Nursing Student Coach

End Stage Liver Failure: Lessons from the ER on Jaundice and Ascites

Lauren Chapnick Season 2 Episode 2

Have you ever seen someone with skin as yellow as the sun or a belly so swollen it seems almost fictional? It's a stark image, one that I, Lauren Chapnick, encountered with a patient we will call Bill during my early ER days—his body ravaged by end-stage liver failure. In this fresh season of Nursing Student Coach, I'm eager to share the critical lessons from that moment, offering up a primer on the liver's crucial functions and the devastating effects when it fails. We're talking jaundice, ascites, and a host of complexities in between, all tailored to give you the understanding you need as a current or aspiring healthcare professional. 

This episode isn't just a rundown of medical facts; it's a narrative steeped in the reality of patient care, with insights gleaned from my transition from nursing school to the high-stakes environment of an emergency department. Your time is valuable as a nursing student, so for the next 10 minutes only, lend me your ears as we explore why conditions like jaundice and ascites happen, what they signal about patient health, and how this knowledge can translate into superior care. No guest needed—just raw, unvarnished experiences and strategies aimed to prepare you for that exam or, even more importantly, for the day you're the one making a difference in the ER.

Speaker 1:

Hello everybody and welcome to season two of Nursing Student Coach. My name is Lauren Chapnick. I'm your host. I'm a registered nurse. Nursing is a second career for me and I found ways to thrive in nursing school and now as a new nurse in an emergency department. I want to take this season to share my stories, experiences and lessons with you so that you can become the best nursing student and the best nurse, and really just the best version of yourself that you could possibly be. All episodes are 10 minutes or less, so you can grab it and go. And a couple more things before we get into today's show. If you could kindly take a couple seconds to pull out your phone, give us a quick five star rating and review. It helps so much more than you even know to put the show in front of more future nurses, because it is my personal mission to help put more great nurses into the world and I need your help to do that. So thank you so much. And lastly, the views and opinions expressed on Nursing Student Coach are those of Lauren Chapnick and hers alone. They are not intended as medical advice and should not replace your institution's policies or procedures. So guys on to today's podcast. It's the Nursing Student Coach Giving you the strategies you need the most. Hey everybody, welcome on in.

Speaker 1:

Today I want to talk about a patient that I had towards the beginning one of my first weeks working in the emergency room, and we'll call him Bill. Bill was wheeled in in a wheelchair and he was yellow as the sun. He was extremely short of breath and he had an extremely large belly. He looked like he was pregnant with quintuplets. It was a huge, huge belly on a very small man who was clearly very sick, very malnourished. Can we take a guess of what was going on with Bill? He had jaundice, that's, the yellow skin, and the big belly. That is called ascites, and these are things that you see in patients with liver failure, and in his case he had end stage liver failure. So we are going to break down today what causes the yellow skin really, what is jaundice and what's the patho behind it, what causes it and what is ascites? What caused this man to have this giant pregnant looking belly and how do you treat it? So first, before we can get into that, let's talk about the liver.

Speaker 1:

The liver does so much for us, but as it relates to jaundice and ascites, I'm just going to talk about two things. The first is it produces or synthesizes a very important protein called albumin. Albumin does a lot for us. It binds to drugs it binds to certain drugs in our body and it transports them, and it also binds to water. And why is that important? Well, because it prevents water from leaking out of our vessels, which is exactly what happens in ascites.

Speaker 1:

Now let's talk about one other thing that the liver does for us in a long list. It breaks down bilirubin, and bilirubin is a pigment that's found in bile. Bile helps us with digestion, and bilirubin is a pigment that's found in bile and really what it is. It's its broken down dead red blood cells, and one of the liver's functions is to get rid of it, to filter it out, and it goes through our digestive system. But if our liver isn't functioning, if your liver is damaged or you're an end-stage liver failure, your liver is just scar tissue, it is not functioning. It's hard as a rock, it's going to get clogged and it's not going to perform these functions that it needs to. So if you're not breaking down bilirubin, where's it going to go, this yellow substance? It's going to leak out. It's going to leak out into the blood and it's going to get deposited into your skin and that is what causes this jaundice.

Speaker 1:

And in this man's case it was an extreme case because he was an end-stage liver failure and there's really not much you can do to treat this. It's not an acute condition, it's chronic. So really what he needed was a liver transplant. I don't know if he was at the point where he was going to get one. I don't know his story, but that is what causes the jaundice. All right, let's get into this ascites. What was causing this giant belly? Well, this is a condition called ascites and it's really just accumulation of fluid and it can happen anywhere. In this man's case and this liver failure, it happened in his belly.

Speaker 1:

It's not just this lack of albumin. There's some portal hypertension going on with the portal vein. But for now we're just going to talk about albumin. So if you're not producing albumin and water is not being retained in the liver and in the vessels, then where's it going to go? It's going to leak out.

Speaker 1:

So you might hear in nursing school something called third spacing and to be honest, in nursing school I understood that the fluid shifted and it went into this third space, but I didn't quite understand. Well, wait a minute. What's the first space and what's the second space? And then what's this third space Like? What's the order? So the first space is inside your vessels, your intravascular space, so inside your veins, your arteries, any vessel. That's your first space. The second space is your cell. So the fluid would get pushed out of the vessel into the cell, your intracellular space, and then, when it doesn't have anywhere else to go after that and it's being kicked out, it's going to go into your third space. That's everywhere else. That's your interstitial space. That's between the blood vessels and the cells. So it just leaks.

Speaker 1:

And if you've got fluid and it's got no albumin to hang on to it, it's just going to leak out into your interstitial space and it's going to cause this giant belly. And what's the risk here? Well, let's see, you've got all of this fluid that's accumulating and it's lacking proteins to help you fight infection because you're malnourished, you don't have albumin and so you're at great risk for infection. And the more fluid accumulation you get in your belly it's gonna push up. If you think about it. If your belly fills up, it's gonna push up into your diaphragm, which is gonna push up into your lungs and you're gonna be extremely uncomfortable and short of breath. That's what happened in this patient's case. And then, when it gets pushed up even more, you're at great risk for that fluid to go into your lungs and to cause pulmonary edema, basically suffocating in your own body.

Speaker 1:

So you wanna treat this. How do you treat it? Well, in this man's case he had an extreme case. He needed what's called a paracentesis, and what happens in a paracentesis is the provider takes a needle and inserts it into the abdomen and drains out all of this fluid. It's literally like sticking a needle inside of a water balloon and not popping it but just sucking it out, draining it out.

Speaker 1:

Now there are other treatments you can do. You can treat it with drugs, with diuretics. You've got ferrosamide, or Lasix is the brand name or spirulactone, basically a diuretic. It's going to take that fluid and you're just gonna pee it out. It's gonna go out of the body and into the potty, as our friend Nurse Mike says about diuretics. You can also treat it with a low sodium diet. But in this man's case he was past any of those treatment options. He just needed a paracentesis. So that's where he went. Okay, so that's what was happening there and that's what was happening with the jaundice.

Speaker 1:

You had increased bilirubin that was built up and up and up and gets deposited into the skin. Let's just talk real quick about lab values. So there's gonna be some different lab values abnormal lab values, in end stage liver failure but let's talk about the ones that we discussed today. The first with albumin, you're going to have low albumin levels in end stage liver failure, cirrhosis, any sort of liver failure, acute or chronic, because your liver is not producing it. Remember, if we don't have our friend Al albumin, that protein to transport the drugs throughout our body or to retain the water and to bind to water, then you are going to have this.

Speaker 1:

Third spacing, this ascites. You're also going to have increased bilirubin, as we discussed, because if your liver can't do its function of breaking down and filtering out that bilirubin, those dead red blood cells that have that yellow tint, then you're going to have increased bilirubin. So if that comes up on an exam for you, I hope that you get it right and I hope that this helped to clarify ascites and jaundice and I hope you have an amazing day. Stay well and I will see you the next time. Bye-bye, thanks for tuning in to the Nursing Student Coach Podcast.

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