Escolar Documentos
Profissional Documentos
Cultura Documentos
ICD-9
50.11
Author
Amy E. Beddoe, RN, PhD
Reviewers
Eliza Schub, BSN, RN Cinahl Information Systems Glendale, California Nursing Practice Council Glendale Adventist Medical Center Glendale, California
Editor
Diane Pravikoff, RN, PhD, FAAN Cinahl Information Systems
4 4
Published by Cinahl Information Systems. Copyright2011, Cinahl Information Systems. All rights reserved. No part of this may be reproduced or utilized in any form or by any means, electronic or mechanical, including photocopying, recording, or by any information storage and retrieval system, without permission in writing from the publisher. Cinahl Information Systems accepts no liability for advice or information given herein or errors/omissions in the text. It is merely intended as a general informational overview of the subject for the healthcare professional. Cinahl Information Systems, 1509 Wilson Terrace, Glendale, CA 91206
4 4 4 4 4
Sixty percent of all complications associated with liver biopsy occur in the first 2 hours after the procedure; 96% of complications occur in the first 24 hours after biopsy (Karamshi, 2008) Postprocedure pain occurs in 25% of patients undergoing liver biopsy (Arora et al., 2011) Piercing the liver more than 3 times during a single biopsy is associated with the increased risk of bleeding (Arora et al., 2011) Hemobilia (i.e., bleeding into the bile ducts and gallbladder) is a rare complication of liver biopsy. Only 4 cases have been reported in more than 68,000 patients who underwent liver biopsy (Arora et al., 2011) Death caused by liver biopsy occurs in 1 per 10,00012,000 patients (Arora et al., 2011)
The nurse should show the patient how to hold his or her breath for approximately 10 seconds during the procedure and practice this
immediately before the procedure. Holding the breath helps to reduce the size of the lung field, while bringing the liver closer to the surface of the abdominal wall The liver sample taken is typically about 1.5 cm in length and 1.22 mm in diameter. This amount of tissue contains about 68 portal triads and is considered adequate for laboratory analysis If there are no complications associated with liver biopsy, the patient typically goes home 26 hours following the procedure Coughing or straining should be avoided if possible for 4 hours after the procedure Patients typically feel sore at the biopsy site for up to 1 week and should avoid heavy lifting or strenuous activities for that week When the patient goes home, he or she should be able to easily return within 30 minutes to the hospital or outpatient center where the procedure was performed if complications develop A friend or family member should stay with the patient during the first night following liver biopsy and provide care as well as transportation to the hospital, if required for severe pain; shortness of breath; chest pain; bleeding from the biopsy site; fever greater than 100.4 F/38 C; abdominal pain; weakness, lightheadedness or sweating; and/or heart palpitations Biopsy results are typically obtained within 1 week The patient should return to the clinician for a scheduled follow-up visit to receive the biopsy results The patients safety is the registered nurses primary responsibility during liver biopsy. Therefore, it is critical that nurses be familiar with the following: Facility protocol regarding liver biopsy, if available Anatomy and physiology of the hepatobiliary system Sterile technique Preliminary steps to be taken before assisting with liver biopsy include the following: Check the treating clinicians order for liver biopsy Review facility protocol for liver biopsy, if available Verify completion of facility informed consent documents Review the patients history/medical record to assess for a history or presence of any contraindications to liver biopsy results of laboratory tests (e.g., PT) to verify they are within normal limits current medications 4 Aspirin and NSAIDs (e.g., ibuprofen) interfere with clotting and should not be taken for at least 1 week prior to the biopsy any allergies (e.g., to latex, medications, other substances); use alternative materials as appropriate Gather prescribed medications Local anesthesia (e.g., lidocaine 1% or 2%) is used to numb subcutaneous skin and the liver capsule during the liver biopsy Patients with high anxiety are sometimes given a small dose of oral or intravenous (I.V.) benzodiazepine (e.g., lorazepam) Rarely adult patients are prescribed medications for conscious sedation such as midazolam or fentanyl Gather the appropriate supplies, which typically include the following: Nonsterile gloves Sterile surgical garb (e.g., sterile gloves, eye protection, gown, and mask) for self and treating clinician I.V. set-up if necessary Liver biopsy equipment, which is available in a prepackaged kit (i.e., liver biopsy tray) and typically includes the following items: Core biopsy needle, preferably 16 gauge, 4.5 inches Facility-approved antiseptic solution (e.g., povidone-iodine) Specimen containers with formalin One injection needle: 21 gauge, 1.5 inches, with 3 mL syringe One injection needle: 25 gauge, 1 inch, with 3 mL syringe Sterile drapes/towels Three 10 mL normal saline solution (0.9%) vials One #11 surgical scalpel and blade Three cotton swabs or 4 X 4 inch gauze pads Two 10 mL syringes Sterile gauze and tape for bandage Emergency medical equipment (e.g., crash cart, oxygen) Vital signs equipment
4 4
4 4 4 4 4 4 4 4
4 4 4 4 4 4
4 4 4 4 4 4 4 4 4
Provide the appropriate level of assistance for the patient to dress in a hospital gown Assess baseline vital signs Establish I.V. access or confirm patency of an existing I.V. line, if I.V. access is necessary Describe and review the breath-holding technique during the procedure; practice full expiration and breath holding with the patient Reinforce the importance of remaining still during the procedure Administer medication for sedation or pain as ordered Assist the patient into a supine position with the right arm extended above the head to maximally expand the intercostal spaces beneath which the liver is located Prepare the patient for determination of the location of the liver (e.g., by CT scanning, US imaging, or percussion) The biopsy site is usually located on the midaxillary line at the 7th or 8th intercostal space Once identified, the treating clinician marks the site with a surgical pen Remove and discard nonsterile gloves Perform hand hygiene and apply sterile surgical garb according to facility protocol Prepare a sterile surgical tray with the necessary equipment per facility protocol Perform sterile draping of the patient per facility protocol Maintain a conversation with the patient throughout the procedure to assess the patients level of pain and anxiety, and to monitor for complications related to the procedure Follow facility protocol to assist the treating clinician as he or she performs the following steps, noting that certain steps may be delegated to the nurse clinician: The skin is disinfected with 3 cotton swabs or gauze pads soaked in povidone-iodine using circular motions, starting closest to the puncture site, and moving outward to cleanse the skin A local anesthetic (e.g., lidocaine) is injected into subcutaneous tissue and into the liver capsule. The nurse clinician may be responsible for cleansing the top of the vial and holding it so the treating clinician can insert the needle and draw up the required amount of anesthetic The patient is assessed to determine whether the anesthetic has taken effect A small incision is made at the selected skin site As the treating clinician inserts the biopsy needle through the incision, ask the patient to take deep breaths, exhale completely, and hold his/her breath Assist the patient in remaining still as the specimen is obtained Instruct the patient when to breathe again and to breathe normally Assist the treating clinician with placement of the specimen in the sterile specimen container Assist with the application of a dressing at the incision site Assist the patient onto the right side using a pillow to support the lower right rib cage; instruct the patient to lie on his or her right side for at least 2 hours Label the specimen container and arrange prompt delivery to the laboratory Discard used supplies and perform hand hygiene Document the following in the patients medical record: Date and time of the liver biopsy Laboratory tests ordered All medications administered Patients tolerance of the procedure Clinical assessment information (e.g., vital signs, level of pain/anxiety/consciousness, cardiovascular, pulmonary, condition of dressing) before and after the procedure The type of dressing and any medication applied to the puncture site The presence of bleeding or drainage at the site Patient and/or family member teaching
Other Tests, Treatments, or Procedures That May be Necessary Before or After Liver Biopsy
4 4 Before liver biopsy, a complete physical exam and history is performed including a review of patients current medications and coagulation studies (e.g., PT, INR, platelet count) After the procedure, the patient requires close monitoring for bleeding and other complications associated with the procedure; elements of monitoring may include assessment, laboratory evaluation, and imaging studies Depending on the patients overall health, whether sedation was used, and whether complications occurred, vital signs and pain level should be assessed every 15 minutes for the first hour, every 30 minutes for the next 2 hours, every hour for the next 4 hours, and then every 4 hours until the patient is stable or until patient discharge Any changes in the patients clinical status should be immediately reported to the treating clinician, including increasing pulse rate, decreasing blood pressure, increased pain intensity, and feelings of apprehension
have minimal postprocedural pain not experience any complications; alternately, any complications will be promptly detected and treated
Red Flags
4 4 Monitor closely for signs and symptoms of hemorrhage (e.g., severe pain, abdominal distention, hypotension, tachycardia, mental status changes) Dyspnea may indicate pneumothorax following liver biopsy
References
Altman, G. B. (2010). Special procedures. In Fundamental & advanced nursing skills (3rd ed., pp. 1435-1442). New York: Delmar Cengage Learning. Arora, G., Ayoub, W. S., & Keeffe, E. B. (2011). Percutaneous liver biopsy. Medscape Reference. Retrieved August 22, 2011, from http://emedicine.medscape.com/article/149684-overview Coleman, J., McGinnis, C., Fort, L. (2010). Hepatic, biliary, and pancreatic disorders. In S. M. Nettina, Lippincott manual of nursing practice (9th ed., pp. 717-718). Philadelphia: Wolters Kluwer Health/Lippincott Williams & Wilkins. Karamshi, M. (2008). Performing a percutaneous liver biopsy in parenchymal liver diseases. British Journal of Nursing, 17(12), 746-752. Xu, J., Kochanek, K. D., Murphy, S. L., & Tejada-Vera, B.,(2010). Deaths: Final data for 2007. National Vital Statistics Reports, 58(19), 5. Retrieved August 22, 2011, from http://www.cdc.gov/NCHS/data/nvsr/nvsr58/nvsr58_19.pdf Zaman, A., Ingram, K., & Flora, K. D. (2011). Diagnostic liver biopsy. Medscape Reference. Retrieved August 22, 2011, from http://emedicine.medscape.com/article/1819437-overview