Pathophysiology
Which condition is NOT a known cause of cirrhosis?
What is E. all are known causes of cirrhosis
A condition in which the skin, whites of they eyes and mucous membranes turn yellow because of high levels of bilirubin
What is Jaundice?
Which laboratory test is prescribed for a client with suspected cirrhosis?
A. O2 level
B. CO2 level
C. WBC count
D. Liver biopsy
What is liver biopsy?
A client diagnosed with chronic cirrhosis who has ascites and pitting peripheral edema also has hepatic encephalopathy. Which of the following nursing interventions are appropriate to prevent skin breakdown?
A. Range of motion every 4 hours.
B. Turn and reposition every 2 hours.
C. Abdominal and foot massages every 2 hours.
D. Sit in chair for 30 minutes each shif
What is Turn and reposition every 2 hours?
The nurse is reviewing the lab results for a pt with cirrhosis and notes that the ammonia level is elevated. Which diet does the nurse anticipate to be presribed for this pt?
What is a Low-protein diet?
Protein provided by the diet is transported to the liver via the portal vein. The liver breaks down protein, which results in the formation of ammonia.
Which fat-soluble vitamins does the liver NOT store?
A. Vitamin A
B. Vitamin K
C. Vitamin C
D. Vitamin E
What is Vitamin C?
Accumulation of protein-containing fluid in the abdomen
What is ascites?
The nurse reviews laboratory results for a client with cirrhosis and finds the following: hematocrit, 72%; blood urea nitrogen (BUN), 42 mg/dL; and sodium, 166 mEq/L. Which action by the nurse is most appropriate?
a. Check the client's blood pressure and pulse.
b. Increase the client's oral fluid intake.
c. Call the health care provider.
d. Document the results in the chart.
What is Check the client's blood pressure and pulse?
These values are all elevated, which can occur in hypovolemia. The nurse should assess the client for signs of hypovolemia, including tachycardia and hypotension. The nurse should consult with the provider about the client's fluid status before increasing oral fluids but after obtaining vital signs. Documentation should occur after all assessments have been completed and must include actions taken.
A patient is admitted with hepatic encephalopathy secondary to cirrhosis. Which meal option selection below should be avoided with this patient?
A. Beef tips and broccoli rabe
B. Pasta noodles and bread
C. Cucumber sandwich with a side of grapes
D. Fresh salad with chopped water chestnuts
What is Been tips and broccoli rabe?
Patients who are experiencing hepatic encephalopathy are having issues with toxin build up in the body, specifically ammonia. Remember that ammonia is the byproduct of protein breakdown, and normally the liver can take the ammonia from the protein breakdown and turn it into urea (but if the cirrhosis is severe enough this can’t happen). Therefore, the patient should consume foods LOW in protein until the encephalopathy subsides. Option A is very high in protein while the others are low in protein. Remember meats, legumes, eggs, broccoli rabe, certain grains etc. are high in protein.
The pt with cirrhosis is being taught self care. which statement indicates the pt needs MORE teaching?
a. if i notice a fast heart rate and irregular beats, this is normal for cirrhosis
b. i need to take good care of my belly and ankle skin where it is swollen.
c. a scrotal support may be more comfortable when i have scrotal edema
d. i can use pillows to support my head to help me breathe when i am in bed.
What is If I notice a fast heart rate and irregular beats, this is normal for cirrhosis?
A client diagnosed with liver cirrhosis is being treated for an infection. For which complication should the nurse monitor the client?
What is hepatic encephalopathy?
During assessment of a pt with obstructive jaundice, the nurse would expect to find:
A. clay colored stools
B. dark urine and stool
C. pyrexia and pruritis
D. elevated urinary urobilinogen
What is Clay colored stools?
During your morning assessment of a patient with cirrhosis, you note the patient is disoriented to person and place. In addition while assessing the upper extremities, the patient’s hands demonstrate a flapping motion. What lab result would explain these abnormal assessment findings?
A. Decreased magnesium level
B. Increased calcium level
C. Increased ammonia level
D. Increased creatinine level
What is Increased ammonia level?
This is due to the buildup of toxins in the blood, specifically ammonia. The flapping motion of the hands is called “asterixis”. Therefore, an increased ammonia level would confirm these abnormal assessment findings.
The nursing assistant is helping a client who has advanced cirrhosis with a bath and other hygiene. Which action by the assistant requires intervention by the registered nurse?
a. Helping the client apply lotion to dry skin areas
b. Giving the client a basin of warm water and soap to use
c. Providing a soft toothbrush for oral care
d. Helping the client keep nails trimmed short
What is Giving the client a basin of warm water and soap to use?
Clients with advanced cirrhosis often have pruritus. These clients should use cool, not warm, water on their skin, and should not use excessive amounts of soap. The other actions are appropriate.
The nurse provides discharge instructions for a 64 y.o. women with ascites and peripheral edema related to cirrhosis. Which statement, if made by the pt, indicates teaching WAS effective?
a. it is safe to take acetaminophen up to four times a day for pain
b. lactulose (cephulac) should be taken everyday to prevent constipation
c. herbs and other spices should be used to season my foods instead of salt
d. i will eat foods high in potassium while taking spironolactone (aldactone)
What is Herbs and other spices should be used to season my foods instead of salt?
low sodium diet is indicated for pt with ascites and edema related to cirrhosis
Blood stops flowing to the liver due to following path of least resistance.
What is portosystemic shunt?
A nurse is caring for a client with cirrhosis. Which assessment finding warrants immediate attention?
A. Pulse of 60 bpm
B. Oxygen saturation of 92%
C. Blood pressure of 110/72 mmHg
D. Abdominal distention
What is abdominal distention?
Abdominal distention, which is an imbalance of fluid within the portal system, might mean ascites in a client with cirrhosis. The vital signs are all within normal limits.
The condition of the pt who has cirrhosis of the liver has deteriorated. Which diagnostic study would help determine if the pt has developed liver cancer?
a. serum a-fetoprotein level
b. ventilation/perfusion scan
c. hepatic structure ultrasound
d. abdominal girth measurement
What is hepatic structure ultrasound?
The client with end-stage cirrhosis presents with GI bleeding, combativeness, and confusion. The nurse anticipates an order to administer which medication?
a. Omeprazole (Prilosec)
b. Somatostatin (Octreotide)
c. Propranolol (Inderal)
d. Lactulose (Heptalac)
What is Lactulose (Heptalac)?
Lactulose helps rid the body of ammonia. Excess ammonia leads to encephalopathy, which this client is manifesting.
The nurse is providing discharge teaching for the client with advanced liver disease. Which statement by the client indicates a need for further teaching?
A. " I don't need hospice because I'm only 55 years old"
B. "I'll ask my wife to contact our local support group"
C. "I plan to talk with the pastor at our church"
D. "My wife and I plan to get Meals on Wheels"
What is " I don't need hospice because I'm only 55 years old"