A patient with chronic liver failure presents with confusion, jaundice, and ascites. Lab results include elevated ammonia levels, low albumin, prolonged PT, and thrombocytopenia. What is the priority nursing intervention to address the patient's current condition?

A) Administer lactulose to decrease ammonia levels.

B) Initiate a low-protein diet to prevent further hepatic encephalopathy.

C) Prepare for a blood transfusion to address thrombocytopenia.

D) Administer vitamin K to correct prolonged PT.

A patient with chronic liver failure presents with elevated bilirubin, high serum ammonia, low albumin, prolonged PT, and thrombocytopenia. Which nursing intervention is most important to prioritize in the immediate management of this patient?

C) Administer lactulose to reduce serum ammonia levels

A) Administer Vitamin K to address the prolonged PT

B) Initiate a low-protein diet to decrease ammonia production

C) Administer lactulose to reduce serum ammonia levels

D) Provide support for alcohol cessation to prevent further liver damage

A patient with an acute exacerbation of chronic liver failure is being treated with lactulose and rifaximin to manage elevated serum ammonia levels. Despite these interventions, the patient suddenly experiences hematemesis and hypotension. What is the priority nursing action?

C) Initiate intravenous fluid resuscitation

A) Administer lactulose to reduce ammonia levels

B) Prepare the patient for an urgent upper endoscopy

C) Initiate intravenous fluid resuscitation

D) Contact the physician to discuss the patient's medication regimen

A patient with chronic liver failure and recent hematemesis due to a suspected upper gastrointestinal bleed is being managed with fluid resuscitation. Considering the current clinical situation, which of the following is the most appropriate nursing intervention to prioritize?

D) Monitor vital signs closely and assess for signs of hypovolemic shock.

A) Continuously monitor the patient's neurological status for signs of hepatic encephalopathy.

B) Prepare the patient for a paracentesis to relieve abdominal pressure.

C) Administer prophylactic antibiotics to prevent infection.

D) Monitor vital signs closely and assess for signs of hypovolemic shock.

A nurse is caring for a patient with a history of chronic liver failure who recently had an upper endoscopy for esophageal varices. Post-procedure, the nurse notes that the patient's blood pressure is stabilizing, but the patient has a hemoglobin level of 7.4 g/dL. Which nursing intervention is most appropriate to prioritize in this situation?

A) Initiate a blood transfusion of packed red blood cells

B) Administer a vasoactive medication to maintain blood pressure

C) Start a continuous infusion of albumin to increase blood volume

D) Prepare the patient for immediate surgical intervention

A patient with chronic liver failure and esophageal varices underwent an urgent endoscopy to control a variceal bleed. Following the procedure and initial stabilization, which of the following interventions should the nurse prioritize to prevent further complications?

A) Administer beta-blockers to reduce portal hypertension

B) Start a high-protein diet to promote liver regeneration

C) Encourage early ambulation to prevent deep vein thrombosis

D) Prepare the patient for immediate liver transplantation evaluation

A patient with advanced liver disease is exhibiting signs of hepatic encephalopathy and ascites. The healthcare team has started lactulose therapy to reduce ammonia levels and is considering a TIPS procedure. As a nurse, what is the most important action to prioritize in the care plan to monitor for potential worsening of encephalopathy?

A) Assess the patient's level of consciousness regularly.

B) Monitor the patient's blood pressure every four hours.

C) Evaluate the patient's intake and output daily.

D) Encourage the patient to ambulate frequently to prevent complications.

A patient with advanced liver disease has developed hepatic encephalopathy and ascites. The healthcare team is considering a TIPS procedure. Which nursing intervention is most critical to monitor for potential complications associated with this procedure?

C) Evaluating changes in mental status

A) Monitoring for signs of infection

B) Assessing for increased abdominal distension

C) Evaluating changes in mental status

D) Checking for electrolyte imbalances

A patient with ascites and worsening coagulopathy is experiencing respiratory changes and discomfort. Which nursing intervention should be prioritized to address the patient's current clinical status?

A) Administering supplemental oxygen to maintain adequate oxygen saturation.

B) Preparing the patient for an immediate paracentesis to relieve abdominal pressure.

C) Initiating diuretic therapy with spironolactone and furosemide as per the physician's order.

D) Transfusing fresh frozen plasma to correct the patient's coagulopathy before any procedures.

A patient with ascites is experiencing mild respiratory alkalosis and coagulopathy, with an increased risk for bleeding. The healthcare team is considering conservative management options. Which nursing intervention should be prioritized to address the patient's current condition and prevent complications?

A) Administering diuretics and monitoring for electrolyte imbalance

B) Preparing the patient for immediate paracentesis to relieve ascites

C) Educating the patient and family about the risks of invasive procedures

D) Initiating fresh frozen plasma transfusion to correct coagulopathy

liver failure - Nursing Case Study

Pathophysiology

• Primary mechanism: Hepatocyte injury and necrosis lead to loss of liver function, resulting in impaired protein synthesis, detoxification, and metabolism. This causes accumulation of toxins like ammonia, leading to hepatic encephalopathy.

• Secondary mechanism: Portal hypertension arises from increased resistance to blood flow in the liver due to fibrosis and regenerative nodules, causing complications such as varices and ascites.

• Key complication: Impaired bile production and excretion result in cholestasis, causing jaundice and further contributing to systemic toxin buildup.

Patient Profile

Demographics:

56-year-old male, construction worker

History:

• Key past medical history: Chronic hepatitis C, alcohol use disorder

• Current medications: Lactulose, spironolactone, propranolol

• Allergies: Penicillin

Current Presentation:

• Chief complaint: Increasing abdominal pain and swelling

• Key symptoms: Jaundice, fatigue, confusion, easy bruising, ascites

• Vital signs: Blood pressure 100/60 mmHg, heart rate 105 bpm, respiratory rate 22 breaths per minute, temperature 37.8°C, oxygen saturation 94% on room air

Section 1

New Diagnostic Results:

The medical team ordered a comprehensive metabolic panel, complete blood count, liver function tests, and coagulation profile to assess the patient's current liver status and related complications. The results highlighted several concerning findings. The liver function tests revealed significantly elevated bilirubin levels at 5.6 mg/dL, indicating worsening jaundice and impaired bile excretion. Serum ammonia was markedly elevated at 180 µmol/L, correlating with the patient's confusion and increasing severity of hepatic encephalopathy. Albumin levels were notably low at 2.5 g/dL, contributing to the patient's ascites and generalized edema.

Additionally, the coagulation profile showed a prolonged prothrombin time (PT) of 19 seconds and an INR of 2.1, suggesting impaired synthetic function of the liver and a heightened risk for bleeding. The complete blood count indicated thrombocytopenia with a platelet count of 90,000/mm³, further increasing the bleeding risk. These lab results, combined with the patient's clinical presentation, suggest an acute exacerbation of chronic liver failure, likely precipitated by ongoing alcohol use and advanced hepatitis C-related liver damage.

These findings necessitate prompt intervention to manage the complications and prevent further deterioration. The healthcare team must consider adjusting the patient's medication regimen, including optimizing doses of lactulose to reduce ammonia levels and considering potential diuretics for ascites management. Close monitoring of mental status, hemodynamic stability, and potential bleeding is crucial. The results also underscore the need for patient education and support to address the underlying alcohol use disorder, a critical step in preventing further liver damage and improving overall prognosis.

Section 2

As the healthcare team began implementing interventions to address the patient's acute exacerbation of chronic liver failure, they closely monitored the patient's response. The initial focus was on controlling the elevated serum ammonia levels by adjusting the dose of lactulose. Within 24 hours, the patient showed a slight improvement in mental status; however, the confusion persisted, suggesting only partial effectiveness of the intervention. The medical team decided to add rifaximin to the regimen to further target the ammonia-producing bacteria in the gut.

Concurrently, the patient's ascites was managed with a low-sodium diet and the cautious use of diuretics. Furosemide and spironolactone were initiated, leading to a gradual reduction in abdominal girth and a slight improvement in respiratory effort, as evidenced by a decrease in respiratory rate from 24 to 20 breaths per minute. Despite these improvements, the patient experienced a new complication: a sudden onset of hematemesis, indicating a potential upper gastrointestinal bleed. The patient's blood pressure dropped to 88/54 mmHg with a heart rate of 112 beats per minute, triggering an immediate concern for hypovolemic shock.

The team quickly halted diuretics and initiated fluid resuscitation with intravenous crystalloids while preparing for an urgent upper endoscopy to identify and potentially control the source of bleeding. This development highlighted the delicate balance required in managing liver failure, where interventions for one complication could exacerbate another. The healthcare team recognized the need for vigilant monitoring and rapid response to stabilize the patient and prevent further deterioration, reinforcing the complexity of liver failure management and the interconnection of systemic complications.

Section 3

As the healthcare team proceeded with the urgent upper endoscopy, they encountered esophageal varices, a common complication in patients with chronic liver failure due to portal hypertension. The procedure revealed multiple varices, one of which had ruptured, leading to the hematemesis. The endoscopist successfully performed band ligation to control the bleeding, a critical intervention to stabilize the patient. Meanwhile, the critical care nurse closely monitored the patient's vital signs, noting a gradual improvement in blood pressure to 98/62 mmHg and a decrease in heart rate to 100 beats per minute following fluid resuscitation and stabilization of the bleed.

Lab results from the arterial blood gas analysis showed a partially compensated metabolic acidosis, likely due to the acute blood loss and hypoperfusion. Hemoglobin levels had dropped to 7.4 g/dL, necessitating the administration of packed red blood cells to address the significant anemia and support oxygen delivery. The patient's liver function tests revealed worsening of the liver profile, with elevated bilirubin and transaminase levels, indicating a potential progression of liver dysfunction.

As the immediate crisis of the gastrointestinal bleed was managed, the team recognized the need to reevaluate the patient's overall treatment plan. They deliberated on the potential benefits of a transjugular intrahepatic portosystemic shunt (TIPS) procedure to alleviate portal hypertension and reduce the risk of future variceal bleeds. This consideration underscored the complexity of balancing immediate interventions with long-term management strategies, as the team aimed to stabilize the patient while minimizing the risk of further complications. The patient's journey now hinged on a delicate interplay between acute management and the strategic prevention of future episodes, emphasizing the need for continuous assessment and adaptive clinical reasoning.

Section 4

As the patient stabilized post-endoscopy, the healthcare team continued to monitor for potential complications. Within 24 hours, the patient's condition began to show new signs of deterioration. The nurse noted that the patient's mental status had altered significantly; he was now increasingly lethargic and had difficulty maintaining a coherent conversation. Suspecting hepatic encephalopathy, a common complication of liver failure characterized by a decline in brain function due to the liver's inability to remove toxins from the blood, the team promptly assessed ammonia levels, which returned elevated at 85 µmol/L (normal range: 15-45 µmol/L).

In response to this new development, the team adjusted the treatment regimen to include lactulose, aiming to reduce the systemic ammonia levels and mitigate the effects of encephalopathy. Despite this intervention, the patient also began to exhibit signs of ascites, with noticeable abdominal distension and shifting dullness upon physical examination. An abdominal ultrasound confirmed significant fluid accumulation, prompting discussion among the team about the need for a therapeutic paracentesis to relieve discomfort and prevent further complications such as spontaneous bacterial peritonitis (SBP).

As the patient grappled with these evolving complications, the team faced a critical juncture. The decision to pursue a TIPS procedure became more pressing, given the dual benefits of addressing portal hypertension and potentially alleviating both variceal bleeding and ascites. This decision required careful weighing of the risks, particularly the potential exacerbation of encephalopathy following TIPS. The interdisciplinary team, including hepatology, gastroenterology, and critical care specialists, engaged in a thorough discussion with the patient's family to consider the procedure's implications and align on the best course of action. This phase of the patient's journey highlighted the complexity of managing advanced liver disease and underscored the importance of a tailored, dynamic approach to treatment.

Section 5

As the healthcare team continued to monitor the patient's condition, they observed a change in his respiratory status. The patient began to exhibit mild tachypnea, with a respiratory rate of 24 breaths per minute, and his oxygen saturation decreased to 92% on room air. Concerned about potential respiratory compromise due to ascites, the team performed an arterial blood gas analysis, revealing mild respiratory alkalosis with a pH of 7.47, PaCO2 of 33 mmHg, and PaO2 of 78 mmHg. These findings suggested that the increasing abdominal pressure from ascites might be impairing the patient's diaphragmatic function, leading to his altered respiratory status.

In addition to respiratory changes, the patient's laboratory results revealed worsening coagulopathy, with an international normalized ratio (INR) of 2.5 and a platelet count of 90,000/µL, indicating a heightened risk for bleeding. This raised further concerns about performing invasive procedures such as paracentesis or TIPS, as the risk of bleeding complications could potentially outweigh the benefits. Nonetheless, the patient's discomfort from ascites was becoming more pronounced, and the risk of spontaneous bacterial peritonitis remained a significant concern.

These developments necessitated a reassessment of the patient's treatment plan. The healthcare team discussed the potential need for fresh frozen plasma or platelet transfusions to correct the coagulopathy before any invasive procedures. Additionally, they considered the possibility of initiating diuretic therapy with spironolactone and furosemide to manage the ascites conservatively. The team also re-evaluated the patient's medication regimen to ensure that nephrotoxic drugs were minimized, aiming to preserve kidney function and prevent hepatorenal syndrome. As they navigated these challenges, the team remained committed to providing comprehensive care, balancing the risks and benefits of each intervention while keeping the patient's family informed and involved in the decision-making process.