Case Study
Hepatic Disorders
Joseph Hubert, age 59 years, was brought to the emergency department with complaints of dizziness, dyspnea, restlessness, and anxiety. Mr. Hubert currently works as an accountant for a large firm. He is married and has two children living at home. He reported a two day history of hematemesis with some bright red blood and large amounts of coffee-ground emesis. Mr. Hubert denied any recent or chronic illnesses and was unable to remember if anyone in his family had ever had problems with gastrointestinal tract bleeding. He did admit to drinking five to six alcoholic beverages almost every day for the last 7 years. Initial assessment revealed cool and clammy skin, distended abdomen with hyperactive bowel sounds, and tachycardia.
Current vital signs and laboratory results are listed below:
BP 92/60; HR 120 BPM; Respirations 28/min; Temperature 36.9 C
Ammonia 60 mcg/dl Glucose 87 mg/dl
LDH 500 U/L PT 26 sec
PTT 85 sec. AST 950 U/L
Alk. Phos. 165 U/L ALT 1000 U/L
Total Bili 2.5 mg/dl Albumin 2.3 g/dl
Three hours after arriving in the emergency department, Mr. Hubert was admitted to the intensive care unit with an IV of NS. Two units of PRBCs were administered. Twenty units of vasopressin in 100 ml of 5% dextrose in water was given intravenously over 20 minutes. A continuous infusion of vasopressin 0.4 U/min was then initiated. Sublingual nitroglycerin was added to the medication regimen. Diagnostic endoscopy, immediately preceded by a saline lavage, was scheduled for the following day. Endoscopy revealed a large esophageal varix above the gastroesophageal junction. Only a small amount of bright red blood was observed, so sclerotherapy was performed. A solution of 5% ethanolamine oleate was given by intravariceal injection. Mr. Hubert remained stable following sclerotherapy and was transferred to the medical floor. Subsequent sclerotherapy sessions were scheduled on a weekly basis for 4 weeks.
1. Define and discuss the pathophysiology of esophageal varices and portal hypertension.
2. What do Mr. Hubert’s laboratory tests indicate about his current health status?
3. Explain how Mr. Hubert’s history and laboratory results related to portal hypertension.
4. Discuss the clinical manifestations of esophageal varices.
5. Identify the diagnostic procedures and nursing implications for esophageal varices.
6. Compare and contrast the treatment options and nursing implications for esophageal varices.
7. Discuss the rationale for Mr. Hubert’s vasopressin therapy, management of side effects, and nursing concerns.
8. Identify the relevant nursing diagnoses for Mr. Hubert while he is in the ICU.
9. Discuss the patient/family teaching indicated for Mr. Hubert.
10. What special nursing considerations are prompted by Mr. Hubert’s past drinking pattern?
11. Discuss the psychosocial aspects of the care of Mr. Hubert and his family.
Case Study
Hepatic Disorders
John Doe, an approximately 50-year-old man, is admitted to your floor from the ED. He
is lethargic, has a cachectic appearance, does not follow commands consistently, and is
mildly combative when aroused. He smells strongly of alcohol and has a notably swollen
abdomen and lower extremities. This man was sent to the ED by local police who found
him lying unresponsive along a rural road. He was aroused somewhat in the ED.
Examination and x-rays are negative for any injury, and he is admitted to your unit for
observation. He has no ID and is not awake enough to give any history or to coherently
answer questions. Admitting orders are: Admit to E3 with R/O hepatic encephalopathy;
IV D51/2NS with 20 mEq KCL at 75 ml/h; add 1 amp MVI to each liter of IVF; foley
catheter to BSD; HOB at 30 to 45 degrees at all times; tap water enemas until clear;
abdominal ultrasound in AM; CBC with diff, Chem 20, NH3 now and in AM; soft
restraints prn; vitamin K 10 mg IM qd X 3 doses; thiamine 1 gm IM qd; folic acid 5 mg
IM qd; pyridoxine 100 mg po qd; low-protein diet, eat with assistance only; call HO for
any sign of GI bleed, DTs, or 140 < SBP < 100, DBP < 50, P > 120.
1. Which of the above orders must be done by the RN? By the aide? By the clerk?
2. The lab work drawn in the ED has come back, the blood alcohol level is 320 mg/dl and the blood ammonia is 85 mcg/dl. What do these values indicate?
While you are getting John Doe settled, you continue your assessment. Neuro: PERRL,
MAE sluggishly, pulling away during assessment, follows commands sporadically.
CV: HR regular but tachy without adventitious sounds. All peripheral pulses palpable and
3+ bilaterally, 3+ pitting edema in lower extremities. IV of D5 ½ NS with 20 mEq KCL/L
at 75 ml/h in L forearm. Resp: Breath sounds decreased to all lobes, no adventitious
sounds audible, client does not cooperate with cough and deep breathing, on RA with
SaO2 at 90%. GI: Tongue and gums are beefy red and swollen, abdomen enlarged and
protuberant, girth is 141 cm, abdominal skin taut and slightly tender to palpitation, BS
X 4 quads. GU: Foley to BSD with 54 ml dark amber urine since admission (2 hrs).
Skin: Color pale to torso and LEs, heavily sunburned to UEs and head; skin thin and dry;
numerous spider angiomas on upper abdomen with several dilated veins across abdomen.
VS are 120/60, 104, 32, 37.3 C. Toxicology screen and electrolytes have been drawn.
3. What is the significance of the spider angioimas, dilated abdominal veins, peripheral edema, and distended abdomen?
4. How would you further assess the distended abdomen, and what is the clinical name for your findings?
5. Which of the following nursing diagnoses are appropriate for John Doe based on the assessment given?
_____ Altered nutrition, less than body requirements
_____ Impaired skin integrity
_____ Fluid volume excess
_____ Fluid volume deficit
_____ Altered thought processes
_____ Risk for injury
_____ Risk for impaired skin integrity
_____ Ineffective individual coping related to alcohol abuse
_____ Ineffective breathing pattern
6. What is your concern about John Doe’s nutritional status? What are your objective reasons?
7. Why is the low-protein diet ordered? How much protein is reasonable?
8. How might you respond to fellow staff nurses’ remarks, “Why are we wasting time with this ‘wino’? He isn’t worth the time or money. Why don’t they let him die?”
9. A nursing diagnosis that is appropriate for John Doe is Risk for Injury. Consider
at least 3 areas of risk injury and identify actions you will take to ensure his
safety.
10. What are the signs and symptoms of DTs?
11. Falls are particularly dangerous for a client in John Doe’s position. Why?
12. The aide asks you why the client has tap water enemas ordered and how many to do “until clear.” You reply the following.
John Doe survives a rocky course of hepatic encephalopathy and near-renal failure. After
27 days, including a week in the ICU, he is discharged to a drug and alcohol
rehabilitation facility. He is employed as a longshoreman; fortunately, his insurance
covers his month of in-house intensive rehabilitation.
Case Study
Hepatic Disorders
P. M., a 24-year-old house painter, has been too ill to work for the last 3 days when he
arrives at your outpatient clinic. He seems an alert but acutely ill young man of average
build, with a deep tan over exposed areas of skin. He reports headaches, severe myalgia,
a low-grade fever, cough, anorexia, and nausea and vomiting, especially after eating any
fatty foot. P. M. describes vague abdominal pain that started about the same time as the
other problems. PMH: no health problems, nonsmoker, drinks a “few” beers each
evening to relax. Assessment: VS are 128/84, 88, 26, 38.1 C, alert and oriented x 3,
MAEW except for aching pain in his muscles; very slight scleral jaundice present; heart
tones clear and without adventitious sounds; breath sounds clear throughout; abdomen
soft and palpable without distinct masses. You note moderate hepatomegaly; liver edge
is easily palpated and tender to palpation. P.M. mentions that his urine has been getting
darker over the last 2 days.
P.M. is presenting with the key signs of hepatitis. Lab work is sent to identify his precise
problem. Results: Na 140 mEq/L, K 3.9 mEq/L, Cl 102 mEq/L, Co2 26 mEq/L, BUN
10 mg/dl, creatinine 1.0 mg/dl, platelets 86 mm3, direct bilirubin 1.6 mg.dl, total
bilirubin 2.3 mg/dl, albumin 3.8 g/dl, total protein 6.2 g/dl, ALT 66 U/L, AST 52 U/L,
LDH 205 U/L, ALP 176 U/L, PT 12 sec., PTT 32 sec., urine urobilinogen 1.6 E U/L,
albuminuria 169 mg/dl, bilirubinuria +, + IgM-class anti-HAV
1. Which key diagnostic tests will determine exactly what type of hepatitis is present?
2. A Chem 20 panel was drawn. Which of the lab tests listed above specifically
indicates liver disease?
3. List 8 or more drugs that can cause increased ALT levels.
4. Considering that the basic pathology of hepatitis involves inflammation, degeneration, and regeneration of the hepatocyte, what type of diet will
you strongly encourage P.M. to follow?
5. Differentiate between hepatitis A, B, and C on the basis of the mode of
transmission and prevention.
6. Name 3 major activities that can be done in a community to prevent the spread of
hepatitis?
7. In P.M.’s case, the IgM-class anti-HAV antibody is positive. This indicates that P.M. is infected with hepatitis A and is in the acute or early convalescent period
of the disease. Is this disease contagious? What precaution would you take?
8. Pruritis is usually associated with jaundice. What will you do to ease this problem
for P.M.?
9. How would you explain to P.M. the likely progression of his disease?
The acute illness runs a 2- or 3-week course with full clinical and laboratory recovery in
9 weeks for hepatitis A, and about 16 weeks for hepatitis B and hepatitis C. The course of
recovery may be longer in 10% of clients and some may even become chronic;
fulminating hepatitis may develop, causing death in 1-3%.
10. P.M is living at home with his parents and 8 younger siblings. The youngest is a 4-year-old. His parents ask how to prevent the rest of the family from getting
hepatitis. What specific instructions will you give? How will you know that these instructions are understood?
11. Given P.M.’s lifestyle, what specific patient teaching points must you emphasize?
12. List 4 critical nursing diagnoses relevant to P.M.’s nursing care.
Case Study
Hepatic Disorders
J.D., with 2 years of sobriety behind him, has been promoted from longshoreman to
nightshift foreman in the warehouse. He has new hope and new friends in his AA groups.
Unfortunately, his cirrhotic liver has not recovered from 20 years of heavy drinking, and
he still has residual effects. During the past 2 days he has had a “bad cough.” This
morning he coughed up bright red blood and came into the ED. His coughing and
bleeding have subsided for now. He is sent to the floor for observation. Shortly after you
admit J.D., you hear coughing while passing his room. You enter and see BRB all over
his gown and bed. He looks very frightened.
1. What needs to be done at once?
2. What specific tasks must be done?
3. What do you think J.D.’s emotional state is? How would his body respond to this
emotion?
4. Recognizing his emotional state, what can you do to intervene?
5. What treatment options exist for esophageal varices? List in the order in which
they are most likely to be tried.
6. How would you prepare J.D for an endoscopic exam?
7. The gastroenterologist performs the fiberoptic endoscopic examination. Neither
cauterization nor sclerotherapy is successful for more than a few minutes and
J.D.’s bleeding intensifies. The physician elects to use balloon tamponade to hold
pressure on the varices until J.D. can more safely undergo surgery. What key
rule will you observe with this tube?
8. What is the major complication of balloon tamponade, and how can you help prevent this?
9. J.D. looks at you and asks, “Am I going to die?” You know that the operative mortality is 5% to 15% in elective cases and 50% in emergency cases. Even the survivors have a curtailed lifespan because of an increased rate of hepatic encephalopathy and liver failure. How would you respond?
10. What is shunt surgery and why is it done?
11. J.D.’s current H/H = 8.6/26. He is to receive 2 units of fresh whole blood and 2 units of salt-poor albumin. How will you know if J.D. is having any negative
reactions to the transfusion, and what would you do to intervene?
12. How much will you expect the hematocrit to rise after the transfusion of 2 units of whole blood?
Case Study
Hepatic Disorders
The client is a
28-year-old single homosexual man who recently traveled to
missionary trip. On the basis of his personal beliefs, the client signed a waiver and
refused a hepatitis vaccine, even though it was highly suggested for people traveling
abroad. After returning home, the client began experiencing fatigue and anorexia. When
his condition failed to improve, he consulted a physician at the AIDS center where he
works. Concerned that he might be positive for HIV, both the physician and the client
decided that a chemistry profile and HIV antibody test should be performed. The client
was found to be HIV negative, but his liver enzymes and bilirubin were elevated.
Subsequently, the physician ordered serologic markers for hepatitis. Further questioning
revealed that the client had been having light-colored stools and voiding dark-colored
urine.
The client is currently hospitalized for treatment of hepatitis B. He denies the use of IV
drugs or alcohol. In general, he has been well except foe mild eczema and generalized
pain and itching, for which he has been taking aspirin.
Upon examination, the client is somewhat slow to respond to questions and appears
drowsy and lethargic. His sclera are slightly yellow, and his skin is dry with evidence
of scratching; he complains of frequent itching. His abdomen is soft and nondistended.
Bowel sounds are present in all four quadrants. He complains of abdominal tenderness
upon palpation, abdominal discomfort, indigestion, and nausea. His urine is of adequate
volume but brownish in color.
Diagnostic findings:
Serum markers: positive HbsAg, anti-HbcAg, HbeAg
Chemistry profile: Bilirubin 5.2 mg/dL, ALT 640 U/L, AST 410 U/L,
alkaline phosphatase 130 U/L
Coagulation: PT 20 seconds
1. What is unique about the alkaline phosphatase and prothrombin time in clients with hepatitis B?
2. How are the client’s positive serology markers significant to his diagnosis?
3. What additional information would help to determine the client’s exposure to
the hepatitis B virus?
4. The client asks if he can continue to take aspirin or Tylenol for his generalized
discomfort. Why are these medications contraindicated in this situation?
5. What is the relationship between the client’s jaundice and his generalized pain
and itching?
6. The client is eager to return to his missionary and AIDS work. What should you tell him to expect regarding his recovery?