Liver:

Labs:
o
o
o

AST: 10 40
ALT: 5 35
Albumin: 3.5 5

o
o

Amylase: 23 85 (normal), >450

(pancreatic damage)
Lipase: 0 160 (normal), >400
(pancreatic damage)

 Hepatitis:
o Hepatitis A: transmitted via fecal-oral route. There is a vaccine for it. Transmission is usually passed
between family members or in an area where there was contamination by a food handler. Once you have
had it, you are immune. It has flu-like symptoms, jaundice, or liver failure. Not chronic.
Serology Markers: M= miserable, G=gone
Anti-HAV immunoglobulin M (IgM) = current infection
Anti-HAV immunoglobulin G (IgG) = previous infection / immunization
Nursing Interventions: Bed rest, fluids/nutrients/vitamins, enteric precautions (gown and
gloves, hand-washing instead of Purel), antiemetics provided, avoid drugs like Tylenol, avoid
alcohol.
Food: High in carbs and low in fat. Small frequent meals recommended. Be careful with carbs &
diabetics.
o Hepatitis B: transmitted via blood, body fluids, semen. Can also be transmitted via needle sticks, renal
dialysis, and very rarely by blood transfusions. There is a vaccine series for it. It can lead to cirrhosis,
chronic hepatitis, flu-like symptoms, jaundice, liver failure, liver cancer.
Serology Markers:
HBsAg: current infection always growing
Anti-HBs: previous infection / immunization
HBeAg: high infectivity extra growing
Anti-HBe: indicates previous infection
Anti-HBc IgM: acute infection miserable
Anti-HBc IgG: previous infection / immunization gone
HBV DNA: virus is replicating
Nursing Interventions: bed rest, increase fluid intake, blood precautions (patient cannot donate
blood), avoid sexual contact until tests are negative, small frequent meals (high carb, low fat).
o Hepatitis C: transmitted via blood and body fluids. No vaccine!! Can progress to chronic hepatitis,
cirrhosis, and death.
Serology Markers:
Anti-HCV: maker for acute or chronic infection with HCV
HCV RNA: ongoing viral replication
Nursing Interventions: Best treated with Interfereon (Ribavirin [Rebetol] for 6-12 months, but
because of side effects patient may not complete thereapy).
o Hepatitis D: very similar to Hepatitis B (blood and body fluid transmission). No vaccine. Not very
common.
Serology Markers:
Anti-HDV: present in past or current Hepatitis D infection
HDV AG: present days after infection
o Hepatitis E: similar to Hepatitis A (fecal-oral transmission). No vaccine, no true serology tests. Mostly
found in 3rd world countries.
Nursing Care for Hepatitis overall focuses on resting and nutrition and fluids, avoiding alcohol. Medications
usually are antiemetics (Compazine, Phenergan, Zofran) and interferons. Patients receiving interferon should have
blood counts and liver function tests performed every 4 to 6 weeks.
Obtain health history for:
o Past health history: hemophilia; exposure to infected persons; ingestion of contaminated food or water;
exposure to benzene, carbon tetrachloride, or other hepatotoxic agents; crowded, unsanitary living
conditions; exposure to contaminated needles; recent travel; organ transplantation; exposure to new drug
regimens, hemodialysis, transfusion of blood or blood products before 1992, HIV status (if known)
o Medications: use and misuse of acetaminophen, new prescription, over-the-counter, or herbal medications
or supplements
o Drug, alcohol abuse, RUQ discomfort, urine and stool color.
Cirrhosis:

Most commonly caused by alcohol, although NSAIDs and Hepatitis C are also causes. Alcoholism
usually is associated with poor protein intake.
o Biliary causes of cirrhosis include primary biliary cirrhosis and primary sclerosing cholangitis. Primary
sclerosing cholangitis is a chronic inflammatory condition affecting the liver and bile ducts that is
frequently found in men.
o Cardiac cirrhosis includes a spectrum of hepatic derangements that result from long-standing, severe
right-sided heart failure. The treatment is aimed at managing the patients underlying heart failure.
o Early symptom is usually fatigue. Later can turn into jaundice, peripheral edema, ascites. Symptoms are
usually due to liver failure and portal hypertension. Skin lesions can also be a later symptom due to
increased estrogen and the livers inability to metabolize steroid hormones.
o Thrombocytopenia, leucopenia, anemia may be due to splenomegaly. Coagulation problems may also
occur and is due to inability to make prothrombin (more bleeding may occur).
o Portal Hypertension:
Almost all of the blood from GI system empty into portal veins and into the liver.
The liver becomes scarred and blood backs up into the GI tract and spleen, and the organs
therefore cannot function properly.
The overload stimulates collateral circulation in the veins of the lower esophagus, abdominal
wall, and hemrroidal veins.
Patients should avoid: ASA products (aspirin), coughing, yelling, Valsalva maneuver.
The danger is hemorrhage of distended veins, as well as varicosities. Esophageal varicies become
swollen and easily bleed. It is life threatening.
o Ascies see picture at end
o With hepatic encephalopathy, the liver can no longer convert ammonia, which can buildup and lead to
changes in LOC. (Treat with Lactulose).
o Generally, Vitamin B complex is low because not absorbed. Vitamin K is low also.
o Jaundice & Pruritis: bile cannot reach the gallbladder and goes into the intestines. Bile is then absorbed
into blood & bile salts and deposited in the skin, leading to jaundice & pruritis. Liver produces less bile.
o Urine is dark color (tea). Stool is clay colored.
Bilirubin Levels measure the ability of the liver to conjugate & excrete bilirubin:
o High levels = jaundice
o Total Serum Bilirubin = 0.1 1 mg/dL
o Direct or Conjugated = 0.1 0.3 mg/dL
o Indirect or Unconjugated = 0.2 0.8 mg/dL
Albumin: (3.5 5 g/dL) holds water in vascular space. Low levels = fluids moving into extracellular space
(edema)
Increased Sodium & Water, decreased Potassium (because of increased aldosterone)
Asterixs = flapping hand tremors
Liver failure = drugs that are detoxed via the liver are now accumulating in the blood.
Nursing Diagnosis: focus on fluid volume excess, altered thoughts (ammonia), impaired skin integrity, altered
nutrition
Nursing Interventions for Cirrhosis: Small frequent meals, oral hygiene, high calories (low fats), vitamin
supplements (especially B), restrict sodium and alcohol, skin care for prurits, administer aldactone (diuretic that
prevents loss of potassium), albumin therapy (to promote reabsorption of ascities fluids), elevate extremities, bed
rest and conserve energy, monitor daily weights and I&Os and abdominal girth, elevate HOB.
Paracentesis: A trocar is inserted into peritoneal cavity through abdominal incision below the umbilicus, the fluid
drains into the trocar (30 60 min), albumin is sometimes prescribed.
o Have patient void before, high Fowlers position, paracentesis tray from supplies, record amount and
character of fluids aspirated, dry dressing over puncture site, check dressing for seepage, monitor for
infection
Shunts may be put in to prevent back flow from the superior vena cava. A Denver shunt allows irrigation of
tubing. Complications with shunts: infections, occlusions, shunt failure.
o

Sengstaken-Blakemore tube has two balloons (gastric and esophageal) and has three lumens (gastric, esophageal,
gastric aspirations). Label the lumens. Deflate balloons for 5 min q8 12 hrs to prevent necrosis.

Cholecystitis (inflammation of gallbladder):

Assessment:
o 5 Fs = female, fair, fat, forty (or older), flatulent
o Intolerant to fatty goods
o Nausea/vomiting, fullness, pain RUQ
o Increased WBC
o Murphys Sign (pain while palpating RUQ)
Diagnostics:
o Ultrasound
o ERCP (Endoscopic Retrograde Cholangiopancreatography): to locate and remove stones in bile duct.
Physician uses a long endoscope (connected to a computer) and injects special dye to help the bile duct
appear better. Stones are captured in a tiny basket and removed with the endoscope.
Interventions:
o Rest, IV fluids, NG suction, analgesics, antibiotics
Pain med of choice is Morphine
o Surgery

Cholelithiasis (inflammation with gallstones):

Assessment:
o Pain
o Nausea/vomiting
o Jaundice
o Clay colored stool, dark urine, high bilirubin
o Fever, increased WBC
Interventions:
o UDCA (Gallstone Dissolution): dissolves cholesterol, not very effective
o ERCP
o Extracorporeal Shock-Wave Lithotripsy (sound waves used to crush small stones).
o Surgery (Laparoscopic: patient to lie flat for several hours to avoid nausea/vomiting and shoulder pain
from CO2. Other issues: pneumonia, atelectasis, hemorrhage, DVT, PE, biliary tract damage)
Medical Management: Reducing pain (IM or IV analgesics, antacids and H2 blockers and proton pump inhibitors
to reduce acid, antibiotics to reduce the chance of infection, NG suctioning to relax bilairy colic), monitor fluid &
electrolytes (NPO, IV fluids)
Post-op: people dont have to limit fat intake, still enough bile from liver to digest food. Diarrhea is the only true
side effect.
Laproscopic Cholycystectomy (post-op):
o Assess respiratory status
o Immediate ambulation
o Monitor biliary tube drainage
o Assess incision site
o Medicate for pain as needed; heating pad OK for shoulder
o NPO
o Shower in 1-2 days
o Bowel Sounds + Flatus = resume regular diet with fat as tolerated
o Patient teaching: report S&S of infection, dark urine, pale stools, pruritis, no heavy lifting (nothing more
than 10 pounds), avoid alcohol
Open Cholycystectomy (post-op):

o
o
o
o
o

Low Fowlers
Maybe NG
NPO until bowel sounds return, then have soft and low fat and high carb diet (caution with diabetics)
Care of biliary drainage system
Administer analgesics as ordered, promote ambulation, turn cough and deep breath, splinting

Pancreatitis:

Is life threatening, and when the enzymes go active, it can begin autodigestion. Enzymes help with digestion
Main causes: alcholoism (mostly in men) and biliary tract disease (gallbladder disease in women). High
incidence in people with AIDS.
Manifestations: LUQ or mid-epigastric pain (deep, piercing, continuous) which is aggravated by eating and
alcohol and lying down, low grade fever, nausea/vomiting, jaundice, decreased BP, decreased bowel sounds,
Cullens sign (blue discoloration of periumbilical area), Turners sign (blue discoloration of flanks)
Diagnostic studies:
o High: amylase, lipase, urinary amylase, blood glucose, bilirubin
o Low: calcium
o Abdominal ultrasound or ct scan may be done. ERCP is for pseudocyst and abscesses
Goals of treatment: relief of pain, prevention of shock, reduction of pancreatic enzymes, control fluids &
electrolytes, maintain nutritional status, maintain effective breathing pattern, prevention of infection, removal of
precipitating cause.
o Patient is NPO and has NG tube to compress stomach. Position patient leaning forward of fetal position.
o Maintain IV fluids, give aniemetics, monitor for metabolic alkalosis (confusion, irritability, tachycardia,
nausea/vomiting, muscle cramps, tetany [muscle spasms due to hypocalcemia]).
o Observe stools for color consistency, steatorrhea (incomplete digestion of fats), oral hygiene. TPN may be
indicated. Low protein, low fat, high carb if they can eat. If giving antacids and using NG tube, clamp off
suction for 20 min to allow the meds to be absorbed.
o Assess for respiratory status, semi-Fowlers position, nasal O2 as needed
Morphine for pain. (Demerol may cause accumulation of antimetabolites). Nitroglycerine allowed to be given.
Antispasmotics (Bentyl or Probantine) can be given unless paralytic ileus.
Diamox (carbonic anhydrase inhibitor) is given to reduce bicarb concentration.
NS can be given with KCl
Teach patients about signs of recurrence: steatorrhea, pain, nausea/vomiting, weight loss, elevated temp,
hyperglycemia. Small frequent meals.
Chronic pancreatitis can be alcohol induced or obstructive (choleithiasis = gallstones). Smoking also implicated.
Leukocytosis, also seen with increased sedimentation rate. OMIT (secretin stimulation test) stimulates pancreatic
enzyme secretion, with an NG tube to first suck out gastric and duodenal contents.
Collaborative care focuses on pain control. Demerol is frequently used, but nonopiod agents like Talwin and
Toredol may also be used. Care also focuses on adequate nutrition (TPN, vitamin supplements, bland high carb
and high calorie foods also advised. Avoid fats.) Viokase and Cotazyme is given within 4 hours of meals or a
snack (swallowed & not chewed). Replace fat soluble vitamins (ADEK), antacids after meals, maintain skin
integrity