 Welcome to Nursing School Explained and this video on cirrhosis which is in-stage liver disease. Cirrhosis occurs because of the liver over time with chronic damage gets very scarred and then eventually the tissue itself becomes fibrotic and is unable to function properly. And the most common causes of liver failure or cirrhosis are due to chronic increased intake of alcohol as well as non-alcoholic fatty liver disease as well as chronic hepatitis B and C so this chronic inflammation of the liver eventually will lead to scarring and fibrosis of the organ. And then cardiac causes involve right-sided heart failure. So when the right side of the heart is not working properly the fluid backs up into the periphery. We can see it evidenced in peripheral edema but it also eventually causes congestion to the organs of the abdomen such as the liver and the spleen and then when the liver gets so congested all the time it just ceases to function. So cardiac causes can also lead to liver failure and if any of these causes here happen in combination so if the patient for example had chronic alcoholism as well as some underlying hepatitis or heart failure then the liver fails sooner so we really need to educate our patients on the causes and try to eliminate those. And so in terms to really understand the signs and symptoms of liver failure I've broken them down into the function, the many functions of the liver and then the signs and symptoms that we're seeing in our patient if the patient's liver is not functioning properly. And so first of all we know that the liver conjugates and excretes bilirubin and if it's unable to do that when the liver is failing we'll see the buildup of that bilirubin in the patient who exhibits jaundice. And that might be as simple as just seeing a slight yellowing of their sclera but the patient might also have very much yellowing of the skin in general or maybe even the mucus membranes that we can see. The liver also detoxifies our bodies from medications, drugs, alcohol but also hormones as well as it excretes ammonia and converts it to urea. Now if the liver is not functioning properly this detoxification is either slowed or completely not working at all which will lead to a buildup of medications in the patient's system and we'll have to be very careful in administering certain medications to patients with liver failure because they can build up this toxicity because the liver is unable to break the medications down. Due to the increases in hormones the estrogen is not being able to excrete it which will lead to gynecomastia so enlarged breasts, decreased libido as well as cysticular atrophy in male patients and because the liver is unable to convert the ammonia it builds up in the system and then causes hepatic encephalopathy and we'll talk more about this complication later. Another function of the liver is also to metabolize aldosterone which plays a very important part in the RAS system random angiotensin aldosterone system that helps us keep our blood pressure up and aldosterone works by reabsorbing sodium and water at the kidneys so that we can have a stable blood pressure but if the liver is not able to metabolize the aldosterone it'll build up and will have increased sodium and water retention which then has dire consequences and we'll look at those again. The liver also stores certain minerals and vitamins copper, zinc, magnesium, iron as well as the fat soluble vitamins A, D, E and K as well as vitamin B12. Now if the liver doesn't function properly this will lead to vitamin and mineral deficiencies as well as B12 deficiency can lead to pernicious anemia and then also peripheral neuropathy that unfortunately is irreversible once it happens. The liver also plays a major role in helping us with our blood glucose levels by storing glycogen so if there is a decreased intake or decreased circulating glucose in the bloodstream it secretes the stored glycogen and then by the process of gluconeogenesis helps us to keep our blood glucose level stable but if it's unable to store glycogen or it doesn't release it at a very constant rate it can lead to fluctuations of our blood sugar levels. The liver also plays a huge role in protein synthesis and the one protein that we always need to pay particular attention to is albumin because albumin helps with the oncotic pressure to keep the fluid in the blood vessels but if the liver is unable to synthesize proteins we'll have low protein levels, low albumin levels as well as low oncotic pressure and that will lead to edema and acides. The liver also plays a huge role in blood clotting function as well as clotting factors so if it's not functioning properly usually the PT and INR will be elevated there'll be a tendency to bleed and the patient will have low platelets so when the bleeding occurs there are usually not enough platelets to help stop the bleeding. And then it also plays a role in the production of immunoglobulins so when we now have decreased function here it'll suppress the immune function and because the patient is at such high risk for acides and the fluid is now seeping into that peritoneal cavity this will put the patient at risk for bacterial peritonitis because of these acides and the fluid that's sitting around in the abdomen. And then from a physical standpoint when the liver is not functioning it causes this congestion because the way that it's supposed to work with the blood vessels transporting certain molecules all these things into the liver and it's congested and it can't really process them it'll lead to a liver enlargement and then in turn it'll also lead to spleen enlargement which is hepatosplenomegaly and that leads to portal hypertension and because of the spleen plays such a huge role in the turnover of the red blood cells it can also lead to anemia and then as the blood backs up into the liver as well as the spleen it also affects the kidneys and then this is a term that we use here leading to hepatorenal syndrome so liver failure eventually will also lead to kidney failure so these four major complications of hepatorenal syndrome, portal hypertension, edema, acides and hepatic encephalopathy are those complications that we want to really know on how to assess our patients for and also know how to treat so we'll go into those complications here in more detail a little bit later diagnostic tests for patients with cirrhosis we want to assess their liver function as well as their ammonia level because we know it can lead to this hepatic encephalopathy we want to assess their protein and specifically their albumin levels to see how the level of their oncotic pressure is and the acides we also want to assess their platelets and their coagulation, PT, INR as well as maybe take an ultrasound to visualize the liver a fibroscan is a more detailed scan of the liver that will kind of determine the degree of the fibrosis but the gold standard is a liver biopsy taking a small sample of the liver and determining the degree of the fibrosis and the degree of the liver failure by analyzing the actual cells of the liver and come into determination there let's now take a closer look at the complications of cirrhosis what happens physiologically what signs and symptoms are we going to see and then what's the treatment at nursing care associated with these complications so first of all, portal hypertension now there is altered blood flow through this fibrotic liver that is so scarred up which leads to an increased pressure in the portal circulation as well as the spleen because they're both related and close to this portal circulation system and then because there is no congestion and the blood can't flow through the liver what the body does it develops these collateral veins and those large collateral veins you might have heard about those before in relation to cardiac issues so whenever there's a blood vessel that is obstructed or there's any problems with it this doesn't just happen over time this is chronic liver failure so the body tries to figure out a way of how to make the blood flow work through the organ so it develops these new blood vessels that are kind of like a u-turn around this fibrotic liver and these collateral veins kind of imagine them being as kind of very close veins that you could see protruding from a patient's lower extremities so they're very torturous they're not very thick wall and they're very pliable and they break very easily and these collateral veins then can lead to gastric or esophageal varices so these are those torturous veins that now kind of surround the stomach and the esophagus because they're trying to kind of make this u-turn around this fibrous liver and these varices they are very prone to bleeding so now signs and symptoms that we might see here is what's called Medusa so think about Medusa with the snakes around her head so we might see those around the patient's umbilicus or also around the entire abdomen and these are kind of like these torturous veins that you might be seeing these kind of varicose veins on the patient's abdomen and again this is end stage liver disease and then hemorrhoids may also form around the patient's rectum because there is this increased blood flow now so all the way to the rectum now when these varices these collateral veins because they are so fragile they tend to bleed so the patient might have black bloody or tarry vomit or stools and that is definitely something that we have to be aware of and act very quickly because there's a high risk for bleeding or actually hemorrhage and then hepatomegaly because the liver again is so that we might be able to palpate it underneath the cost of margin where it's not supposed to be but now it's enlarged and we can detect this on our physical exam so for treatment and nursing care for the portal hypertension we want to prevent the bleeding by decreasing the pressure in this portal circulation and beta blockers actually work really well to do that we want to tell our patient to avoid alcohol and sets an aspirin that will just make them more likely to bleed and if there is bleeding we want to do as always our A, Bs and Cs so have suction equipment ready maybe the patient will need to be intubated if there is now a GI bleeding that continuously vomiting blood and then certainly we also need to administer IV fluids to keep the blood pressure up even administer blood products and then the way to really stop the splitting of the varices is for the GI doctor to perform an endoscopy and do a band ligation to kind of just clamp down that bleeding blood vessel or do a balloon thumping out where they kind of put pressure from the inside on these bleeding varices there is also a medication called sandastatin or vasopressin that vasopressin constricts the blood vessels and helps to decrease the bleeding in that regard by just putting more pressure on the blood vessels now then over here the peripheral edema and asides because we know that the liver has to do with protein production now if we don't have enough proteins we have decreased oncotic pressure and this portal hypertension will lead to peripheral edema that we can see in the patient's lower extremities but also these proteins now shift from the intravascular space into the lymph tissue and then from there the lymph tissue gets so overloaded that now it backs up into the peritoneal cavity and this peritoneal cavity then gets so filled with fluid that we can actually visualize as asides and then what also happens this osmotic pressure pulls additional fluid from the intravascular space into the asides into the peritoneal cavity and then even contributing more to the asides and then remember that we said aldosterone is metabolized by the liver so if the liver is not functioning we have increased aldosterone which leads to sodium and water retention and then again this increased leak into the peritoneal cavity because now we are retaining all this fluid but we don't have the plasma proteins to keep the fluid in the intravascular space it leaks out making the asides worse and in addition it drops the blood patients blood volume and blood pressure which then the kidneys don't get perfused leading to renal impairment so signs and symptoms that we might see here is the peripheral edema and the asides as well as probably your low urine output because now the kidney might be acutely or actually chronically failing if this is something that's been going on for a while as for treatment we want to have the patient on a low sodium diet so that we're not retaining all these fluids we want to put them on diuretics and spironolactone which is an aldactone antagonist so it counteracts this increased absorption or decreased secretion or excretion really of the aldosterone it works really well here spironolactone now it is a potassium sparing diuretic so we have to be carefully monitoring the patient's electrolytes as well because of the sodium the decreased sodium in the diet if the asides gets so bad that it's just completely distended and it needs to be drained then the provider will perform a paracentesis where they basically place a needle under sterile technique into the patient's abdominal cavity and drain that fluid out and then we can also administer IV albumin because that will help create the synchotic pressure and pull the fluid back from the edema in the lower extremities as well as the asides pull it back from that third space into the intravascular compartment and help stabilize the blood pressure and excretion here now third we have hepatic encephalopathy which occurs to the increased buildup of the ammonia which crosses the blood-brain barrier and is neurotoxic that is very bad in patients with insatural disease many times will come in they will be altered they might have inappropriate behavior or they might be completely obtunded because this ammonia will bring the brain onto the brain cells and they might also have these acerixes which is this kind of a tremors that they have in their hands so you would ask them to hold their hands out and then they just tremble they just can't control it and that is the ammonia that's building up in their system so what do we do about that? Lactylose is a nice medication that helps to bind the ammonia and it can be given P.O. but if the patient is altered they might not be able to swallow so it can also be given rectally via an enema or by an NG tube but for an NG tube I would always caution you to be very careful because of these gastric and esophageal barices that tend to bleed so you might have the GI doctor or the physician perform the placement of the NG tube to make sure that you are not nipping the blood vessel as you are placing this NG tube and then for hepatorenal syndrome so now these waste products are building up in the patient's system just like when the kidneys are not working the liver is unable to detoxify which leads to esotemia so build up of these waste products and decrease urine output and then because we have this tractable acidity so there's just all these mechanisms that just build up the leakage of the fluid into that intra-abdominal cavity so now the fluid is third spacing it's in the space where it's not belongs it leaks out of the intravascular system which then drops the patient's intravascular volume their blood pressure and we know when the blood pressure drops there's not enough perfusion to the important organs and that also leads to decreased renal vision which then can cause renal failure signs and symptoms we'll see decrease in urine output and certainly decrease in blood pressure because of this decreased intravascular volume and the treatment for that is everything that we talked about here for treating the asides there are a few other treatment options available for patients with in-stage liver disease or cirrhosis that cannot only be medically managed but are more of a permanent solution to the hepatic failure so first is a procedure called a TIPS procedure which stands for trans-juggler intra-hepatic portal systemic shunt I know it's a mouthful so let's think about this so there's a catheter inserted through the jugular vein into the liver through to make a shunt from the portal vein to the systemic vein so the inferior vena cava and so basically what happens usually the blood will enter the liver from the GI tract and the spleen through the portal vein and the liver will process the nutrients and the blood and detoxify and do all those good functions that it does and then it leaves the liver by the means of the hepatic vein and there's usually not a connection between the two because the liver performs all these functions in between now when the liver is not functioning we have this portal hypertension that we're dealing with because now everything is being backed up causing a very season all those things so the TIPS procedure is this catheter this artificial U-turn if you want to call it that that is between the portal vein and the hepatic vein to kind of bypass the liver is really what that is and so it's this catheter in the jugular vein to the hepatic vein shunts the blood between the systemic and the portal vena systems decreases the portal hypertension decompresses the varices that are so highly likely to bleed and helps to control that bleeding in turn so it's a very nice procedure that can be done of course we have to do all these other measures still to keep the patient from detoxifying their system helping with the asides and any of those other complications we already discussed and then number two there is a liver dialysis that's very similar to renal dialysis where basically a machine is just used to filter the blood and detoxify it's just not as common as kidney dialysis now when everything fails and the patient qualifies they can be put on a transplant list to receive a new liver which then in turn will replace the diseased organ and hopefully the patient through a rejection medications will be able to tolerate the transplant and then be back to normal functioning and one thing that's also always important is nutrition and so patients with liver failure because of all the pathophysiological mechanisms that are going on now if they don't have any of these tips, procedure dialysis or liver transplant or even if they do we want to keep them on a high calorie diet a high diet in complex carbohydrates and also low to moderate fat because we don't want the cholesterol to be building up and then low in protein so that we don't have this accumulation of the plasma proteins that just leak out making the society worse thank you for watching this lengthy video on serosis I hope it has helped you understand really the pathophysiology complications it can lead to signs and symptoms as well as treatments available and that you now have a better understanding of what is going on and I'm a firm believer that if you understand what's going on physiologically you're better able to understand signs and symptoms complications and then also this will help you in taking your exams as well as the big exam at the end of your nursing career the influx so thanks so much for watching give me the thumbs up if 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