISEASE PROCESS At the onset of disease, toxic hepatitis Drug-induced liver disease is the most
resembles viral hepatitis. common cause of acute liver failure

ASSESSMENT History History

Physical assessment Physical assessment

Signs and Symptoms Anorexia, nausea, and vomiting the onset is abrupt, with chills, fever, rash,
jaundice and hepatomegaly pruritus, arthralgia, anorexia, and nausea.
Later - jaundice, dark urine, and an enlarged
and tender liver.

Medical Management Recovery from acute toxic hepatitis is rapid if A short course of high-dose corticosteroids
the hepatotoxin is identified early and Liver transplant
removed.
Liver transplant

Nursing Management Therapy is directed toward restoring and Assess for signs of infection
maintaining fluid and electrolyte balance, Promote comfort and supportive measures
blood replacement, and comfort and
supportive measures.
FULMINANT HEPATIC
FAILURE
• Fulminant hepatic failure is the clinical syndrome
of sudden and severely impaired liver function in
a previously healthy person.
• The generally accepted definition is that
fulminant hepatic failure develops within 8 weeks
after the first symptoms of jaundice
• Three categories are frequently cited:
1. Hyperacute - the duration of jaundice before
the onset of encephalopathy is 0 to 7 days;
2. Acute - the duration of jaundice is 8 to 28 days;
3. subacute liver - the duration of jaundice is 28
to 72 days
Causes of fulminant
hepatic failure
1. Viral hepatitis
2. Toxic medications (e.g., acetaminophen)
3. Chemicals (e.g., carbon tetrachloride),
4. Metabolic disturbances (e.g., Wilson
disease, a hereditary syndrome with
deposition of copper in the liver),
5. Structural changes (e.g., Budd–Chiari
syndrome, an obstruction to outflow in
major hepatic veins)
Clinical manifestations
• Jaundice and profound anorexia may be the
initial reasons the patient seeks health care.
• Fulminant hepatic failure is often accompanied
by;
• coagulation defects,
• kidney disease and
• electrolyte disturbances,
• cardiovascular abnormalities,
• infection,
• hypoglycemia,
• encephalopathy, and
• cerebral edema
• Supporting the patient in the ICU and
assessing the indications for and
feasibility of liver transplantation are
hallmarks of management.
• The use of antidotes for certain
conditions may be indicated such as N-
acetylcysteine for acetaminophen
toxicity and penicillin for mushroom
poisoning.
• Treatment modalities may include Medical
plasma exchanges (plasmapheresis) to Management
correct coagulopathy, to reduce serum
ammonia levels, and to stabilize the
patient awaiting liver transplantation,
and prostaglandin therapy to enhance
hepatic blood flow.
 Nursing
management

• Other support measures

include monitoring for and
treating hypoglycemia,
coagulopathies, and
infection.
 HEPATIC CIRRHOSIS
• Cirrhosis is a chronic disease
characterized by replacement of
normal liver tissue with diffuse
fibrosis that disrupts the structure
and function of the liver
• There are three types of cirrhosis or
scarring of the liver:
• Alcoholic cirrhosis, in which the scar
tissue characteristically surrounds
the portal areas. This is most
frequently caused by chronic
alcoholism and is the most common
type of cirrhosis.
 HEPATIC CIRRHOSIS
• Postnecrotic cirrhosis, in which there
are broad bands of scar tissue. This is a
late result of a previous bout of acute
viral hepatitis.
• Biliary cirrhosis, in which scarring
occurs in the liver around the bile
ducts. This type of cirrhosis usually
results from chronic biliary obstruction
and infection (cholangitis); it is much
less common.
 Bacteria, Virus, Anoxia, Metabolic disorders, Toxins, Medications, Nutritional
Deficiencies and Hypersensitivity states

Derangements of hepatic
Primary liver diseases Obstruction of bile flow
circulation.

Damage to the liver’s

parenchymal cells

Hepatic dysfunction

Chronic injury of
hepatocytes

Fibrosis or scaring Cirrhosis

 CATEGORIES
OF CIRRHOSIS
1. Compensated cirrhosis
• its less severe, often vague
symptoms, may be discovered
secondarily at a routine physical
examination.

2. Decompensated cirrhosis
• result from failure of the liver to
synthesize proteins, clotting
factors, and other substances
and manifestations of portal
hypertension
 • Compensated • Decompensated
Cirrhosis Cirrhosis
• Abdominal pain • Ascites
CLINICAL • Clubbing of fingers
• Ankle edema
MANIFESTATI • Continuous mild fever
• Firm, enlarged liver
ON OF • Epistaxis
• Flatulent dyspepsia
CIRRHOSIS • Gonadal atrophy
• Intermittent mild fever • Hypotension
• Palmar erythema • Jaundice
(reddened palms) • Muscle wasting
• Splenomegaly • Purpura (due to decreased
• Unexplained epistaxis platelet count)
• Sparse body hair, White nails
• Vague morning
indigestion • Spontaneous bruising
• Weakness and Weight loss
• Vascular spiders
 • HISTORY
• PHYSICAL EXAMINATION
• Serum alkaline phosphatase,
• AST,
• ALT
• GGT
• ULTRASOUND
• CT SCAN
• MRI
• Radioisotope liver scans, and
Elastography studies
ASSESSMENT AND • LIVER BIPOPSY
DIAGNOSIS (CONFIMATORY)
• ABG
 • Antacids/H2 antagonist – to
decrease gastric acid
• Vitamins and nutritional
supplements – to promote
healing of damage liver
• Potassium sparring diuretics
(Spinorolactone or
triamterene) to decrease
ascites

Medical
Management
 • Antifibrotic activity for treatment of Cirrhosis
colchicine,
angiotensin system inhibitors,
statins,
diuretics including spironolactone (Aldactone),
Immunosuppressants,glitazones such as
pioglitazone (Acto) or rosiglitazone (Avandia).
Herb milk thistle (Silybum marianum) to treat
jaundice for end-stage liver disease (ESLD) with
cirrhosis
SAM-e (S-adenosylmethionine) to improve liver
function
ursodeoxycholic acid (Actigall, Urso) for Primary
Medical biliary cirrhosis to improve liver function
Management
 • Nursing interventions are directed
toward;
promoting patient’s rest, (Activity and
mild exercise, as well as rest, are
planned.)
improving nutritional status, (small
frequent feedings)
providing skin care (frequent change in
position, apply lotion)
reducing risk of injury, (raise side rails,
use electric razor, soft bristle
toothbrush)
monitoring and managing potential
NURSING MANAGEMENT complications.(bleeding, hemorrhage,
FOR CIRRHOSIS hepatic encephalopathy, fluid volume
excess)
 • Hepatic tumors may be malignant or benign.
CANCER OF• Benign liver tumors were uncommon until oral
contraceptives were in widespread use.
THE LIVER
• Now, benign liver tumors such as hepatic adenomas occur
most frequently in women in their reproductive years who
are taking oral contraceptives
 • Primary liver tumors usually are
associated with chronic liver disease,
hepatitis B and C infections, and
cirrhosis.

• HCC (hepatocellular carcinoma) is

the most common type of primary
liver cancer, responsible for 75% of
all liver cancers,

• Other types of primary liver cancer

include;
• fibrolamellar carcinoma,
• angiosarcoma,

Primary Liver • hepatoblastoma,

• cholangiocellular carcinoma
Tumors • combined hepatocellular and
cholangiocellular carcinoma.
 RISK FACTORS FOR HCC
• Cirrhosis,
• chronic infection with HBV and
HCV,
• exposure to certain chemical
toxins (e.g., vinyl chloride,
arsenic)
• Cigarette smoking AND alcohol
use
• aflatoxin
Liver Metastases
• Metastases from other primary
sites, particularly the digestive
system, breast, and lung, are found
in the liver 2.5 times more
frequently than tumors due to
primary liver cancers
• First evidence of cancer in an
abdominal organ is the appearance
of liver metastases; unless
exploratory surgery or an autopsy
is performed, the primary tumor
may never be identified.
 Clinical Manifestations
• EARLY MANIFESTATION -pain—a
continuous dull ache in the right
upper quadrant, epigastrium, or
back.
• Weight loss,
• loss of strength,
• anorexia, and
• Anemia
• Enlargement of liver upon palpation
• Jaundice
• Ascites
Assessment and Diagnostic Findings
• Patient History
• Physical Examination
• Laboratory results • X-rays,
• Increased serum levels of bilirubin,
alkaline phosphatase, AST, GGT, and • liver scans,
lactic dehydrogenase • CT scans,
• Leukocytosis (increased white blood
cells)
• ultrasound studies,
• Erythrocytosis(increased red blood • MRI,
cells), • arteriography,
• hypercalcemia,
• hypoglycemia, and • Laparoscopy
• Hypocholesterolemia • PET (Positron emission
• alpha-fetoprotein (tumor marker) tomography)
• carcinoembryonic antigen (marker for • BIOPSY (CONFIRMATION)
advance cancer
 Medical Management
• Radiation therapy
• EFFECTIVE METHODS
• TARE-transarterial
chemoembolization
• Percutaneous placement
of a high-intensity source
for interstitial radiation
therapy
• Internal radiotherapy
• Chemotherapy -targeted
molecular therapy, sorafenib
(Nexavar)
• Systemic chemotherapy
 Medical Management
• Percutaneous Biliary Drainage
• Other Nonsurgical Treatments
• Laser hyperthermia
• Immunotherapy
• Transcatheter arterial
embolization
• ultrasound-guided injection
of alcohol
• Although these therapies may
prolong survival and improve
quality of life by reducing pain
and discomfort, their major
effect is palliative.
Surgical
Management
• Surgical resection
• Lobectomy
• Local Ablation
• Liver
Transplantation
 • For patients with liver cancer
anticipating surgery, support,
education, and encouragement
are provided to help them
prepare psychologically for the
surgery.
• Close monitoring and care for
the first 2 or 3 days, similar to
postsurgical abdominal and
thoracic nursing care.

• Educating Patients About Self-

Care
Nursing • The nurse collaborates with the
other members of the health
Management care team
 • Liver transplantation is used
to treat life-threatening
ESLD for which no other
form of treatment is
available.
• The transplantation
procedure involves total
removal of the diseased
liver and replacement with
a healthy liver from a
cadaver donor or with the
right lobe from a live donor
LIVER in the same anatomic
location (orthotopic liver
TRANSPLANTATION transplantation [OLT]).
Complications of
Liver
Transplantation
• Immediate postoperative
complications may include
bleeding,
infection,
rejection.
• Disruption, infection,
obstruction of the biliary
anastomosis, and impaired
biliary drainage may occur.
• Vascular thrombosis and
stenosis are other potential
complications.
 • The most frequently
occurring
complications include
• pulmonary emboli,
• portal vein
thrombosis,
• bile duct injury, and
• liver insufficiency
secondary to a
Complications of the resection that is too
extensive
LDLT Donor
Nursing Management
• The nurse must be aware of these issues and attuned to
the emotional and psychological status of the patient
and family.
• Referral to a psychiatric liaison nurse, psychologist,
psychiatrist, or spiritual advisor may help them cope
with the stressors associated with ESLD and liver
transplantation
• The nurse, surgeon, hepatologist, and other health care
team members provide the patient and family with full
explanations
• The need for close follow-up and lifelong adherence to
the therapeutic regimen, including immunosuppression,
is emphasized to the patient and family.
 • Two categories of liver abscess have been identified:
1. amebic -most commonly caused by Entamoeba
LIVER histolytica.
ABSCESSES 2. pyogenic. - much less common, but they are more
common in developed countries than the amebic
type
 Infection

Infection develops in the biliary or GI tract

infecting organisms may reach the liver through the biliary system, portal venous
system, or hepatic arterial or lymphatic system.

destroyed promptly, but occasionally some gain a foothold.

toxins destroy the neighboring liver cells and the resulting necrotic
tissue serves as a protective wall for the organisms.
The result is an abscess cavity full of a liquid
leukocytes migrate into the infected
containing living and dead leukocytes,
area
liquefied liver cells, and bacteria.
 • The clinical picture is one of sepsis with few or
no localizing signs.
Clinical Manifestations • Fever with chills and diaphoresis,
• malaise,
• anorexia,
• nausea, vomiting, and
• weight loss may occur.
• The patient may complain of dull abdominal
pain and tenderness in the right upper
quadrant of the abdomen.
• Hepatomegaly,
• jaundice,
• anemia, and
• pleural effusion may develop.
• Sepsis and shock may be severe and life
threatening
Assessment and
Diagnostic Findings
• Blood culture
• Aspiration of the liver abscess,
guided by ultrasound, CT, or MRI,
may be performed to assist in
diagnosis
• Percutaneous drainage of pyogenic
abscesses is carried out to
evacuate the abscess material and
promote healing.
Medical
Management
• Treatment includes
IV antibiotic therapy; the specific
antibiotic used in treatment
depends on the organism identified.
• Continuous supportive care is
indicated because of the serious
condition of the patient.
• Open surgical drainage may be
required if antibiotic therapy and
percutaneous drainage are
ineffective
• The nursing management depends on the
patient’s physical status and the medical
management that is indicated
• For patients who undergo evacuation and
drainage of an abscess, monitoring the drainage Nursing
and providing skin care are imperative Management
• Vital signs are monitored to detect changes in the
patient’s physical status.
• The nurse administers IV antibiotic therapy as
prescribed
• The white blood cell count and other laboratory
test results are monitored closely for changes
consistent with worsening infection.
• The nurse prepares the patient for discharge by
providing instruction
• Reference :

Thank you!!!