ADVANCED MEDICAL-SURGICAL

NURSING II

Presented by:John Henry O. Valencia, RN, RMMaster of Arts in Nursing

CASE SCENARIO:

Robert, a 58-year old male, was admitted to the ER and the nurse on duty

did an initial comprehensive nursing history. Past medical history of

Robert revealed the following:

2008: Hepatitis A

2009: PUD managed by medications. BPH with symptoms of dysuria

and nocturia

2010: Rectosigmoid cancer stage 3, underwent Abdominoperineal

resection (APR) with descending permanent colostomy, underwent

radiotherapy and chemotherapy

2011: Cirrhosis with portal hypertension, hemorrhoids, esophageal

varices.

During the interview by the nurse the patient revealed that he

is a smoker, alcoholic drinker since he was 17 and fond of eating fatty,

less fiber food. He had undergone many diagnostic exams and

procedures like colonoscopy with biopsy, esophagogastrocopy,

sclerotherapy, paracentesis for ascites, chemotherapy and

radiotherapy. He had been fatigued and anemic for the past year and

had taken vitamin and iron supplements. He narrated that he had

undergone major abdominal surgery with colostomy, after which he

was placed on PCA morphine, post op monitors and were taught to

take care of his colostomy site.

During your interview with Robert, he is also taking Aldactone,

Lactulose. At times he has been disoriented and had memory

problems. You noticed ascites, some edema on his lower extremities.

Additional tests were done like serum enzyme tests, serum bilirubin,

total protein A/G ratio, PT.

QUESTIONS:

A. What can cause Robert’s liver cirrhosis?

B. Cite the complications of Liver cirrhosis that already exist based on the cues of his presenting signs and symptoms?

C. Give the rationale of the above management and diagnostic assessments for his cirrhosis.

During the 5th week of Robert’s confinement, the nurse

observed the patient to be restless and suddenly vomited

fresh blood.

D. What would be your immediate management

at this time?

E. What could have caused the vomiting of fresh

blood? What are your other parameters of

assessment with this advancing liver condition?

For the succeeding days Robert became comatose, ascites

and edema worsening and was hooked to dopamine for his

dropping blood pressure and was confined in ICU with decreasing

GCS everyday. The physician explained to the relatives the

irreversible effects of his advanced liver disease and deteriorating

condition. Later on the family and relatives signed for DNR. What

ethical concepts are related to issues at end of life happening to

Robert?

F. Discuss the different responsibilities of the nurse

undergoing different diagnostic procedures and

surgical procedures related to the GI and the liver?

G. Interpret lab findings seen in different disorders

mentioned in the case ?

ALL ABOUT THE DISEASE…

LIVER CIRRHOSIS

Is a chronic disease that causes cell

destruction and fibrosis (scarring) of

hepatic tissue.

Fibrosis alters normal liver structure

and vasculature, impairing blood and

lymph flow and resulting in hepatic

insufficiency and hypertension in the

portal vein.

TYPES: Laennec’s (alcohol induced) Cirrhosis

Fibrosis occurs mainly around central veins and portal areas.

This is the most common form of cirrhosis and results from chronic alcoholism and malnutrition.

Postnecrotic (micronodular) Cirrhosis Consist of broad bands of scar tissue and results from previous acute viral hepatitis or drug-induced massive hepatic necrosis.

Biliary Cirrhosis Consist of Scarring of bile ducts and lobes of the liver and results from chronic biliary obstruction and infection (cholangitis), and is much rarer than the preceding forms.

BACK TO THE CASE…

WHAT CAN CAUSE ROBERT’S LIVER CIRRHOSIS?

ALCOHOL Consumption

OVER used of Medications

Nutritional Supplements

SMOKING

VIRAL Hepatitis A

CHEMOTHERAPY

CITE THE COMPLICATIONS OF LIVER CIRRHOSIS THAT ALREADY EXIST BASED ON THE CUES OF HIS PRESENTING SIGNS AND SYMPTOMS?

COMPLICATIONS:

• PORTAL Hypertension causing:a)Ascitesb)Esophageal Varicesc)Hemorrhoidsd)Bipedal Edemae)Anemia

•MILD Hepatic Encephalopathy (Stage I)

PHYSICAL ASSESSMENT:

Approach the examination of the liver from the right side of the patient.

Have the patient lying supine.

Preserve the patient’s privacy by draping the top of their body with the gown and below the waist with a sheet.

For the best exam, make sure the patient is warm and comfortable.

Additionally make sure your hands are warm so as to not startle the patient.

INSPECTION

LOOK at the Skin, Hand and Nails for signs of Liver Disease:

A. Jaundice

B. Palmar Erythema

C. Nail Changes

Muehrcke's nails

Leukonychia Strata

Terry’s nails

D. Asterixis

PALMAR ERYTHEMA

LEUKONYCHIA

MUEHRCKE’S NAILS

TERRY’S NAILS

HOW TO TEST HEPATIC FLAP (ASTERIXIS)

Ask the patient to stretch out their hands in front of them with the hands dorsiflexed at the wrists and fingers outstretched and separated.

The patient should hold that position for at least 15 seconds.

If flap is present, the patient's hands will move in jerky, irregular flexion/extension at the wrist and MCP joints.

The flap is nearly always bilateral. May be subtle and intermittent.

Check for the Facial features that suggests Liver Disease:

A.SIALADENOSIS (SIALOSIS / Parotid Gland Enlargement)

B. ICTERUS (Jaundice of Sclera)

Look for gross asymmetries across the abdomen. Look at the skin for signs of liver disease, such as:A. Caput MedusaeB. Spider AngiomaC. Ascites

SILADENOSIS

CAPUT MEDUSAE

SPIDER ANGIOMA

Look at the Chest Wall Features:A. Gynaecomastia (tender and firm enlarged

breast bud) and loss of secondary sexual hair in men

B. Breast atrophy in women.

AUSCULTATION: Follow the inspection of the liver, as with the rest of the abdominal exam, with auscultation. Listen over the area of the liver for bruits or venous hums (Cruveilhier-Baumgarten murmur)

PERCUSSION:TECHNIQUE: ASCITES

There are several physical examination maneuvers described for detection of ascites described below that are at least moderately sensitive and specific.

No single maneuver is both highly sensitive and specific; therefore at least two maneuvers are necessary to increase the accuracy of physical exam for ascites.

A. Bulging Flanks

B. Flank Dullness

C. Shifting Dullness

D. Fluid Wave

BULGING FLANKS

1. With the patient supine, the examiner

visually observes whether the flanks

are pushed outward (presumably by

large amounts of ascitic fluid).

Positive test: simply the presence of

bulging flanks

Note: A patient with an obese abdomen

may also have flanks that bulge,

although the fat of obesity extends

further posterior than fluid in the

peritoneum.

FLANK DULLNESS

1. The patient is examined in the supine position.

2. Direct percussion is done over the abdomen, from the umbilicus to the flanks.

3. The location of the transition from tympany to dullness is noted.

Positive test: Percussion note is tympanitic over the umbilicus and dull over the lateral abdomen and flank areas

Note: The tympany over the umbilicus occurs in ascites because bowel floats to the top of the abdominal fluid at the level of the fluid meniscus.

REMEMBER:Bulging flanks and flank dullness are both very sensitive (≥72% and ≥80%, respectively) but poorly specific for ascites, thus unable to separate it from other conditions.

SHIFTING DULLNESS1. This maneuver is performed with the patient supine.

2. Percuss across the abdomen as for flank dullness, with the point of transition from tympany to dullness noted.

3. The patient then is rolled on his/her side away from the examiner, and percussion from the umbilicus to flank area is repeated.

Positive test: When ascites is present, the area of dullness will shift to the dependent site. The area of tympany will shift toward the top.

Note: The shift in zone of tympany with position change will usually be at least 3 cm when ascites is present.

REMEMBER:

It, too, has good sensitivity (≥83% in two separate studies, indicating the presence of at least 500–1000 mL of fluid), but low specificity. Nonetheless, due to its high sensitivity, a negative shifting dullness argues strongly against the presence of gross ascites.

FLUID-WAVE MANEUVER1. Have the patient lying supine.

2. The patient or an assistant places one or both hands (ulnar surface of hand downward) in a wedge-like position into the patient's mid abdomen, applying with slight pressure.

3. The examiner places the fingertips of one hand along one flank, and with the other hand firmly gives a sharp tap along the opposite flank.

Positive test: The examiner is able to detect "a shock wave" of fluid moving against the fingertips pressed along the flank, as the fluid is pushed from one side of the abdomen to the other by the force of the tap along the opposite flank.

This is only Quite reliable, with specificity of 80–90%. In fact, this is probably the only truly specificbedside test for ascites. Hence, a positive fluid wave can help ruling in the disease. If negative, though, it should not exclude it, since its sensitivity is just 50% (it detects only large volumes).

PUDDLE SIGN1. It is a sign of auscultatory percussion, performed by

asking patients first to lie on their belly for 5 minutes and then eventually to raise themselves by supporting their body weight on the knees and stretched forearms .

2. Place the diaphragm of your stethoscope over the lowest abdominal area, while at the same time flicking a finger over a localized flank area.

3. Then gradually move your stethoscope over the opposite flank.

Positive: When there is a sudden increase in intensity and clarity of the sound, signalling that the stethoscope has passed the edge of the peritoneal fluid.

DIAGNOSIS OF ASCITES:

Maneuver Sensitivity (%) Specificity (%)

History

Increased abdominal girth 90 60

Recent weight gain 60 70

Ankle swelling 100 60

Physical examination

Bulging flanks 70 60

Flank dullness 80 60

Shifting dullness 90 60

Fluid wave 60 90

Puddle sign 50 70

GIVE THE RATIONALE OF THE ABOVE MANAGEMENT AND DIAGNOSTIC ASSESSMENTS FOR HIS CIRRHOSIS. DIAGNOSTIC ASSESSMENT FOR CIRRHOSIS:

BLOOD TESTS LIVER Function Test

ENDOSCOPY Esophagogastroscopy

IMAGING Sonography (Ultrasound) Computed Tomography MRI

Liver Biopsy

BLOOD TESTS Liver Function TestProthrombin Time

BASIC NURSING CONSIDERATION1. Explain test procedure. Explain that slight discomfort may

be felt when the skin is punctured.

2. Encourage to avoid stress if possible because altered physiologic status influences and changes normal hematologic values.

3. Explain that fasting is not necessary. However, fatty meals may alter some test results as a result of lipidemia.

4. Apply manual pressure and dressings over puncture site on removal of dinner.

5. Monitor the puncture site for oozing or hematoma formation.

6. Instruct to resume normal activities and diet.

LIVER FUNCTION TEST

The liver plays an important role in synthesis, excretion, storage and detoxification

Its multiple metabolic and excretory functions mean disease of the liver can have serious consequences

The most obvious indication of liver disease is jaundice, a sign of high levels of bilirubin

Although the liver largely regenerates after damage, if damage is prolonged it loses its ability to do so

There are few clinical situations where a diagnosis can be made based on a single blood test

LIVER FUNCTION TEST CONTD… A panel of tests used to evaluate liver function. Includes:

Alanine aminotransferase (ALT) Alkaline phosphatase (ALP) Aspartate aminotransferase (AST) Bilirubin Albumin Total protein

Used in the evaluation of symptoms associated with liver disease (jaundice, nausea, vomiting and/or diarrhea; loss of appetite; ascites, hematemesis, melena; fatigue or loss of stamina; history of alcohol or drug abuse).

SERUM BILIRUBIN Bilirubin is a by-product of the the breakdown of hemoglobin. Most bilirubin is chemically attached (conjugated) to another substance. This is called direct bilirubin. Unconjugated builirubin is called indirect bilirubin.

Serum bilirubin is considered a true test of liver function, as it reflects the liver's ability to take up, process, and secrete bilirubin into the bile.

High bilirubin levels cause jaundice and are seen in liver disease and biliary obstruction.Interpretation Total

BilirubinConjugated

BilirubinUnconjugated Bilirubin

Normal Value 0.1 – 1.0 mg/dL

0.1 – 0.3 mg/dL

0.2 – 0.8 mg/dL

Liver Cell Damage

increased

Hemolysis of RBC increased normal increased

AMINOTRANSFERASES Alanine Aminotransferase (ALT) or Serum Glutamic Pyruric Transaminase (SGPT):

Enzyme found liver, muscle, brain, other tissues.

Aspartate aminotransferase (AST) or Serum Glutamic Oxaloacetic Transaminase (SGOT) or Serum Glutamic Aspartate Transaminase (SGAT):

Enzyme found mostly in heart and liver (but also skeletal muscle, pancreas, kidney)

Increase in level proportional to extent of damage to heart or liver cells

Normal Value Clinical Implication

AST 10 – 40 Units (4.8-19 U/L)

These enzymes can be indicative of liver disease. However, these enzymes are also found in other body tissues such as bone, heart, kidney, etc. Isoenzyme tests usually must be performed in order to isolate the isoenzyme that is elevated and if the source is the liver.

ALT 5 – 35 Units (2.4-17 U/L)

ALKALINE PHOSPHATASE This is a liver enzyme test. Alkaline phosphatase (ALP) is produced in the liver and bone, it is also derived from the kidney, intestine, and placenta. In obstructive biliary disease, there is elevated serum ALP.

Normal Values:20-90 U/L at 30 degrees C. - adult40-300 U/L - child

TOTAL PROTEIN WITH A/G RATIO

Test Normal Clinical Implication

Total Serum Protein

7.0-7.5 g/dL (70-75g/L)

Proteins are manufactured by the liver. Their levels may be affected in a variety of liver impairments

Serum Albumin 4.0-5.5g/dL (40-55g/L)

Serum Globulin 1.7-3.3 g/dL (17-33g/L)

A/G Ratio A>G or 1.5:1 – 2.5:1 A/G Ratio is reversed in chronic liver disease. (Decreased albumin and increased Globulin)

These tests show characteristic results depending on the nature of the hepatic insult.

Normal AST and ALT levels do not preclude the diagnosis of cirrhosis.

In most chronic liver diseases (except for alcoholic liver disease), ALT is more elevated than AST, but as the disease process progresses, there may be a reversion of this finding.

Total bilirubin may be normal in patients with compensated cirrhosis, but as the cirrhosis progresses, serum levels generally rise.

It is important to recognise that these tests can be elevated in conditions other than liver disease. For example, aminotransferases can be elevated in systemic diseases without primary liver involvement, such as thyroid disease, muscle disorders, and coeliac disease; alkaline phosphatase can be elevated with bone disease; and total bilirubin will be elevated in the setting of haemolysis.

PROTHROMBIN TIME (PT) AND INTERNATIONAL NORMALIZED RATION

-rothrombin is a vitamin K dependent glycoprotein produced by the liver for fibrin clot formation

-o monitor response to warfarin sodium (Coumadin)

P

T

Normal Values:PT:

9.6 to 11.8 secs (male)9.5 to 11.3 secs (female)

INR:2.0 to 3.0 (standard warfarin tx)3.0 to 4.5 (high dose warfarin tx)

NURSING CONSIDERATIONS

- baseline PT should be drawn before anticoagulation therapy

-e sure to apply direct pressure to the venipuncture site

-oncurrent warfarin therapy with heparin therapy can lengthen the PT

-iets high in green leafy vegetables can shorten PT

-xpect 1.5 to 2 times longer PT if on anticoagulation therapy

-or PT greater than 30 secs, initiate bleeding precautions

ABCDEF

ENDOSCOPIC PROCEDURES

Esophagogastroscopy

ESOPHAGOGASTRODUODENOSCOPY / UPPER GI FIBROSCOPYAllows direct visualization of the oesophageal tract, gastric and duodenal mucosa through a lighted endoscope (Gastroscope).

Can either be diagnostic or therapeutic

Therapeutic endoscopy can be used to treat gastric bleeding and esophageal varices.

Sclerosing solutions can be injected through the scope in an attempt to control bleeding

NURSING INTERVENTIONS PRE AND INTRA PROCEDURE:

1. Patient should be NPO for 8 hours before examination

2. Before the introduction of the endoscope, local anesthetic gargle or spray must be given:

a)Midazolam – provides moderate sedation and relieves anxiety

b)Atropine – reduces secretionc)Glucagon – relaxes smooth muscles

3. Patient will be in LEFT LATERAL POSITION – facilitates clearance of pulmonary secretion and smooth entry of the scope

POST PROCEDURE:

1. Assessment includes: LOC V/S O2 Sat Pain Level Signs of perforation

2. After gag refelex has returned, give lozenges, saline gargle and oral analgesics to relieve minor throat discomfort.

IMAGING STUDIESSonographyCT ScanMRI

COMPUTED TOMOGRAPHY Provides cross sectional images of the abdominal organs and structures.

Multiple xray images are taken from numerous angles, digitized in a computer, reconstructed and then viewed in a computer monitor.

NURSING CONSIDERATIONS

ssess allergies to iodine and seafoods

e sure to obtain informed consent

onscious sedation for claustrophobia

o remove jewelries and hair pins

xplain hot flushed sensation and metallic taste in the mouth when dye is injected

luids and hydration

ive instruction to lie supine with small pillow under the head

old if pregnant

t takes 20 minutes

A

B

CD

E

FG

H

I

PRETEST

REMEMBER:

Determine serum creatinine level and urine HCG before administration of contrast

If patient is allergic to contrast, premedicate with IV PREDNISONE 24 hours, 12 hours and 1 hour before the scan.

Renal Protective measures include administration of: IV Sodium Bicarbonate: 1 hour before and 6 hours after IV Contrast

Oral Acetylcysteine (Mucomyst): before and after study BOTH ARE FREE RADICAL SCAVENGERS OF contrast byproducts

MAGNETIC RESONANCE IMAGING

Is used in gastroenterology to supplement UTZ and CT Scan.

Uses magnetic fields and radio waves to produce images of the area being studied.

Use of Oral contrast agents enhances diagnosis in GI diseases.

PRETEST-etal objects must be removed

-ssess for ineligibility and contraindications

-ive instruction to lie supine with small pillow under the head

-ormal audible humming, thumbing, grating, or knocking sounds

-ncourage conscious sedation for claustrophobia

-akes 45 to 60 minutes-nformed consent-ompletely enclosed in scanner

MA

G

N

E

TIC

POSTTESTRESUME normal activitiesFluids and Hydration

THERAPEUTIC MODALITIES

SCLEROTHERAPYPARACENTESIS

ASCITES

abnormal intraperitoneal accumulation of watery fluid containing small amounts of protein

due to: intravascular

colloidal pressure capillary hydrostatic

pressure Na and H2O retention Failure of the liver to

metabolize aldosterone

MEDICAL MANAGEMENT

Treatment aimed at the underlying cause of the hepatic disease and at the ascitic fluid itself

Dietary sodium restriction Limiting sodium intake to 88 meq (2000 mg) per day

The most successful therapeutic regimen is the combination of single morning oral doses of Spironolactone and Furosemide, beginning with 100 mg and 40 mg

Two major concerns with diuretic therapy for cirrhotic ascites: Overly rapid removal of fluid Progressive electrolyte imbalance

PARACENTESIS

is a procedure in which a needle or catheter is inserted into the peritoneal cavity to obtain ascitic fluid for diagnostic or therapeutic purposes.

can be done for diagnostic or therapeutic purpose

Diagnostic paracentesis refers to the removal of a small quantity of fluid for testing.

Therapeutic paracentesis refers to the removal of 5 liters or more of fluid to reduce and relive:

a) intra-abdominal pressure b) dyspnea,c) abdominal pain, and d) early satiety.

NEEDLE ENTRY SITEThe two recommended areas of abdominal wall entry for paracentesis are as follows:

a) 2 cm below the umbilicus in the midline (through the linea alba)

b) 5 cm superior and medial to the anterior superior iliac spines on either side(in update 3cm)

NURSING CONSIDERATION PRETEST:

A. Checked for signed consentB. Instruct patient to voidC. Patient in upright position on the edge of the

bed or in a chair with feet supported on a stool. Fowler’s if confined in bed.

D. Place BP Cuff on patient’s arm

DURING PROCEDURE

Help patient maintain position throughout prodcedure

Measure and record BP

Monitor for signs of vascular collapse:

Pallor Increased PR Decreased BP

POSTPROCEDURE:

Monitor VS

Assess for Hypovolemia, electrolyte shifts, changes in mental status and encephalopathy

When taking VS check puncture site for bleeding or leakage.

CASE…

During the 5th week of Robert’s confinement, the nurse

observed the patient to be restless and suddenly

vomited fresh blood.

D. What would be your immediate

management at this time?

E. What could have caused the vomiting of

fresh blood? What are your other

parameters of assessment with this

advancing liver condition?

ESOPHAGEAL VARICES distention of the smaller blood vessels of the

esophagus as a result of portal hypertension – due to obstruction of venous circulation w/in the damaged liver

the portal venous pressure causes blood to be forced into these vessels – become tortous and fragile

blood vessel become prone to injury by mechanical trauma from ingestion of coarse food and acid pepsin erosion which may result in bleeding

bleeding may also occur as a result of coughing, vomiting, sneezing, straining at stool or any physical exertion that abdominal venous pressure

MEDICAL MANAGEMENT

find the source of bleeding – esophagoscopy, angiography

control bleeding a. Gastric lavage, administration of antacid via NGTb. Surgical bypass procedures (splenorenal shunt) c. Variceal band ligation (esophageal variceal

ligation (EVL))d. Endoscopic sclerotherapy or injection

sclerotherapye. Balloon tamponade

insertion of Sengstaken–Blakemore tube with gastric and esophageal balloon that are inflated to stop bleeding

SCLEROTHERAPHY

Sclerosing agent is injected through a fiberoptic endoscope into the esophageal varices (bleeding).

The procedure is done to treat acute GI haemorrhage but is not recommended for prevention of first and subsequent variceal bleeding episodes.

POST PROCEDURE:

Observed for: Bleeding Perforation Aspiration Pneumonia Esophageal Stricture

Administer:

Antacids

H-2 Receptor Antagonists: Cimetidine (Tagamet)

Proton Pump Inhibitor: Pantoprazole (Protonix)

This is to counteract the chemical effects of the sclerosing agent on the esophagus and the acid reflux associated with therapy.

ESOPHAGEAL BANDING THERAPY (VARICEAL BAND LIGATION) A modified endoscope loaded with an elastic rubber band is passed through an overtube directly onto the varix to be banded.

BACK TO THE CASE… What would be your immediate management at this time?

In an actively bleeding patient, medications are administered initially because they can be obtained and administered quicker than other therapies.

VASOPRESSIN (Pitressin): produces constriction of the splanchnic arterial bed and decreases portal pressure.

Monitor VS and electrolyte level, it can cause hyponatremia

Propranolol (Inderal) and Nadolol (Corgard): Beta blocking agents that decreases portal pressure Used to prevent first bleeding episodes and prevent rebleeding

Somatostatin and Octreotide (Sandostatin):

produces constriction of the splanchnic arterial bed and decreases portal pressure.

CASE …

For the succeeding days Robert became

comatose, ascites and edema worsening and was

hooked to dopamine for his dropping blood pressure

and was confined in ICU with decreasing GCS everyday.

The physician explained to the relatives the

irreversible effects of his advanced liver disease and

deteriorating condition. Later on the family and

relatives signed for DNR. What ethical concepts are

related to issues at end of life happening to Robert?

HEPATIC ENCEPHALOPATHY is defined as a spectrum of neuropsychiatric abnormalities in patients with liver dysfunction, after exclusion of other known brain disease.

is a worsening of brain function that occurs when the liver is no longer able to remove toxic substances in the blood.

characterized by personality changes, intellectual impairment, and a depressed level of consciousness.

CLINICAL MANIFESTATIONSa) Asterixis

b) Fetor Hepaticus - sweet musty aroma of the breath believed to be secondary to the exhalation of mercaptans.

c) Hyperventilation

d) Decreased body temperature

e) Extrapyramidal symptoms - including tremor, bradykinesia, cog-wheel rigidity, and shuffling gait can also be seen

f) Mental function disturbances - Changes in thinking, Confusion that is mild, Forgetfulness, Mental fogginess, Personality or mood changes, Poor concentration and Poor judgment

Grading of the symptoms of hepatic encephalopathy is performed according to the so-called West Haven classification system :GRAD

ECRITERIA

0 Minimal hepatic encephalopathy (also known as covert hepatic encephalopathy and previously known subclinical hepatic encephalopathy); lack of detectable changes in personality or behavior; minimal changes in memory, concentration, intellectual function, and coordination; asterixis is absent.

1 Trivial lack of awareness; shortened attention span; impaired addition or subtraction; hypersomnia, insomnia, or inversion of sleep pattern; euphoria, depression, or irritability; mild confusion; slowing of ability to perform mental tasks

2 Lethargy or apathy; disorientation; inappropriate behavior; slurred speech; obvious asterixis; drowsiness, lethargy, gross deficits in ability to perform mental tasks, obvious personality changes, inappropriate behavior, and intermittent disorientation, usually regarding time

3 Somnolent but can be aroused; unable to perform mental tasks; disorientation about time and place; marked confusion; amnesia; occasional fits of rage; present but incomprehensible speech

4 Coma with or without response to painful stimuli

SERUM AMMONIA

An elevated blood ammonia level is the classic laboratory abnormality reported in patients with hepatic encephalopathy.

SPECIMEN: Only arterial or free venous blood specimens must be assayed. Blood drawn from an extremity to which a tourniquet has been applied may provide a falsely elevated ammonia level when analyzed.

VOLUME: 0.5 mL blood. Tube must be full, tightly capped, and PLACED ON ICE IMMEDIATELY.

USES: Liver function test, supports clinical diagnosis of hepatic encephalopathy, hepatic cirrhosis, Reye's Syndrome, or aminoacidurias of infancy.

NURSING CONSIDERATION NPO for 8 – 12 hours before the test

Withhold drugs that can affect result like:AlcoholAcetazolomideNarcoticsValproic acid

A high Protein diet can increase the serum ammonia level

OTHER TESTS:

Classic EEG changes associated with hepatic encephalopathy are high-amplitude low-frequency waves and triphasic waves.

Computed tomography (CT) and magnetic resonance imaging (MRI) studies of the brain may be important in ruling out intracranial lesions when the diagnosis of hepatic encephalopathy is in question.

OTHER DISCUSSIONS

ASSESSING PAIN IN THE GI SYSTEM