A Stop Over

Finally, the ICA for Acute Liver Failure is completed today. In fact, the lecturer said it was very good. Hahaha. Really gotta thank all my group members for putting in the effort to make this presentation good and informative.

Thanks Phui Yun, Jeyamalar, Xueqin and Ting Ting, it was great working with you gals and no one stumbled when the class raised any questions, you really did well to rehearse on your part and you know your details well. A few of the classmates had said the presentation was well done too. One even commented that the information was good despite the whole presentation is only limited to 20mins. Hahaha.

It was really a challenge to try to bring in all the relevent details within 20mins. There is just so much things to talk about and everything was so hard to understand! I had to read through pages after pages of information and technical terms and simplify them until it can be easily understood.

I tried to summarize one particular information from 2 to 3 pages into less than half the page and I made it simple enough for any layman to understand. I send one of the final draft to Eunice, who had no experience in the healthcare section, to read through and she could understand. Good! Hahaha.

Here's a detailed copy of what we presented today. It is not exhaustive, remember, we only have 20mins to present so we have to be selective on what we want to present.


ICA on Acute Liver Failure


Learning Objectives
(presenter: Phui Yun)

Summary of the case study
Explain the pathophysiology of Acute Liver Failure.
State the rationale for the investigation done.
Describe the abnormal laboratory findings.
Presentation of drugs.
Discuss the collaborative management.
Discuss health education to be given to patient.
Conclusion of today’s presentation.



Summary of Case
(Presenters: Benjamin & Phui Yun with role-play)

Name: Ms Tan (F)

Age: 23

Race: Chinese

Social history: Single post graduate student

Drug Allergy: Nil

Date admitted: 01/07/2005

Time clerked: 10.45am

Diagnosis: Paracetamol Overdose with Acute Liver Failure

Present History:
Admitted twice for Paracetamol overdose in the past six months
Noted to take 10 paracetamol for menstrual pain 2 weeks ago, last menstrual period on 19/06/2005
Took 8 tablets of Paracetamol today because of “stomach pain”

Complained of:
Nausea and vomiting, fatigue, diarrhea and loss of appetite for 2 weeks
Jaundice for 1 week.

Family History:
Mother has hypertension
Father died of “old age”


Sign and Symptoms Presented by the patient:
(Presenters: Benjamin and Phui Yun with role-play)

Physical Examination

Normal vital signs except for fever of 38.2°C
Ø Could be due to infection as the liver failed to detoxify toxins and other harmful agents in the system.

Poor nutrition with Nausea, Vomiting, Diarrhea and Loss of Appetite
Ø As part of the digestive system, the liver regulates the breakdown and metabolism of certain food substance (e.g. lipids).
Ø Liver failure will disturb the normal functioning of the GI tract and cause the patient to have Nauseas and Vomiting, Diarrhea, Loss of Appetite.

Looks weak
Ø Due to poor nutrition

Dehydrated skin
Ø Poor nutrition
Ø Loss of appetite
Ø Loss of liver function to regulate blood volume

Tenderness of the abdomen
Ø May be cause by pain in the liver and discomfort in the GI tract in relation to liver failure.

Sluggish bowel sounds
Ø May be caused by poor function GI functions in relation to liver failure

Jaundiced skin
Ø Yellowing of the skin due to accumulation of bilirubin in the skin as the liver fail to metabolize it.

Slightly confused
Ø Accumulation of urea as ammonia is converted cause encephalopathy


Introduction to Acute Liver Failure
(Presenter: Ting Ting)

Functions of the Liver
To detoxify drugs
To produce proteins for the synthesis of clotting factors and albumin
To regulate glucose/biblirubin metabolism
To serve a blood volume regulator
To aid in digestion of certain nutrients e.g. lipids

What is Acute Liver Failure?
Acute Liver Failure occurs when large parts of the liver become damaged rapidly (in as little as 48 hours) and the liver is no longer able to function.
This is a life threatening condition.

What are the Causes of Acute Liver Failure?
Paracetamol overdose - most common
Hepatitis A, B, and C
Reactions to certain prescription medications
Ingestion of poisonous wild mushrooms

Pathophysiology of Acute Liver Failure due to Paracetamol Overdose
Acetaminophen, the parent compound of Paracetamol, is nontoxic, but hepatic metabolism leads to formation of a toxic metabolite, N-acetyl-benzoquinoneimine (NAPQI).

The liver will then release Glutathione which will bind with NAPQI and form nontoxic conjugates which will be excreted. As glutathione stores are used up, NAPQI is not detoxified and binds to the lipid bilayer of hepatocytes causing centrilobular necrosis.

In simple terms, it means when the glutathione is used up, the remaining NAPQI will bind with the liver cells instead and destroys them, causing Acute Liver Failure.

Complications of Acute Liver Failure
· Liver Cirrhosis
· Renal failure
· Multi-organ failure
· Hepatic Encephalopathy
· Coma
· Death


Investigations
(Presenter: Xue Qin)

Note - First of all, let’s understand that Liver Failure can lead to multi-organ failure.

FBC- Full Blood Count
This is to check for any abnormalities in the blood in the patient by checking the level of RBC, WBC, platelets, Hb and RBC size, which could determine any form of blood loss or infection

U/E/Cr – Urea/ Electrolytes/ Creatinine
This investigation test the level of urea, electrolytes and Creatinine in the blood which could be used to assess liver function, kidney function and possible electrolyte imbalanced due to vomiting and diarrhea

PT/PTT – Prothrombin Time/ Partial Thromboplastin Time
This test is ordered to determine if the patient have any impaired blood clotting and risk for bleeding

Amylase Test
As the pancreas is responsible for amylase production, this test is ordered for the patient to check for pancreatic functions.

Liver Function Test
This test is ordered for the patient to check for level of certain enzymes and substances such as AST, ALT and albumin which are used to assess liver function

GXM - Group and Cross Match
To check the blood group so as to prepare the patient for blood transfusion if required

CXR & AXR – Chest X-Ray, Abdominal X-Ray
This test screen for any abnormalities of the patient’s liver and other organs

Urine C/S – Culture and Sensitivity
This is to determine if there is any infection in the patient’s urinary system

Paracetamol level
This is to test the patient’s paracetamol level since she had paracetamol overdose

ABG - Arterial Blood Gas
This is to test the patient’s respiratory and metabolism functions by checking the pH, oxygen and carbon dioxide of the arterial blood


Explanation of Abnormal Laboratory Results
(Presenter: Xue Qin)

Low Glucose Level
The loss of glycogen stores in the liver from damaged cells and impaired gluconeogenesis result to hypoglycemia.
Hypoglycemia can also be attributed to the loss of appetite and poor nutrition.

High level of Albumin, AST, ALT, Amylase and Bilirubin
High level of Albumin indicates dehydration
Elevation of the activity of AST & ALT in serum is believed to be the result of leakage from damage cells and this reflects hepatocyte injury.
ALT is found in high concentration in liver cells, small amounts in cardiac, renal and skeletal tissues, so ALT is a better marker of liver problems.
Amylase is produced primarily by the pancreas, but is also produced in the salivary glands and liver.
Elevated levels of serum amylase are found with pancreatitis, bile stones or obstruction and perforated peptic ulcer etc
High serum bilirubin level suggest liver disorder

Increased Prothrombin Time and Activated Partial Thromboplastin Time
The liver produces proteins that are essential for the synthesis of certain clotting factors. Liver failure will cause poor coagulation as the clotting factors in the system decreases.

High level of White Blood Cells
A raised level of WBC mean that the patient is having some form of infection. Infection is common as a result of neutrophil and kupffer cell dysfunction.


Collaborative Management – Pharmacology
(Presenter: Xue Qin)

I/V Acetylcysteine
Theraupeutic effects - Acetylcysteine is converted in the body into metabolites that could function like glutathione to bind and detoxify NAPQI
Indications - Paracetamol overdose
Contraindications - Known hypersensitivity to the drug
Adverse Reactions - Rash, pruritus, nausea, vomiting, wheezing, angioedema, tachycardia, bronchospasm, hypertension, flushing and hypotension, especially with IV administration
Drug Interactions – Can interact with activated charcoal. Not recommend to give immediately after activated charcoal is given through lavage
Note:
1) This antidote is most efficacious within 8 hours of ingestion and should be given as soon as possible. Re-assess when serum concentration result is available.
2) Late administration of NAC has been found to be beneficial. Therefore, NAC is still recommended in patients who are already in liver failure.


I/V Omeprazole
Drug Class- Proton pump inhibitor
Theraupeutic effects- suppress the gastric acid secretion relieving gastrointestinal distress and promoting ulcer healing
Indications - For alternative use to oral medication in duodenal ulcer, gastric ulcer, reflux oesophagitis.
Contraindication - Known hypersensitivity to omeprazole
Adverse Reactions - Headache, diarrhoea, constipation, abdominal pain, nausea/vomiting, flatulence.

Nursing Care after drug administration
Monitor the patient for any adverse reaction and report to doctor if there is any.
Since both drugs may cause vomiting and general GI discomfort, report to the doctor if patient’s condition worsen and stop the drug or administer additional drugs such as antiemetics if prescribed by the doctor.


Collaborative Management – Medical + Nursing
(Presenter: Jeya)

Management of Fever and Infection
Observe strict hand-washing
Perform cold compress or tepid sponging for the patient
Administer antibiotics or antipyretics if prescribed by doctor
Monitor vital signs, especially temperature regularly to monitor the progress of the treatment

Management of Liver Function
Administer paracetamol antidote, Acetylcysteine
Regular liver function test and other necessary lab test to monitor the progress of recovery and effectiveness of treatment and to determine the discontinuation of the paracetamol antidote, Acetylcysteine
When serving of any medication, ensure the medication doesn’t contraindicate with liver failure, e.g. paracetamol

Management of poor nutrition/dehydration/nauseas/vomiting/diarrhea
NBM until patient is able to eat without vomiting or when GI discomfort is manageable
Administer any IV nutrition if prescribed by doctor
When patient is able to eat, start with soft diet before progressing on to full diet to allow the gastric to slowly improve it’s tolerance level
Administer Antacids (Omeprazole) to relieve GI discomfort if prescribed by doctor
Administer Antiemetics to relieve nauseas and vomiting if prescribed by doctor
Administer Anti-diarrhea drugs to relieve diarrhea if prescribed by doctor
Administer Vitamins and Electrolyte supplements to improve overall nutrition when prescribed by doctor
Make arrangement with dietician if referred by the doctor
Strict I/O to monitor the nutritional progress of the patient

Management of hypoglycemia
Maintain glucose levels > 4.0mmol/l
Administer IV Dextrose to increase blood glucose level if prescribed by doctor
Follow the MOH guideline to do hourly hypocount or as prescribed by doctor
Strict I/O to monitor the calories intake of the patient

Management of poor coagulation/risk for bleeding
Order for GXM and prepare for blood/platelet transfusion if prescribed by doctor
Ensure patient is CRIB or RIB to reduce risk of injury when ordered by doctor
Inform patient of her bleeding tendency and instruct her to call for help if she needs to get out of bed
Attend to patient promptly so that she will know that help is readily available and will not risk getting herself injured

Management of confusion/depression/risk for suicide
Promote communication that contributes to the patient’s sense of integrity such as providing care-takers with health information and giving respect to the patient during conversation
Provide sufficient and meaningful sensory input to the patient such as discussing about current events and giving one instruction at a time
Promote safety of patient such as ensuring patient swallow every medication that is served and allocating a bed that is visible from the nurses’ station
Arrange with MSW if the patient has any personal problems if referred by the doctor
Arrange with psychiatrist to treat depression/ confusion if referred by the doctor
Monitor conscious level of patient with Conscious Level Chart


Health Education
(Presenter: Benjamin and Phui Yun with role play)

Educate the patient about the danger of drug overdose
Inform the patient that drug overdose cause acute liver failure which may lead to death if no emergency treatment given promptly
To teach patient to how to find and follow the recommended dosage when taking any over-the-counter drugs

Inform patient about acute liver failure
Teach the patient about liver failure and the most common causes of liver failure
Teach patient to identify signs and symptoms.
Inform her about the complications of liver failure. E.g. Encephalopathy, renal failure etc

Instruct the patient about the need to change in lifestyle after acute liver failure
Encourage her to take low salt and low fat diet
Inform the patient that alcohol is strictly not allowed as it might harm the liver even further and delay the recovery progress
Encourage her to adapt a more pleasant lifestyle and discourage a sedentary lifestyle
Encourage the patient to quit smoking if she smokes

Discuss with the patient and family members about depression and suicidal tendency management
· Teach patient about stress management as she might be facing a lot of stress at home or even at work, so we would like to highlight some easy-to-do relaxation technique like Meditation, or she may go out with friends to go shopping or movies once in awhile.
· Encourage supportive care by involving the patient’s family, peer and support group: Family and peer involvement is vital as she can’t be coping alone.
· Try to boost up her self-esteem.
· We could give her the Hotline for counseling @ Samaritans: 1800-221 4444 (24 hours hotline available) so that she can find someone to talk to if she needs
· Encourage patient to express herself, encourage her to talk to her parents or friends whenever she wants, do not keep things to her own


Conclusion
(Presenter: Benjamin)

We have learnt:

Paracetamol overdose can lead to Acute Liver Failure

Signs and Symptoms, Pathophysiology and Complication of Acute Liver Failure

Liver Function Test is the testing of the level of AST, Alt and albumin in blood to assess liver function

How liver dysfunction can affect certain laboratory results

Acetylcysteine is the antidote for Paracetamol Overdose

The Collaborative Management for the symptomatic treatment of a Liver Failure patient

Collaborative Management of a Confused, Depressed and Suicidal Drug Overdosed patient

A need to change in lifestyle after Acute Liver Failure

Helpline for Depressed patients


References

Capenito-Moyet, L. J (2006) Handbook of Nursing Diagnosis (11th ed.). Philadelphia: Lippincott Willaims & Wilkins.

Joyce, L. K (2005) Handbook of Laboratory & Diagnostic Tests with Nursing Implication (5th ed.). New Jersey: Pearson Prentice Hall

Lemone, P., Burke, K. M. & Carpenito-Moyet, L. J (2000) Clinical Handbook Medical Surgical Nursing: Critical Thinking in Client Care (2nd ed.). New Jersey: Pretence Hall Health.

Wilson, B. A., Shannon, M. T. & Stang, C. L. (2006) Nurse’s Drug Guide 2006 Australia: Pearson Education Inc

http://http://www.medlineplus.com/ (2006, January 24)

http://www.nlm.nih.gov/medlineplus/ency/article/003436.htm (2006, January 24)

http://www.emedicine.com/ped/topic7.htm (2006, January 24)

http://www.moh.gov.sg/cmaweb/attachments/publication/management.pdf (2006, January 24)

http://www.thorne.com/altmedrev/fulltext/acetyl3-2.html (2006, January 24)

http://www.hpb.gov.sg/hpb/default.asp?pg_id=1862 (2006, January 24)

http://www.asia.cmpmedica.com/cmpmedica_sg/regindex.cfm?sec=21&dcname=sg (2006, January 24)

Disclaimer: I am not responbile for the accuracy of the information I had posted here. This is the original copy that we submitted to our lecturer and it may not be free of mistakes. But in any case you spot any inaccuracy, you can always notify me but I will not change anything on this post because my intention to post here is to keep it as a memory of my team's presentation and not as a reference point. Therefore, if you wish to use any information posted here, you use it at YOUR OWN RISK.

For now, gonna rest as much as I can and get as many ang baos for Chinese New Year. Hahaha.

GOD IS GOOD. Hahaha.