Cirrhosis of the Liver Nursing Care Management Symptoms NCLEX

this is sarah with registernursern.com and in this video i'm going to be going over cirrhosis and this video is part of an nclex review series over the gastrointestinal system and as always at the end of this video don't forget to take the free quiz i will test you on this condition so let's get started so what is cirrhosis cirrhosis is a liver disease where the liver cells become so severely damaged that they become replaced with this fibrosis tissue so your liver cells start to become scarred so whenever you think of cirrhosis think of scarring you have major liver scarring which is preventing these cells from doing their job in the liver now what can cause cirrhosis well a couple of things number one a viral infection like from hepatitis c or b and what happens that virus gets in those liver cells attacks them and they no longer function and do their jobs so the patient can develop scarring of the liver another cause is heavy alcohol consumption and these two top ones are the most common causes here in the u.s of cirrhosis then another cause is increased fat collection in the liver and this causes actually on the rise due to increased number of people with obesity also patients who do not manage their cholesterol they have long-term hyperlipidemia and diabetes can lead to this condition as well also problems with the bile duct and why is that okay well really your liver and your gallbladder work together your liver produces the bile which goes down through the common bile duct and hangs out in the gallbladder until you need that bile to help digest the fats in your food well if you get a stone in here that can cause that bile not to drain down properly which can backflow into the liver and damage those cells hence over time leading to cirrhosis and of course anything that is like an autoimmune condition that attacks those hepatocytes within the liver now let's take a look at the role of our liver because in order to understand those complications that you're going to see in a patient with cirrhosis along with our nursing interventions the whole rationale while we're doing what we're doing we have to understand the basic function of our liver okay so what does our liver do our liver is a super important organ i know i say that about every organ but it's really really true about the liver because in a nutshell what our liver is doing is it's taking that blood that is receiving because what's cool about the liver is that it receives its blood supply from two sources which we're going to go over here in a second and it's going to take that blood and it's going to filter it and it's going to do several things of the to the substances found in that blood it's going to metabolize many of those substances it's going to detoxify remove some of those substances from the blood that we don't need like drugs we've taken or things that have just built up in the body that we don't need it's going to store some of those substances and then it's going to produce some really important substances like bile proteins that play a role in clotting and like albumin and things like that so it's super super important now how does it do that well it does that through its blood supply so let's talk about those two routes it receives its blood okay the first one that i really want you to commit to memory is called the hepatic portal vein that's this in blue because this is a big complication that is going to happen in cirrhosis called portal hypertension so you have this hepatic portal vein and it is receiving blood from your organs that play a role in digestion so the blood that is shooting through that hepatic portal vein is really rich in nutrients but it's really poor in oxygen so in order to really for your liver to survive it needs some oxygenated blood which is going to come through that hepatic artery and the hepatic artery has came off from the aorta and remember the aorta has just came off from the heart and has received that nice fresh oxygenated blood and it's going through the body now what are those organs connected to the hepatic portal vein which you want to remember because whenever we develop portal hypertension some of these organs are going to be affected so we have the pancreas coming off from the hepatic portal vein our stomach our spleen very important and our small and large intestines and it's sanding because you just ate food and you have all those cells that have taken the nutrients gathered it from your food and it's going to take it to the liver so the liver can do what it needs with it now as all this blood enters the liver through the hepatic artery and the hepatic vein it's eventually going to mix together and make its way back through the heart once it's been filtered but how is it filtered what's doing this well in your liver are these little functional units called hepatic lobules and they are the areas that contain the liver cells that do all the hard work to filter the blood i like to compare it to whenever we were talking about the kidney remember in each kidney you have the nephrons and there was millions of those little nephrons and the nephrons had these little systems that took and remove this filtrate here put this here and in the end produce urine and maintain homeostasis in our body well in a sense the liver is doing a little bit of the same but it doesn't produce urine of course so whenever you look at the lobule if you took it and sliced it like this you could see these little areas of where the hepatic portal veins coming in the artery and the common bile duct and how it's all flowing into that central vein which is going to go back to the heart so if you cut it in half like i said you will find this hexagon shape and within each corner of the hexagon shape you have in green the common bile duct which is going to receive bile from the hepatocytes because in this white area which i represented in blue here are your hepatocytes and your hepatocytes are really what does majority of the job in the liver with metabolizing storing and producing everything like that and they're going to send the bile that they produce through that common bile duct which is going to go eventually down to the gallbladder and be stored whenever you need it to help digest fats and it's going to be squirted down into the duodenum and remember bile plays a role in this and us absorbing fats and those fat soluble vitamins then here you have the hepatic artery and the hepatic portal vein and together this is called the portal triad and the blood is going to flow from the hepatic artery in the hepatic portal vein into the sinusoid which is represented in this like blue area that's going to flow down there and eventually drain into the central vein and go back to the heart well in this sinusoid is this really neat cell called the cook for cell and it's a type of microphage and it is here in purple and this macrophage what do they do they like to clean up the area and its job is going to be removing debris removing bacteria and most important of all that i want you to remember is removing those old red blood cells because the cook fur and the padded sides in a sensor a team in how they turn unconjugated bilirubin into conjugated bilirubin which is really a big thing in cirrhosis whenever we're talking about jaundice so remember that okay now let's analyze what it does and hit the highlights of what it metabolizes detoxify stores and produces because it ties in to our signs and symptoms nursing interventions and everything okay so metabolizing big thing that your liver metabolizes is glucose because it just received all this blood that is very rich in glucose from those digestion organs and what it's going to do is it's going to take those excessive amounts of glucose in the blood and it's going to synthesize it and store it as glycogen for later in case we need it so think back to whenever a patient's liver isn't working in cirrhosis what's going to happen well the liver isn't going to take that extra glucose in the blood because those cells aren't working what's going to happen to our blood sugars we're going to have hyperglycemia okay so they're going to be struggling with that in really late stages of cirrhosis another thing that the liver does with this is it converts glycogen to glucose so when a patient is sick or whatever they need their blood sugar to be go up the liver is going to help play a role in turning that glycogen into glucose which is going to in turn increase our blood sugar but if the patient has cirrhosis say they're sick they're not eating they're not going to have this ability to increase that blood sugar because this right here isn't happening so they're also going to struggle with hypoglycemia and that's why a lot of times people with cirrhosis may be termed hepatic diabetes they develop diabetic type symptoms with cirrhosis and that is the reasoning behind it because the liver is not metabolizing and messing with the glucose and the glycogen like it should now let's talk about how it metabolizes lipids and specifically proteins i want to hit on the proteins okay proteins what is the byproduct of protein breakdown it is ammonia well ammonia is really toxic to our body and our liver knows that so it will take that ammonia and convert it into urea which is a little less toxic and the kidneys can deal with that urea and the kidneys will take it and excrete it out and get rid of it so the liver helps do that but if we have cirrhosis this process is not taking place and instead we're not going to have the conversion to urea we're going to be keeping the ammonia and this causes toxic effects on the brain which is why you will see in severe cases of cirrhosis so those neurological changes which we're going to talk about in our signs and symptoms so keep that in mind now let's talk about storage liver is a great place for storage it stores our vitamins like b12 vitamin a c e d and k in a second we're going to learn how those hepatocytes which i talked about a little bit produce bile well bile plays a role in us absorbing fats and absorbing those fat soluble vitamins well if we're not producing enough bile to do the job we're not going to be absorbing these fat soluble vitamins which is going to be very toxic for us because vitamin d what does vitamin d do it plays a role in allowing us to absorb calcium if we can't absorb calcium what happens to our bone health it decreases so patients with cirrhosis can experience bone fractures vitamin k that plays a huge role in the whole clotting process we don't have enough of that we can't even absorb it because our bile is not there and then we can't even store it for further use so we're going to have issues with clotting and here in a second you're going to see how the proteins that the liver produce play a role in clotting as well along with the liver also stores our iron and of course of course the glycogen now the liver also plays a role in digestion and we just learned that the hepatocytes make bile and what bile does well in the bile is a substance called bilirubin now how in the world did the bilirubin get in the bile well remember those cook for cells we were talking about that are found in the hepatic lobule well they removed all red blood cells and they break down lysis those red blood cells and break down that hemoglobin into groups a heme and a globin group now your hepatocytes will take the heme that was broken down from the hemoglobin and will metabolize it into iron and bilirubin so what we're interested in is the bilirubin so the bilirubin after it's metabolized from the hepatocyte will go down into that common bile duct mix with the bile and it will leave the body in the stool so that's why the stool is brown because bilirubin is like this yellowish brownish color and gives the stool its color so that's why whenever you look at the stool in patients with jaundice their stools are going to be clay colored they're not going to be that normal brown now why is that let's talk about that okay in cirrhosis those hepatocytes are damaged so they're not able to take this bilirubin like it should and put it into the bile instead it's going to leak and it's going to leak down into our blood system and go into the blood and we shouldn't have all this bilirubin in our blood which is why we can check bilirubin levels and that can help in diagnosing liver disease so get bilirubin in the blood which is this yellowish brown color that is going to leak into our skin which is why we're going to see jaundice so jaundice you can see the yellowing of the sclera of the eyes the whites of the eyes this skin can get yellow i've seen patients it's like a pumpkin looking hue to their skin and their mucous membranes and of course there's no bilirubin in the stool because it's all hanging out in the blood so that is why you're going to have those clay colored stools another thing is that our liver produces our blood plasma proteins which plays a role in our overall health one important protein that i want to talk about is albumin and we've talked a lot about albumin and what albumin does is it maintains the oncotic pressure within our capillaries so water likes to stay with albumin so that keeps the water inside the capillary then going into that interstitial tissue well in cirrhosis you don't have any albumin hardly so what's happening is that there's no water to cling to the albumin so the water just flows out of the capillary into that interstitial tissue which is why you're going to be seeing the societies in that patient the swollen abdomen and swelling in the lower legs also it makes fibrogen and prothrombin and these are our proteins that play a role in our clotting abilities so not producing those what's going to happen this patient is at major risk for bleeding out not being able to clot another thing our liver does is it detoxify so detoxification so whenever we take medications what it does is it helps make those medications less harmful to our body so it's really important the patient has good liver function when taking medicines and they have really bad liver disease and long-term cirrhosis they want to avoid drugs like sedatives especially tylenol and things like that also want to re remove drinking any alcohol because the liver removes alcohol makes it less toxic to your body and if you don't have that ability you drink alcohol you're going to get very major toxic effects also a very interesting thing that our liver does is that it helps remove hormones in our body that are produced by our glands and one hormone i want to hit on is estrogen okay so what will happen is that you have the hormones that naturally go through your body and your liver is going to remove them and take them out and keep this nice balance well saying cirrhosis patient has this the body is not going to metabolize estrogen so if we're not metabolizing estrogen and getting rid of it what's going to happen it's just going to hang out in the body so those levels are going to increase even more and this is not good especially in our male patients because they can start experiencing gynecomastia which is enlargement of the breast tissue in males and this is why you're also going to see these other signs and symptoms because the estrogen levels can be high such as the itchy red palms of the hands along with also seeing what's called spider angiomas and this is these areas hence why they're called a spider that you will see on the skin looks like breaks in the skin and you have the area in the center that's red and it just branches out and these can be on the chest and on the arms and if you have a patient with cirrhosis look at their skin you may see that and that's from those increased estrogen levels now let's look at the complications that can happen with cirrhosis okay we just hit on the anatomy and the role of the liver okay so what are some complications because remember we have scarred tissue in the liver those cells are no longer working it's being replaced with all this fibrosis tissue so one thing that can happen is called portal hypertension now remember that hepatic portal vein what happens is that it becomes narrowed due to all the scar tissue in the liver so what's going to happen you're going to have restriction of blood flow to the liver itself and the pressure is going to increase in that hepatic portal vein to all those organs that were connected to the portal vein and you're going to have some major problems which is going to lead to all this other stuff you can see an enlarged spleen in these patients with cirrhosis proper term is splenomegaly now what does our spleen do let's think back to that our spleen normally stores our platelets and our white blood cells well if you have all this increased pressure in this portal vein going to this spleen what's going to happen nothing's going to really flow out of there so those platelets and those white blood cells are going to get stuck in there and what's going what's going to happen to our platelet count it's going to decrease what's going to happen to our white blood cell count it's going to decrease so we're going to be at risk for bleeding out because we don't have platelets readily accessible to us and our immune system is going to suffer because our white blood cells help us fight infection another thing these patients can develop is called esophageal varices and this can also they can also develop gastric varices and this is where you get these engorged dilated vessels and what's happened is that increased pressure in that hepatic portal vein is just really enlarging these vessels and over time they can become weak and they can rupture and if this happens this is an emergency it's life-threatening because why is it life-threatening well they're going to bleed out in this location the esophagus or the gastric area well we don't have our clotting ability to clot we have low platelets because of what's going on up here we also have decreased vitamin k because we're not really absorbing it and we're not storing it in our liver because our liver is not working it's scarred and we have decreased clotting factors so it's a double whammy on these patients and some more complications that can be seen are of course fluid volume overload you can see swelling in the lower parts of the legs at the ankles and the feet and in really severe cases in the abdomen and we call this ascites this is where the abdomen will be really swollen out and it's full of fluid and with this the patient is at a high risk for developing infection because think about it the gut normally has all this bacteria but it's okay if it stays there but if we have all this fluid surrounding all that gut tissue with that bacteria the patient's at risk for developing an infection plus they probably already have a compromised immune system due to the low white blood cell count that we talked about with the whole splenomegaly so they're at risk for that and this is due to that venous congestion coming in from the hepatic portal vein because it's narrowed and it's increasing all that pressure along with that low albumin level the liver is not really producing this albumin albumin maintains our oncotic pressure so we don't have fluid just flowing out into that interstitial tissue so that's why you're getting the swelling there also jaundice which we really hit on when we talked about the function of the liver with the cook fur and the hepatocytes you can see the yellowing of the skin and the clay colored stools they can also in really severe stages experience renal failure in a condition called hepatorenal syndrome and really cirrhosis in those late stages is going to be can cause multi-organ failure it's going to affect everything your brain and the renal system another condition that you really want to remember is it can cause what's called hepatic encephalopathy and why is this this is because the liver is unable to detoxify itself the blood from things that normally could so those toxins like ammonia because remember that's the bipod product of protein breakdown and the liver will take that emotion and turn it into urea and get rid of it well it can't do that so ammonia is going to collect in our brain along with other toxins and what's going to happen to your patient their mental status is going to change so you really need to monitor their mental mental status be asking them those questions how are they responding to you it can lead to a coma another thing it can cause from the collection of ammonium the ketones and everything in the system is a condition called asterixis and i would remember that and how you elicit this response is to have the patient hold up their hands like this and you will see this involuntary flapping of the hands like this and that's why sometimes people may refer refer to it as hand flapping and you will see that another thing this is seen in late stages of cirrhosis very in very severe it's called hepatic fetor or fetor hepaticus and this is where the patient's breath will have this pungent musty sweet smell to it and it's from where again the ammonium and the ketones have collected in the blood and what's happening is that you have all this portal shunting of this blood and it's affecting the heart and it's causing from all those toxins to build up as they pass through the lungs it enters into the lungs and as the patient breathes out and talks it will mix in with that air that they're breathing out and you can actually smell that and again that's a really late sign the patient can also experience liver cancer along with bone fractures and that was again because of our low vitamin d it's not being stored and vitamin d plays a role in how we absorb our calcium so they can have that along with diabetes and that's tied back to the way that our body stores glycogen and then breaks synthesizes the glycogen and turns it into glucose so we can manage our blood sugars now let's sum up everything that we have learned and look at the signs and symptoms that this patient may have with cirrhosis now in the early stages when a patient has cirrhosis they may be unaware that they have cirrhosis because they really don't have signs and symptoms until it gets really severe in the long term and whenever they do it as you've seen it affects everything so they're going to have lots of signs and symptoms so to help us remember the signs and symptoms let's remember the mnemonic the liver is scarred because this is what is going on our liver scarred and that's why we're having all these problems okay t for tremors that was that asterixis the flapping of the hands h hepatic fat that was that musty smelly pungent breath light sign e for eye and skin yellowing the jaundice that you're going to see from the bilirubin hanging out in the blood it should be in the stool but hepatocytes aren't working so it's in the blood and it's causing everything to become discolored l for loss of appetite why would they have a loss of appetite well their spleen is probably going to be enlarged the spleen and the stomach or in close proximity it's going to push on that stomach causing the patient to feel full plus just all the extra fluid on the stomach if they have ascites can cause that as well i for increased bilirubin and ammonium levels that that's some blood test the physician can order look in that bilirubin level and the ammonium level which we'll talk about a little bit later because we can give a medication to help decrease that v for varices those esophageal or gastric varices and remember if they rupture that is a medical emergency e for edema in the legs r for reduced platelets which if you have reduced platelets what's going to happen increase risk of bleeding out and reduce white blood cells have that increased risk of infection i for itchy skin that's buildup of the toxins in the blood s spider angiomas and that's from that increased estrogen s for splenomegaly c for confusion slash coma increase toxins in the body a for a cities again that's because of decreased albumin and that venous congestion r for redness on the palms that's from the increased estrogen as well r for renal renal failure e for enlarged breast and men again from increased estrogen because your liver is not metabolizing and removing the estrogen from the body so it's hanging out and the last part of the mnemonic d deficient on vitamins like vitamin b12 a c d e and k now let's look at how is this condition diagnosed the nursing interventions we're going to do for this patient and the treatment okay a lot of times cirrhosis is diagnosed through a liver biopsy they can have other imaging like an ultrasound other tests to assess the structure of the liver also the physician can order blood tests to look at things that can be tied in with cirrhosis like those liver enzymes specifically albumin look at the platelet levels are they low the ptinr the clotting levels vitamin levels the bilirubin along with seeing does this patient have hepatitis b or c because remember that's one of the causes of this condition now let's switch gears and look at our nursing interventions okay whenever we're looking looking at nursing interventions let's look at our problems because our problems tie in for what we're going to do with this patient and remember with cirrhosis this is like a multi-organ involved condition and there's a lot of things going on so one thing they're going to be having glucose issues probably going to have what looks like diabetes hepatic diabetes so we want to monitor them for high blood sugars and low blood sugars because their liver can't store that glycogen and then take it out turn it into glucose and help manage glucose stability so we need to monitor them for that there are risks for bleeding because they're not making those proteins that help with clotting so we might want to monitor their ptinr and from our standpoint we want to limit invasive procedures like starting all those ivs if we do have to start an iv or do anything that punctures the skin hold pressure for at least five minutes or more because our risks were bleeding out with mouth care the gums want to use a soft toothbrush so we don't nick a gum and just keeps bleeding and checking their stool for blood and looking at the skin do they have petechiae which is where they're having bleeding underneath the skin also tying in with this those varices they can have esophageal or gastric type varices and they're at risk for bleeding because these can rupture so we want to make sure that they haven't ruptured look at those vital signs are they hypotensive tachycardic are they throwing up blood are they have a lot of blood in their stool we want to monitor for that and we want to limit and educate them about activities to help decrease the risk of rupturing them well if the patient has esophageal varices they could cough excessive coughing can make one of those ruptures vomiting consuming alcohol or constipation that increased pressure can pop one of those vessels open next they are having toxin buildup so from our standpoint we want to monitor that mental status very closely are they deteriorating they're getting worse because more could be collecting in the brain checking their reflexes checking them for that hand flapping the asterixis also monitoring that ammonium level ordered on this patient and if they do have a high emotion level a lot of times physicians order lacto-lows through a po or an enema route you're going to be assessing that jaundice and because that's remember where that bilirubin is leaking into the blood so they're going to have the yellowing of the sclera of the eyes of the skin and also they their urine can be really dark colored from where it's leaking into the urine as well so let look at that now let's talk about diet because it's important if you have hepatic encephalopathy going on where you do have this toxin buildup with cirrhosis they need to have a low protein diet if they're confused because remember that ties back to what we were talking about protein byproduct it goes into ammonium the liver takes it turns it into urea so it's not as toxic but that's not happening in this condition so we want to limit the amount of protein they're eating if they are confused but if they're not confused they don't have hepatic encephalopathy we want them to consume a high lean protein diet because we need protein this condition because our liver is not making our proteins but they want to have a low sodium diet because we have all the extra fluid and water and sodium love each other so we want low sodium absolutely no alcohol or raw seafood like oysters so educate your patient this no seafood because oysters for instance contains a bacteria that normally if they had a strong immune system it could fight it off but their immune system isn't as strong and they can get sick and plus the liver is not going to filter and detoxify itself from this bacteria in the seafood so none of that fluid restriction and po vitamins may be ordered for the physician because the patient is not storing these like they should so that was our nutrition next fluid volume overload so with this we want to perform strict eyes and o's intake output where are they taken in what are they putting out measuring the abdominal girth especially if they have ascites is it increasing or is it decreasing that can help us know is our treatments working in the edema in the legs daily weights so important they're weighed every day on the same scale and the same amount of clothes so we can measure if they're retaining fluid because that's one of the earliest signs we can see if a patient's retaining fluid or not turning every two hours because that skin that's swollen is at risk for breakdown and we don't want it to break down because they can get infection and again these patients are at risk for infection due to what's going on with them and because they have ascites all that swelling in the belly you don't want to put them on their back lying down the supine position because that's going to put a lot of pressure on the lungs and on the heart cause difficulty breathing and also be careful with these patients because they're going to have activity intolerance moving around so they're at risk for falls and safety issues now let's look at our treatments let's hit the highlights of that how can this condition be treated a liver transplant where they get a new liver also shunting surgery because remember our hepatic portal vein is narrowed and it's shunting blood at a high pressure to other organs that can go in there and shunt that elsewhere to alleviate that pressure also diuretics for the swelling or beta blockers or nitrates to help with all this congestion going on helps slow that heart rate down nitrates relax those vessels also maybe ordered our blood products like platelets things like that to help with the clotting factors along with vitamin k administration for clotting and another thing they can do if they have ascites a lot of fluid on the belly they can go for a paracentesis and this is where they take a needle aspirate fluid off the belly so the patient can breathe better and have less swelling it's absolutely amazing how much fluid they can actually remove from the stomach in these procedures okay so that wraps up this nclex review over cirrhosis thank you so much for watching don't forget to take the free quiz and to subscribe to our channel for more videos

Channel: RegisteredNurseRN

Views: 1,348,820

Keywords: cirrhosis, cirrhosis of the liver, cirrhosis of the liver end stage, cirrhosis nursing, cirrhosis of the liver symptoms, cirrhosis of the liver stages, cirrhosis registered nurse rn, cirrhosis of the liver nursing, cirrhosis symptoms, cirrhosis nclex, cirrhosis nursing care, cirrhosis nursing management, cirrhosis nclex review, cirrhosis nursing interventions

Id: Shx-hmyLdXA

Length: 34min 22sec (2062 seconds)

Published: Fri Oct 27 2017