Chapter 49

Assessment and Management

of Patients With Hepatic
Disorders

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Hepatic Dysfunction
• Acute or chronic, cirrhosis of the liver
• Most common cause is malnutrition related to alcoholism
• Infection
• Anoxia
• Metabolic disorders
• Nutritional deficiencies
• Hypersensitivity states

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Manifestations

• Jaundice
• Portal hypertension, ascites, and varices
• Hepatic encephalopathy or coma
• Nutritional deficiencies

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Jaundice

• Yellow- or green-tinged sclera and skin caused by

increased serum bilirubin levels
• Hemolytic, hepatocellular, obstructive
– Hereditary hyperbilirubinemia
• Hepatocellular and obstructive jaundice are most
associated with liver disease

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Portal Hypertension

• Obstructed blood flow through the liver results in

increased pressure throughout the portal venous system
• Results in
– Ascites
– Esophageal varices

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Ascites: Fluid in Peritoneal Cavity—Causes
• 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

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Hepatic Encephalopathy and Coma
• Life-threatening complications: accumulation of
ammonia and other toxic metabolites in the blood
• Assessment
– EEG
– Changes in LOC
– Potential seizures
– Monitor fluid, electrolyte, and ammonia levels

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Bleeding of Esophageal Varices
• Occurs in about one third of patients with cirrhosis and
varices
• First bleeding episode has a mortality rate of 30% to
50%
• Manifestations include hematemesis, melena, general
deterioration, and shock
• Patients with cirrhosis should undergo screening
endoscopy every 2 years

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TIPS

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Endoscopic Sclerotherapy

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Esophageal Banding

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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.
– A and E: fecal–oral route
– B and C: bloodborne
– D: only people with hepatitis B are at risk
– Hepatitis G and GB virus-C
• Nonviral hepatitis: toxic and drug induced
• Refer to Table 49-4

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Hepatitis A

• Spread by poor hand hygiene; fecal–oral

• Incubation: 15 to 50 days
• 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 flulike 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
– Good handwashing, safe water, and proper sewage
disposal
– Vaccine
– Refer to Chart 49-7
– 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 49-9
• Long incubation period: 1 to 6 months
• Manifestations: insidious and variable; similar to hepatitis
A

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Management of Hepatitis B
• Medications for chronic hepatitis type B include alpha
interferon and antiviral agents: lamivudine (Epivir),
adefovir (Hepsera)
• Bed rest and nutritional support
• Vaccine: for persons at high risk, routine vaccination of
infants
– Passive immunization for those exposed
– Standard precautions and infection control measures
– 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 49-10
• Incubation period is variable
• Symptoms are usually mild
• Chronic carrier state frequently occurs

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Management of Hepatitis C
• Antiviral medications: interferon, ribavirin (Rebetol)
• Measures to reduce spread of infection as with hepatitis B
• 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 and E
• Hepatitis D
– Only persons with hepatitis B are at risk
– Blood and sexual contact transmission
– Likely to develop fulminant liver failure or chronic
active hepatitis and cirrhosis
• Hepatitis E
– Transmitted by fecal–oral route,
– Incubation period. 15 to 65 days
– Resembles hepatitis A; self-limiting, abrupt onset, not
chronic

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Other Liver Disorders

• Nonviral hepatitis
– Toxic hepatitis
– Drug-induced hepatitis
• Fulminant hepatic failure

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Hepatic Cirrhosis
• Types
– Alcoholic
– Postnecrotic
– Biliary
• Pathophysiology: refer to Table 49-5
• Manifestations: liver enlargement, portal obstruction,
ascites, GI varices, edema, vitamin deficiency, anemia,
mental deterioration; refer to Chart 49-11

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Nursing Process: The Care of the Patient
With Cirrhosis of the Liver—Assessment
• Focus: onset of symptoms, history of precipitating factors
• Alcohol use or abuse
• Dietary intake and nutritional status
• Exposure to toxic agents and drugs
• Assess changes in mental status, ADL and IADLs, job and
social relationships
• Monitor signs and symptoms related to bleeding;
changes in fluid volume and laboratory data

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Nursing Process: The Care of the Patient
With Cirrhosis of the Liver—Diagnosis
• Activity intolerance
• Imbalanced nutrition
• Impaired skin integrity
• Risk for injury and bleeding

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Collaborative Problems and Complications
of Cirrhosis of the Liver

• Bleeding and hemorrhage

• Hepatic encephalopathy
• Fluid volume excess

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Nursing Process: The Care of the Patient
With Cirrhosis of the Liver—Planning

• Goals may include increased participation in activities,

improvement of nutritional status, improvement of skin
integrity, decreased potential for injury, improvement of
mental status, and absence of complications

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

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

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Other Interventions
• Impaired skin integrity
– Frequent position changes
– Gentle skin care
– Reduce scratching related to pruritus
• Risk for injury
– Prevent falls, trauma related to risk for bleeding

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

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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
– Lobectomy
– Cryosurgery
– Liver transplant

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Nursing Care of the Patient Undergoing a
Liver Transplantation

• Preoperative nursing interventions

• Postoperative nursing interventions
• Patient teaching
• Ethical dilemma: refer to Chart 49-13
• Caregiver stress: refer to Chart 49-14

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