COLLABORATIVE DIAGNOSIS: Potential complications

  1. bleeding related to:
    1. decreased production of clotting factors associated with impaired liver function and decreased available vitamin K (can occur from malnutrition, antimicrobial therapy, and impaired absorption of vitamin K as a result of bile flow obstruction)
    2. thrombocytopenia associated with hypersplenism (if venous congestion has resulted in splenomegaly, the spleen will destroy platelets faster than usual);
  2. ascites related to:
    1. low plasma colloid osmotic pressure associated with hypoalbuminemia (a result of decreased hepatic synthesis of albumin and prolonged inadequate nutrition)
    2. increased pressure in the portal system and hepatic lymph system associated with blood flow backup resulting from structural changes in the liver
    3. a generalized increase in hydrostatic pressure associated with fluid volume excess;
  3. hepatorenal syndrome related to decreased renal blood flow possibly associated with:
    1. a decrease in intravascular volume resulting from:
      1. third-spacing and sequestration of fluid in the splanchnic system
      2. treatment-induced fluid loss (e.g. paracentesis, diuretic therapy)
    2. intrarenal vasoconstriction that may result from increased levels of certain renal arteriolar vasoconstrictors (e.g. angiotensin, endothelin), increased sympathetic nervous system activity, and impaired synthesis of renal vasodilators such as prostaglandin E2;
  4. bleeding esophageal varices related to:
    1. tortuosity and increased fragility of small vessels in the esophagus associated with portal hypertension
    2. increased bleeding tendency;
  5. hepatic (portal-systemic) encephalopathy (hepatic coma) related to altered brain function associated with:
    1. the effect of toxic substances (e.g. ammonia, mercaptans) on the brain
    2. replacement of true neurotransmitters by false neurotransmitters
    3. increased brain sensitivity to certain substances (e.g. benzodiazepines, gamma-aminobutyric acid [GABA]).
Desired Outcome
The client will not experience unusual bleeding as evidenced by:
  1. skin and mucous membranes free of petechiae, purpura, ecchymoses, and active bleeding
  2. absence of unusual joint pain
  3. no further increase in abdominal girth
  4. absence of frank and occult blood in stool, urine, and vomitus
  5. usual menstrual flow
  6. vital signs within normal range for client
  7. stable or improved Hct and Hb.
Nursing Actions and Selected Purposes/Rationales
  1. Assess client for and report signs and symptoms of unusual bleeding:
    1. petechiae, purpura, ecchymoses
    2. gingival bleeding
    3. prolonged bleeding from puncture sites
    4. epistaxis, hemoptysis
    5. unusual joint pain
    6. further increase in abdominal girth
    7. frank or occult blood in the stool, urine, or vomitus
    8. menorrhagia
    9. restlessness, confusion
    10. decreasing B/P and increased pulse rate
    11. decrease in Hct and Hb levels.
  2. Monitor platelet count and coagulation test results (e.g. prothrombin time or International Normalized Ratio [INR], activated partial thromboplastin time, bleeding time). Report abnormal values.
  3. Implement measures to prevent bleeding:
    1. perform actions to reduce risk of bleeding from esophageal varices (see action B in bleeding esophageal varices complication)
    2. avoid giving injections whenever possible; consult physician about prescribing an alternative route for medications ordered to be given intramuscularly or subcutaneously
    3. when giving injections or performing venous or arterial punctures, use the smallest gauge needle possible and apply gentle, prolonged pressure to the site after the needle is removed
    4. caution client to avoid activities that increase the risk for trauma (e.g. shaving with a straight-edge razor, using stiff bristle toothbrush or dental floss)
    5. whenever possible, avoid intubations (e.g. nasogastric) and procedures that can cause injury to the rectal mucosa (e.g. taking temperature rectally, inserting a rectal suppository, administering an enema)
    6. pad side rails if client is confused or restless
    7. perform actions to prevent falls (see Diagnosis 10, action a.1)
    8. instruct client to avoid blowing nose forcefully or straining to have a bowel movement; consult physician about an order for a decongestant and/or laxative if indicated
    9. administer the following if ordered to improve clotting ability:
      1. vitamin K (e.g. phytonadione) injections
      2. platelets
      3. fresh frozen plasma (FFP)
      4. cryoprecipitate.
  4. If bleeding occurs and does not subside spontaneously:
    1. apply firm, prolonged pressure to bleeding area(s) if possible
    2. if epistaxis occurs, place client in a high Fowler's position and apply pressure and ice pack to nasal area
    3. maintain oxygen therapy as ordered
    4. implement measures identified in action C in bleeding esophageal varices complication if esophageal bleeding occurs
    5. administer vitamin K (e.g. phytonadione) injections, whole blood, or blood products (e.g. fresh frozen plasma, platelets) as ordered
    6. assess for and report signs and symptoms of hypovolemic shock (e.g. restlessness; confusion; significant decrease in B/P; rapid, weak pulse; rapid respirations; cool skin; urine output less than 30 ml/hour).
Desired Outcome
The client will have decreased ascites if present as evidenced by:
  1. decrease in abdominal girth
  2. abdominal percussion note more tympanic.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for signs and symptoms of ascites:
    1. increase in abdominal girth (abdominal girth should be measured daily at the same time and in the same location on the abdomen with client in the same position)
    2. dull percussion note over abdomen with finding of shifting dullness
    3. presence of abdominal fluid wave
    4. protruding umbilicus and bulging flanks.
  2. Implement measures to reduce fluid volume excess, promote mobilization of fluid back into the vascular space, and prevent further third-spacing (see Diagnosis 2) in order to promote the resolution of ascites.
  3. If signs and symptoms of ascites are present and persist or worsen:
    1. consult physician
    2. assist with paracentesis and administer colloid replacement infusions (e.g. albumin, dextran) if ordered
    3. prepare client for a portal systemic shunt procedure (e.g. transjugular intrahepatic portosystemic shunt [TIPS]) if planned to treat portal hypertension and subsequently reduce ascites.
Desired Outcome
The client will maintain adequate renal function as evidenced by:
  1. serum creatinine level within normal range
  2. creatinine clearance and urine sodium within normal range
  3. urine output at least 30 ml/hour.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of hepatorenal syndrome (e.g. increased serum creatinine, decreased creatinine clearance, low urine sodium, urine output less than 30 ml/hour).
  2. Implement measures to reduce the risk for hepatorenal syndrome:
    1. perform actions to maintain adequate renal blood flow:
      1. maintain an adequate fluid intake; if client is on a fluid restriction, maintain the maximum fluid intake allowed
      2. administer albumin infusions if ordered to increase the intravascular volume
      3. consult physician about reducing the dose of diuretic ordered if client loses more than 1 kg of weight/day (vigorous diuresis can reduce the intravascular volume enough to decrease renal blood flow and precipitate the hepatorenal syndrome)
    2. consult physician regarding discontinuation of prescribed medications that can precipitate the hepatorenal syndrome (e.g. nonsteroidal anti-inflammatory agents, aminoglycosides).
  3. If signs and symptoms of the hepatorenal syndrome occur:
    1. administer intravenous infusions of dopamine, ornipressin, and/or albumin if ordered
    2. prepare client for dialysis if indicated.
Desired Outcome
The client will not experience bleeding of esophageal varices as evidenced by:
  1. absence of hematemesis and melena
  2. B/P and pulse within normal range for client
  3. stable or improved RBC, Hct, and Hb levels.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of bleeding esophageal varices (e.g. hematemesis; melena; decreased B/P; increased pulse; decreasing RBC, Hct, and Hb levels).
  2. Implement measures to reduce risk of bleeding from esophageal varices:
    1. perform actions to reduce fluid volume excess (see Diagnosis 2) in order to reduce pressure in esophageal vessels
    2. instruct client to avoid activities such as straining to have a bowel movement, coughing, sneezing, and lifting heavy objects in order to prevent a sudden increase in intra-abdominal pressure; consult physician about an order for a laxative, antitussive, and/or decongestant if indicated
    3. administer a nonselective beta-adrenergic blocker (e.g. propranolol, nadolol) to reduce portal pressure (a nitrate [e.g. isosorbide] may be given with the beta blocker to further reduce portal pressure)
    4. administer vitamin K and blood products if ordered to improve clotting ability.
  3. If signs and symptoms of bleeding esophageal varices occur:
    1. turn client on side and suction as necessary to reduce risk of aspiration
    2. maintain oxygen therapy as ordered
    3. assist with administration of vasopressin or octreotide acetate (Sandostatin) if ordered to constrict splanchnic vessels and reduce blood flow to the portal vein (nitroglycerin is often given with vasopressin to lower portal pressure and also reduce the vasoconstrictor side effects of vasopressin)
    4. prepare client for endoscopic sclerotherapy or ligation of varices if planned
    5. assist with insertion of a gastroesophageal balloon tube (e.g. Sengstaken-Blakemore tube, Minnesota tube); maintain balloon pressure and suction and perform lavage as ordered
    6. administer vitamin K (e.g. phytonadione) injections, whole blood, or blood products (e.g. fresh frozen plasma, platelets) as ordered
    7. prepare client for a transjugular intrahepatic portosystemic shunt (TIPS) or surgery (e.g. esophageal transection with reanastomosis, distal splenorenal shunt) if planned.
Desired Outcome
The client will not develop hepatic encephalopathy as evidenced by:
  1. usual speech and handwriting
  2. usual mental status
  3. absence of asterixis and fetor hepaticus
  4. serum ammonia level within normal range.
Nursing Actions and Selected Purposes/Rationales
  1. Assess for and report signs and symptoms of hepatic encephalopathy (e.g. change in handwriting, inability to draw simple figures or numbers, slow or slurred speech, inability to concentrate, emotional lability, disordered sleep, agitation, belligerence, disorientation, lethargy, asterixis, fetor hepaticus [musty or fruity odor on breath], unresponsiveness).
  2. Monitor serum ammonia results. Report elevated values.
  3. Implement measures to reduce the risk for hepatic coma:
    1. perform actions to eliminate or control the following factors that increase levels of ammonia and other nitrogenous substances:
      1. constipation (results in increased formation and absorption of ammonia and mercaptans from the gut)
      2. gastrointestinal hemorrhage (intestinal bacteria convert the protein in blood to ammonia and other nitrogenous substances)
      3. hypokalemia and/or metabolic alkalosis (both conditions contribute to increased cerebral levels of ammonia)
      4. renal failure (results in decreased excretion of ammonia)
      5. excessive protein intake (intestinal bacteria convert protein to ammonia and other nitrogenous substances)
      6. infection (bacteria that produce urease break urea into ammonia)
      7. dehydration/hypovolemia (reduced blood flow to the liver results in decreased detoxification of ammonia and other toxins)
    2. consult physician about discontinuation of prescribed medications that are potential hepatotoxins (e.g. isoniazid, amiodarone, methyldopa, phenytoin) in order to prevent further liver damage
    3. administer central nervous system depressants such as narcotics, sedative-hypnotics, and antianxiety agents with extreme caution (many of these agents are metabolized in the liver and may precipitate nonnitrogenous coma).
  4. If signs and symptoms of hepatic encephalopathy occur:
    1. maintain client on strict bed rest to reduce metabolic demands on the liver
    2. maintain dietary protein restrictions as ordered; increase protein intake slowly as encephalopathy resolves and encourage intake of vegetable proteins rather than animal proteins (vegetable proteins are less ammoniagenic)
    3. ensure a high carbohydrate intake or administer intravenous glucose or tube feedings as ordered to provide a rapid energy source and decrease metabolism of endogenous proteins
    4. administer enemas and/or cathartics as ordered to hasten expulsion of intestinal contents so that bacteria have less time to convert proteins to ammonia and other nitrogenous substances
    5. administer the following medications if ordered:
      1. antimicrobials that suppress activity of the intestinal flora (e.g. neomycin, metronidazole) to decrease protein breakdown in the intestine and subsequently reduce the formation of nitrogenous substances
      2. lactulose to stimulate catharsis and create an acidic medium in the intestine (the acidity reduces bacterial growth and the resultant formation of nitrogenous substances and also traps ammonia in the colon by promoting the conversion of NH3 to the poorly absorbed NH4)
      3. benzodiazepine receptor antagonists (e.g. flumazenil) to block benzodiazepine uptake in the brain
      4. zinc supplements to stimulate ureagenesis (several enzymes in the urea cycle are zinc dependent)
    6. institute general safety precautions.