Clicker Liver Failure

1. ALF stands for B Acute Liver Failure

2. The most frequently used scale to access and manage AWS is: the National Institute for

Alcohol abuse and alcoholism (NIAAA)

3. Portal hypertension is the result of the amount of blood draining into the portal arterial

system and the amount of resistance to the blood flowing out of the portal arterial

system. True

4. My favorite Halloween candy is: D other, Reese’s

Case Study Questions

 What should be the first priority in the pts care? To maintain her airway if/when she is

vomiting. Once her airway is cleared, you should start caring for her hemorrhagic shock.

 What additional information would the nurse want to obtain? The nurse would need a

full assessment. The nurse would need to know her respiratory status, blood pressure

including MAP, LOC. The nurse would also want information on her blood labs.

 What factors are contributing to the severity of the pts bleeding? The patient has a

history of liver disease. She will more than likely have abnormal clotting studies. Plus,

she is vomiting which makes bleeding from varices more severe.

 What factors contributed to the likelihood that she would re-bleed from her varices?

She has a history of severe liver disease with a previous bleed, and she continues to

drink alcohol.

 What should the nurse do to prepare the pt endoscopy and possible banding? Gastric

lavage is sometimes performed prior to an endoscopy. Erythromycin might be

 administered to clear the stomach or blood clots to make finding the source of the

bleeding easier. The nurse will maintain NPO, remove the dentures, make sure there is

informed consent, monitor vitals, and provide education the patient and family.

 What alternatives are there to banding to control bleeding from esophageal varcies?

Esophageal variceal ligation (EVL) is an effective therapeutic modalities in stopping the

bleeding in the majority of the patients. However, in situations in which there is severe

active bleeding and poor visibility, banding may be more difficult. The use of endoscopic

therapy in combination with a vasoactive agent (octreotide) is more successful than

either therapy alone.

 Should the nurse be concerned that the patient might undergo AWS (alcohol withdrawal

syndrome) during this hospitalization? It is not clear if the patient will undergo AWS

since we do not know how much she was drinking in the past week.

 How should the nurse respond to the change in the pts mental status? The nurse should

do labs and tell the physician.

 What is probably happening to the patient? What is the most likely collaborative

management? The patient has most likely developed hepatic encephalopathy. The

collaborative management involves identifying and treating precipitating factors (in this

case the upper GI bleed and hypokalemia), determining Barbara’s serum ammonia level,

and using lactulose or oral antibiotics to lower the level.

 Would the pt be a good candidate for TIPS? Why or why not? Yes, is at high risk for

either an invasive or surgical procedure to lower portal pressure. However, once she is
 no longer actively bleeding and has stabilized, only reduction in portal pressure will be

likely to prevent her from recurrent bleeding.

Clicker GI Bleed

 The 2 most common causes of pancreatitis are: B alcohol abuse and gallstones

 The presence of melena would lead you to believe the source of the bleeding was from

the: A small intestines

Case Study questions

 What is the first thing you will want to do for this patient? --start two large iv’s

 Why? Air way stable- Studies have indicated that short large-bore peripheral IV cathe-

ters are capable of faster flow rates than longer central line catheters of the same

gauge.

 Assess vitals—what are they going to tell us?—Low BP/High HR=hypovolemic—

Her hemoglobin is less than 7g/dl so the patient will need blood! Hypotension (systolic

blood pressure less than 90 and mean arterial pressure less than 60 mmHg). Associated

with a blood loss of approximately 40%. Tachycardia (heart rate greater than 100).

Focus on resting heart rate and consider whether rate is influenced by beta blocker

medication. Her O2 does not require oxygen yet.

 NGT—Why/why not? Only if ordered by physician! Study (mentioned in your book on

pg359) showed shorter times to Endoscopy, however, there was no difference in

mortality, length of stay.

 What other orders might you anticipate?—Blood, NS—fluid depleted-blood may take a

while. Protonix drip. Why would you want to start a Protonix gtt?—PPI—Diminishes the

accumulation of acid in the gastric lumen, with lessened acid reflux. It is usually started

at 8-10 mg/h IV for 72 hours.

 Want to look at:

 WBC’s—9,000 mm3

 NA 135 mEq/L

 Other pt info—ETOH usage—drinks 1 glass of wine night—8oz

 Husband with her

 Takes ibuprofen 2 times a day