Liver (hepatic) failure is a loss of liver function because of the death of many hepatocytes. The
damage can occur suddenly, as with a viral infection, or slowly over time, as with cirrhosis.
Acute liver failure (ALF) is a term referring to both fulminant hepatic failure (FHF) and subfulminant hepatic failure. FHF occurs when sudden (within 8 weeks from onset), severe liver decompensation caused by massive necrosis of the liver leads to coagulopathies and encephalopathy. Subfulminant hepatic failure, also known as late-onset hepatic failure, occurs in patients with liver disease for up to 26 weeks prior to the development of hepatic encephalopathy. Approximately 2000 cases of FHF occur each year in the United States.
Because of the complex functions of the liver, liver failure leads to multiple system complications. When ammonia and other metabolic byproducts are not metabolized, they accumulate in the blood and cause neurological deterioration. Without normal vitamin K activation and the production of clotting factors, the patient has coagulation problems. Patients are at risk for infections because of general malnutrition, debilitation, impairment of phagocytosis, and decreased liver production of immune-related proteins. Fluid retention occurs because of decreased albumin production, leading to decreased colloidal osmotic pressure with failure to retain fluid in the bloodstream. Renin and aldosterone production cause sodium and water retention. Ascites occurs because of intrahepatic vascular obstruction with fluid movement into the peritoneum.
Complications of liver failure include bleeding esophageal varices, hemorrhagic shock, hepatic encephalopathy, hepatorenal syndrome, coma, and even death.
The leading causes of FHF are viral hepatitis and hepatotoxic drug reactions. Although viral hepatitis can lead to liver failure, fewer than 5% of patients with viral hepatitis actually develop it. Other causes include chronic alcohol abuse, hepatotoxic drug reactions (acetominophen in particular), acute infection or hemorrhage that leads to shock, prolonged cholestasis (arrest of bile excretion), and metabolic disorders. Many of these lead to cirrhosis, a chronic liver disease that results in widespread tissue fibrosis, nodule formation, and necrosis of the liver tissue.
Nursing care plan assessment and physical examination
Take a detailed medication history with particular attention to hepatotoxic medications, such as anesthesia agents, analgesics, antiseizure medications, cocaine, alcohol, isoniazid (INH), and oral contraceptives. Ask about any recent travel to China, southeast Asia, sub-Saharan Africa, the Pacific Islands, and areas around the Amazon River, which may have exposed the patient to hepatitis B. Explore the patient’s occupational history for hepatitis exposure; patients who are daycare workers, dental workers, physicians, nurses, or hospital laboratory workers are particularly at risk. Ask the patient if she or he has experienced previous liver or biliary disease. Intravenous (IV) drug users and male homosexuals are at risk for hepatitis and, therefore, liver failure. Those who eat raw shellfish are at similar risk. Early symptoms include personality changes (agitation, forgetfulness, disorientation), fatigue, anorexia, drowsiness, and mild tremors. Some patients experience sleep disturbance and low-grade fevers. As larger areas of the liver are destroyed, the patient has increasing fatigue, confusion, and lethargy. If the patient has long-standing liver failure, he or she experiences jaundice, dry skin, early-morning nausea, vomiting, anorexia, weight loss, altered bowel habits, and epigastric discomfort. If sudden FHF occurs, the patient may develop encephalopathy (decreased mental status, fixed facial expression), peripheral swelling, ascites, and bleeding tendencies. Urine is often dark from bilirubin, and stools are often light-colored because of the absence of bilirubin.
The patient with acute liver failure usually has jaundiced skin and sclera. Fluid retention results in ascites and peripheral edema. The patient’s facial expression appears fixed, her or his movements are hesitant, and speech is slow. Usually, the patient’s mental status is markedly decreased, and you may smell fetor hepaticus, a sweet fecal odor, on the patient’s breath. The patient may have multiple bruises, a bloody nose, or bleeding gums. The patient’s peripheral pulses are bounding and rapid, indicating fluid overload and a hyperdynamic circulation. You may also palpate peripheral edema, an enlarged firm liver in acute failure and a small hard liver in chronic failure, an enlarged spleen, a distended abdomen, and an abdomen with shifting dullness to percussion and a positive fluid wave because of ascites. As ascites worsens, the patient develops hernias, an everted umbilicus, and an elevated and displaced heart because of a raised diaphragm. Usually, the patient with late disease has neck vein distension, and men develop gynecomastia (enlarged breasts), testicular atrophy, and scant body hair. When you monitor the patient’s vital signs, you may find an elevated temperature and a low-to-normal blood pressure; if the physician initiates hemodynamic monitoring, the cardiac output may be low if ascites is decreasing the right ventricular filling pressure and if the systemic vascular resistance is low.
The patient may feel upset or guilty if he or she contracted the disease while traveling. Use a nonjudgmental approach to elicit the patient’s feelings if the condition is related to alcohol abuse. If the patient is a candidate for a liver transplant, determine the patient’s emotional stability, ability to cope with a complex medical regimen, and ability to rely on significant others.
Nursing care plan primary nursing diagnosis: Fluid volume excess related to water and sodium retention.
Nursing care plan intervention and treatment plan
Patients are managed with supportive therapy, depending on their symptoms. Fluid and electrolyte imbalances, malnutrition, ascites, respiratory failure, and bleeding esophageal varices can all occur with liver failure. Unless the patient has clinically significant hyponatremia, the patient usually receives limited IV fluids and food that contains sodium because increased sodium intake makes peripheral edema and ascites worse. Patients with ascites are usually restricted to 500 mg of sodium per day. A paracentesis may be used to remove 4 to 6 L of fluid. If the ascites is refractory, surgical placement of a peritoneal-venous shunt may be needed. Hypokalemia usually needs to be corrected with IV replacements. If the patient has serious fluid imbalances, a pulmonary artery catheter may be inserted for hemodynamic monitoring.
If respiratory failure is present, the patient may need endotracheal intubation and mechanical ventilation with supplemental oxygen. To manage nutrition in patients without evidence of hepatic encephalopathy, a high-calorie, 80- to 100-g protein diet is prescribed to allow for cellular repair. Some patients may need enteral or total parenteral nutrition to maintain calorie and protein levels. Hepatorenal failure is treated by fluid restriction, maintenance of fluid and electrolyte balance, and withdrawal of nephrotoxic drugs. Renal dialysis is generally not used because it does not improve survival and can lead to additional complications.
If the patient develops hepatic encephalopathy, serial neurological assessments are needed. In patients with signs of elevated intracranial pressure or hepatic coma, the physician may place an intracranial monitoring system. Some patients with liver failure are candidates for transplantation. A liver transplant is indicated for patients with irreversible progressive liver disease who have no alternatives to transplantation. Prior to liver transplantation for FHF, mortality generally was greater than 80%; about 5% of liver transplants in the United States are for FHF.
The most common problem for patients with liver failure is fluid volume excess. Measure the patient’s abdominal girth at the same location daily, and mark the location as a reference point for future measurements. Notify the physician if the girth increases by 2 inches in 24 hours. Provide the required fluid allotment over the three meals and at night. If the patient desires, reserve some fluids to be used as ice chips. Provide mouth care every 2 hours. Because areas of edema are likely to be fragile and prone to skin breakdown, provide skin care.
One of the most life-threatening complications of liver failure is airway compromise because of neurological or respiratory deterioration. Keep endotracheal intubation equipment and an oral airway at the bedside at all times. Elevate the head of the patient’s bed to 30 degrees to ease respirations, and support the patient’s arms on pillows to decrease the work of breathing. It is essential to be at the bedside and to perform serial assessments of all critical systems. Space all activities and limit visitors as needed so that the patient gets adequate rest. To encourage rest, consider nonpharmacologic methods such as diversionary activities and relaxation techniques.
The patient may be anxious, depressed, angry, or emotionally labile. Allow the patient to verbalize anxieties and fears. If needed, refer the patient to a counselor. Evaluate thoroughly anyone who is a candidate for a liver transplant to ensure that she or he has the ability to cope with a complex situation. Answer all questions, and explain the risks and benefits. Refer to an alcohol counselor if appropriate.
Nursing care plan discharge and home health care guidelines
Teach the patient to follow prescribed sodium and fluid restrictions. Assist the patient to individualize a diet plan to maximize personal choices, including a dietitian if necessary. Encourage sodium-restricted patients to read labels on all canned soups, sauces, and vegetables and on all over-the-counter medications. Be sure the patient understands any pain medication prescribed, including dosage, route, action, and side effects. Teach the patient and family the need to limit the rise of infections by good hand washing, avoidance of others with colds, and prompt treatment by a healthcare provider when an infection occurs. Refer the patient to an alcohol support group.