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

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.

Episode Transcript

Speaker 1 (00:00):
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 forme and I found ways to thrive in
nursing school and now as a newnurse in an emergency
department.
I want to take this season toshare my stories, experiences

(00:22):
and lessons with you so that youcan become the best nursing
student and the best nurse, andreally just the best version of
yourself that you could possiblybe.
All episodes are 10 minutes orless, so you can grab it and go.
And a couple more things beforewe get into today's show.
If you could kindly take acouple seconds to pull out your

(00:43):
phone, give us a quick five starrating and review.
It helps so much more than youeven know to put the show in
front of more future nurses,because it is my personal
mission to help put more greatnurses into the world and I need
your help to do that.
So thank you so much.
And lastly, the views andopinions expressed on Nursing

(01:04):
Student Coach are those ofLauren Chapnick and hers alone.
They are not intended asmedical advice and should not
replace your institution'spolicies or procedures.
So guys on to today's podcast.
It's the Nursing Student CoachGiving you the strategies you
need the most.
Hey everybody, welcome on in.

(01:30):
Today I want to talk about apatient that I had towards the
beginning one of my first weeksworking in the emergency room,
and we'll call him Bill.
Bill was wheeled in in awheelchair and he was yellow as
the sun.
He was extremely short ofbreath and he had an extremely

(01:54):
large belly.
He looked like he was pregnantwith quintuplets.
It was a huge, huge belly on avery small man who was clearly
very sick, very malnourished.
Can we take a guess of what wasgoing on with Bill?
He had jaundice, that's, theyellow skin, and the big belly.

(02:15):
That is called ascites, andthese 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 downtoday what causes the yellow
skin really, what is jaundiceand what's the patho behind it,

(02:37):
what causes it and what isascites?
What caused this man to havethis giant pregnant looking
belly and how do you treat it?
So first, before we can getinto that, let's talk about the
liver.
The liver does so much for us,but as it relates to jaundice

(02:59):
and ascites, I'm just going totalk about two things.
The first is it produces orsynthesizes a very important
protein called albumin.
Albumin does a lot for us.
It binds to drugs it binds tocertain drugs in our body and it
transports them, and it alsobinds to water.

(03:20):
And why is that important?
Well, because it prevents waterfrom leaking out of our vessels
, which is exactly what happensin ascites.
Now let's talk about one otherthing that the liver does for us
in a long list.
It breaks down bilirubin, andbilirubin is a pigment that's

(03:46):
found in bile.
Bile helps us with digestion,and bilirubin is a pigment
that's found in bile and reallywhat it is.
It's its broken down dead redblood cells, and one of the
liver's functions is to get ridof it, to filter it out, and it

(04:06):
goes through our digestivesystem.
But if our liver isn'tfunctioning, if your liver is
damaged or you're an end-stageliver failure, your liver is
just scar tissue, it is notfunctioning.
It's hard as a rock, it's goingto get clogged and it's not
going to perform these functionsthat it needs to.
So if you're not breaking downbilirubin, where's it going to

(04:30):
go, this yellow substance?
It's going to leak out.
It's going to leak out into theblood and it's going to get
deposited into your skin andthat is what causes this
jaundice.
And in this man's case it was anextreme case because he was an
end-stage liver failure andthere's really not much you can

(04:50):
do to treat this.
It's not an acute condition,it's chronic.
So really what he needed was aliver transplant.
I don't know if he was at thepoint where he was going to get
one.
I don't know his story, butthat is what causes the jaundice
.
All right, let's get into thisascites.
What was causing this giantbelly?
Well, this is a conditioncalled ascites and it's really

(05:13):
just accumulation of fluid andit can happen anywhere.
In this man's case and thisliver failure, it happened in
his belly.
It's not just this lack ofalbumin.
There's some portalhypertension going on with the
portal vein.
But for now we're just going totalk about albumin.
So if you're not producingalbumin and water is not being

(05:38):
retained in the liver and in thevessels, then where's it going
to go?
It's going to leak out.
So you might hear in nursingschool something called third
spacing and to be honest, innursing school I understood that
the fluid shifted and it wentinto this third space, but I
didn't quite understand.

(05:59):
Well, wait a minute.
What's the first space andwhat's the second space?
And then what's this thirdspace Like?
What's the order?
So the first space is insideyour vessels, your intravascular
space, so inside your veins,your arteries, any vessel.
That's your first space.
The second space is your cell.

(06:19):
So the fluid would get pushedout of the vessel into the cell,
your intracellular space, andthen, when it doesn't have
anywhere else to go after thatand it's being kicked out, it's
going to go into your thirdspace.
That's everywhere else.
That's your interstitial space.
That's between the bloodvessels and the cells.

(06:40):
So it just leaks.
And if you've got fluid and it'sgot no albumin to hang on to it
, it's just going to leak outinto your interstitial space and
it's going to cause this giantbelly.
And what's the risk here?
Well, let's see, you've got allof this fluid that's
accumulating and it's lackingproteins to help you fight

(07:03):
infection because you'remalnourished, you don't have
albumin and so you're at greatrisk for infection.
And the more fluid accumulationyou get in your belly it's
gonna push up.
If you think about it.
If your belly fills up, it'sgonna push up into your
diaphragm, which is gonna pushup into your lungs and you're

(07:25):
gonna be extremely uncomfortableand short of breath.
That's what happened in thispatient's case.
And then, when it gets pushedup even more, you're at great
risk for that fluid to go intoyour lungs and to cause
pulmonary edema, basicallysuffocating in your own body.
So you wanna treat this.
How do you treat it?
Well, in this man's case he hadan extreme case.

(07:48):
He needed what's called aparacentesis, and what happens
in a paracentesis is theprovider takes a needle and
inserts it into the abdomen anddrains out all of this fluid.
It's literally like sticking aneedle inside of a water balloon
and not popping it but justsucking it out, draining it out.

(08:10):
Now there are other treatmentsyou can do.
You can treat it with drugs,with diuretics.
You've got ferrosamide, orLasix is the brand name or
spirulactone, basically adiuretic.
It's going to take that fluidand you're just gonna pee it out
.
It's gonna go out of the bodyand into the potty, as our

(08:32):
friend Nurse Mike says aboutdiuretics.
You can also treat it with alow sodium diet.
But in this man's case he waspast any of those treatment
options.
He just needed a paracentesis.
So that's where he went.
Okay, so that's what washappening there and that's what
was happening with the jaundice.

(08:54):
You had increased bilirubin thatwas built up and up and up and
gets deposited into the skin.
Let's just talk real quickabout lab values.
So there's gonna be somedifferent lab values abnormal
lab values, in end stage liverfailure but let's talk about the
ones that we discussed today.
The first with albumin, you'regoing to have low albumin levels

(09:19):
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 ourfriend Al albumin, that protein
to transport the drugsthroughout our body or to retain
the water and to bind to water,then you are going to have this

(09:44):
.
Third spacing, this ascites.
You're also going to haveincreased bilirubin, as we
discussed, because if your livercan't do its function of
breaking down and filtering outthat bilirubin, those dead red
blood cells that have thatyellow tint, then you're going
to have increased bilirubin.

(10:06):
So if that comes up on an examfor you, I hope that you get it
right and I hope that thishelped to clarify ascites and
jaundice and I hope you have anamazing day.
Stay well and I will see youthe next time.
Bye-bye, thanks for tuning into the Nursing Student Coach

(10:28):
Podcast.