Ncm 30 Study Guide on the Child

8/14/2019 Ncm 30 Study Guide on the Child

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NCM 30 STUDY GUIDE ON

THE CHILD WITH GASTROINTESTINAL DYSFUNCTION

CIRRHOSIS (p.1431 of Wong)

a liver disease characterized by permanent scarring of the liver that

interferes with its normal functions

Occurs as an end stage of many chronic liver diseases, including biliary

atresia and chronic hepatitis.

This condition is irreversibly damaged.

It affects about three million Americans a year.

CAUSES

Infection Autoimmune (0.6% to 2%) Toxic factors (Prolonged exposure to certain types of chemicals and

medications like arsenic, methotrexate, toxic doses of vitamin A)

Chronic diseases such as hemophilia and cystic fibrosis

Hepatitis B and C (African Americans)

Bile duct disorders such as primary biliary cirrhosis and primary sclerosingcholangitis.

Metabolic disorders such as hemachromatosis, Wilsons disease, and

alpha-1 antitrypsin deficiency

Others like Schistosomiasis,

RISK FACTORS

Obesity

Genetic factors

Moderate to heavy alcohol users.

Co-infection with hepatitis B.

Co-infection with HIV.

Having large iron stores in the liver.

nonalcoholic steatohepatitis (NASH)

nonalcoholic fatty liver disease (NAFLD)

Weight gain in the area of and abovethe waist (apple type) is more

dangerous than weight gained aroundthe hips and flank area (pear type).

Fat cells in the upper body have


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different qualities than those found inhips and thighs.

PATHOPHYSIOLOGY:

COMPLICATIONS:

Ascites (fluid buildup in the abdomen) Variceal hemorrhage, severe bleeding from varices (enlarged veins in the

esophagus and upper stomach) Spontaneous bacterial peritonitis, a severe infection of the abdominal fluid Hepatic encephalopathy, damage to the brain caused by buildup in the body

of toxins such as ammonia Hepatocellular carcinoma, a type of liver cancer

Hepatorenal syndrome, when kidney failure occurs along with severecirrhosis

Others:

Kidney Failure

Osteoporosis

Insulin Resistance and Type 2 Diabetes.


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Heart Problems.

CLINICAL MANIFESTATION

Cirrhosis is divided into two stages: Compensated and Decompensated.

Compensated cirrhosis means that the body still functions fairly welldespite scarring of the liver. Many people with compensated cirrhosisexperience few or no symptoms.

Fatigue and loss of energy

Loss of appetite and weight loss

Nausea or abdominal pain

Spider angiomas may develop on the skin. These are pinhead-sized red

spots from which tiny blood vessels radiate. (upper torso)

Decompensated cirrhosis means that the severe scarring of the liver hasdamaged and disrupted essential body functions. Patients withdecompensated cirrhosis develop many serious and life-threateningsymptoms and complications.

Fluid buildup in the legs and feet (edema) and in the abdomen(ascites). (Ascites is associated with portal hypertension, which isdescribed in the Complications section of this report.)

Jaundice. This yellowish cast to the skin and eyes occurs because theliver cannot process bilirubin for elimination from the body.

Other Manifestations:

Poor growth

Muscle weakness

Lethargy

Impaired pulmonary function ( dyspnea and cyanosis during exertion)

Intrapulmonary shunts (hypoxemia)

Children (impaired intrahepatic blood flow)

Ascites

Edema

GI bleeding

Anemia

Abdominal pain

DIAGNOSTIC EXAMINATION


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Past health history

Physical examination (firm, often enlarged and rock-hard)

Laboratory evaluation

Liver function tests:

o Bilirubin

o Aminotransferase

o Ammonia

o Albumin

o Cholesterol

o Prothrombin time

Imaging Tests

o Magnetic resonance imaging (MRI)

o computed tomography (CT) scan

Liver biopsy (Transjugular Liver Biopsy, Percutaneous Liver Biopsy and

laparoscopy)

***liver biopsy can cause internal bleeding thats why monitoring vital signs

and laboratory values, especially hematocrit, is very important to check forany signs of hemorrhage or shock.

Doopler ultrasonography of the liver and spleen ( to check for ascites)

Therapeutic Management

Monitor liver function and manage specific complications such as esophageal

varices and malnutrition

Nutritional support

IV fluids

Blood products

Vasopressin

Gastric lavage

Balloon tamponade with a Sengstaken-Blakemore tube ( to control bleeding )

Endoscopic sclerotherapy

Endoscopic banding ligation

Diuretics ( potassium sparring)

Albumin administration or paracentesis ( for ascites )


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Limit the ammonia formation and absorption by administering neomycin and

lactulose.

Treatment of Underlying Conditions

Treatment for cirrhosis depends on the cause of cirrhosis.

Chronic Hepatitis. Many types of antiviral drugs are used to treat chronic hepatitisB, including pegylated interferon, nucleoside analogs, and nucleotide analogs.Patients with chronic hepatitis C are treated with combination therapy withpegylated interferon and ribavarin. [For more information, see In-Depth

Autoimmune Hepatitis. Autoimmune hepatitis is treated with the corticosteroidprednisone and also sometimes immunosuppressants, such as azathioprine(Imuran).

Bile Duct Disorders. Ursodeoxycholic acid (Actigall), also known as ursodiol orUDCA, is used for treating primary biliary cirrhosis but does not slow theprogression. Itching is usually controlled with cholesterol drugs such ascholestyramine (Questran) and colestipol (Colestid). Antibiotics for infections in thebile ducts and drugs that quiet the immune system (prednisone, azathioprine,cyclosporine, methotrexate) may also be used. Several surgical procedures mayalso be tried to open up the bile ducts.

Nonalcoholic Fatty Liver Disease (NAFLD) and NonalcoholicSteatohepatitis (NASH). Weight reduction through diet and exercise, anddiabetes and cholesterol management are the primary approaches to treating thesediseases. Investigators are also studying whether various drugs used to treat type 2diabetes may help treat NAFLD and NASH.

Hemochromatosis. Hemachromatosis is treated with phlebotomy, a procedurethat involves removing about a pint of blood once or twice a week until iron levelsare normal.

MEDICAL MANAGEMENT:

Cirrhosis is an irreversible condition. Treatment focuses on slowing the

progression of liver damage and reducing the risk of further complications. Yourdoctor will treat any underlying medical conditions that are the cause of yourcirrhosis. If liver damage progresses to liver failure, patients may be candidates forliver transplantation. Liver donations can come from either a cadaver or from aliving donor. Patients with cirrhosis who have a liver transplant have very goodchances for survival.

LIVER TRANSPLANT

Assess the childs degree of liver dysfunction to be evaluated for

transplantation at the appropriate time.

NURSING CARE MANAGEMENT:

The goal of cirrhosis therapy is to remove or alleviate the underlying cause of

cirrhosis, prevent further liver damage, and prevent or treat complications:

Vitamins and nutritional supplements promote healing of damaged hepatic

cells and improve the patients nutritional status.


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Na consumption is usually restricted, and liquid intake is limited to or

reduces to help manage ascites and edema.

Drug therapy requires special caution detoxify harmful substances efficiently.

Antacids may be prescribed to reduce gastric distress and decrease the

potential for GI Bleeding.

Alcohol is restricted.

Sedatives should b avoided. Acetaminophen is especially hapatotoxic,

particularly when combined with alcohol.

To minimize the risk of bleeding, warn the patient against taking non-

steroidal anti-inflammatory drugs, straining to defecate, and blowing his nose

or sneezing too vigorously. Suggest using an electric razor and a soft

toothbrush.

Advise the patient to take adequate rest because it decreases the metabolic

demands of the liver.

Teach the patient to have small frequent meals. Teach him to alternate

periods of rest and activity to reduce the oxygen demand and prevent

fatigue.

Tell the patient to avoid stress and to avoid exposure to infection.

Emotional support for the family of the child (to reduce anxiety in

preparation for liver transplantation or unexpected death)

Ncm 30 Study Guide on the Child

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