Hepatic cirrhosisDhuha F Shamsaldeen

Learning objectives : Identify the metabolic functions of the liver and

the alterations in these functions that occur with liver disease.

Explain liver function tests and the clinical manifestations of liver dysfunction in relation to pathophysiology alterations of the liver.

Describe the medical, surgical, and nursing management of patients with cirrhosis.

Use the nursing process as a framework for care of the patient with cirrhosis of the liver.

Liver The liver, is the largest gland of the body, located

behind the ribs in the upper right portion of the abdominal cavity.

Some of the functions of the liver

Glucose metabolism. Ammonia conversion. Protein metabolism. Fat metabolism. Vitamins and iron storage. Bile formation. Bilirubin excretion. Drug metabolism.

Symptoms shows that the person has liver dysfunctions :

N/V Anorexia Abdominal distention Changes in bowel habits Weight loss Weakness and fatigue Abdominal pain Bleeding in ( skin, stool, urine ) Edema Dark urine Ascites Jaundice

Hepatic Cirrhosis

Is a chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupt the structure and function of the liver.

Types of the hepatic cirrhosis :

Alcoholic cirrhosis

In which the scar tissue

characteristically surround the portal al

areas .

Biliary cirrhosis

In which scarring occurs in the liver

around the bile ducts. This type of cirrhosis

usually result from chronic biliary

obstruction and infection.

Postnecrotic cirrhosis

In which there are broad bands of scar tissue. This is a late result of a previous bout of acute viral

hepatitis.

Assessment compensated decompensated

Intermittent mild feverVascular spidersPalmar erythema ( reddened palms )Unexplained epistaxis ankle edemaVague morning indigestionFlatulent dyspepsia Abdominal painEnlarged liverSplenomegaly

AscitesJaundiceFatigueMuscle wastingWeight lossContinuous of liverClubbing of liverpruritusSpontaneous bruisingEpistaxisHypotensionSpare body hairWhite nailsGonadal atropy

The stressors

1- physiological Autoimmune Poor nutrition Toxic substances Infections

2- developmental Older adults ( age )

3- sociocultural Feeding habits Adults circumcision

Laboratory assessment Direct Bilirubin Indirect Bilirubin Serum amylase Serum lipase Ammonia AST ( Aspartate Amino Transfers ) ALT ( Alanine Amino Transfers ) SGOT ( Serum Glutamic Oxaloacetic Transaminase) LDH ( Lactic Acid Dehydrogenase ) ALP ( Alkaine Phosphatase ) GGT ( G-Glutamyl Transfers)

Diagnostic tests : CT scan MRI Liver biopsy

Medical management : Antacids / Histamine-2 ( H2 ) antagnosis:To decrease gastric distress and minimize the possibility of GI bleeding. Vitamins and nutritional supplements:To promote healing of damaged liver cells and improve the patient`s general nutritional status. Potassium-sparing diuretics such as

spironolactone or triamterene ( Dyrenium ):To decrease ascites and minimize the fluid and electrolyte changes.

Nursing care plans

Nursing diagnosis: activity intolerance r/t fatigue.

Goal: pt. reports decrease in fatigue and reports increased ability to participate in activity.

Nursing interventions

rationale Expected outcomes

1. Assess level of activity tolerance and degree of fatigue when performing routine activities of daily living.

2. Assist when activities and hygiene when fatigued.

3. Encourage rest when fatigued or when abdominal pain or discomfort occurs.

4. Assist with selection and pacing of desired activities and exercise.

5. Provide diet high in carbohydrates with protein intake consistent with liver function.

6. Administer supplemental vitamins ( A, B complex, C, and K ).

1. Provides baseline for future assessment and criteria for assessment of effectiveness of environment.

2. Promotes exercise and hygiene within pt`s level of tolerance.

3. Conserves energy to protects the liver.

4. Stimulates patient`s interest in selected activities.

5. Provides calories for energy and protein for healing.

6. Provides additional nutrient.

• Exhibits increased interest in activity and events.

• Participate in activities and gradually increases exercise within physical limits.

• Reports increased in strength and well-being.

• Reports absence of abdominal pain and discomfort.

• Plans activities to allow ample periods of rest.

• Takes vitamins as prescribed.

Nursing diagnosis: imbalanced nutrition; less than body requirements, r/t abdominal distention and discomfort and anorexia.

Goal: positive nitrogen balance, no further loss of muscle mass; meets nutritional requirements.

Nursing interventions

rationale Expected outcomes

1. Assess dietary intake and nutritional status through diet history and diary, daily weight measurements, and laboratory data.

2. Provide diet high in carbohydrates with protein intake consistent with liver function.

3. Assist pt in identifying low sodium foods.

4. Elevate the head of the bed during meals.

5. Provides oral hygiene before meals and pleasant environment for meals at meal time.

6. Offer smaller, more frequent meals.

7. Eliminate alcohol.8. Apply an ice collar for

nausea.

1. Identifies deficits in nutritional intake and adequacy of nutritional state.

2. Provides calories for energy, sparing protein for healing.

3. Reduces edema and ascites formation.

4. Reduces discomfort from abdominal distention.

5. Promotes positive environment and increased appetite; reduced unpleasant taste.

6. Decrease feeling of fullness and bloating.

7. Eliminates “empty calories” and further damage from alcohol.

• Exhibits improved nutritional status by increased weight ( without fluid retention ) and improved laboratory data.

• States rationale for dietary modifications.

• Identifies foods high in carbohydrates and within protein requirements ( moderate to high protein in cirrhosis ).

• Reports improved appetite.• Participates in oral hygiene

measures.• Gains weight without

increased edema or ascites formation.

Nursing diagnosis: impaired skin integrity r/t pruritus from jaundice and edema.

Goal: decrease potential for pressure ulcers development; breaks in skin integrity.

Nursing interventions

Rationale Expected outcomes

1. Assess degree of discomfort r/t pruritus and edema.

2. Note and record degree of jaundice and extent of edema.

3. Keep patient`s fingernails short and smooth.

4. Provide frequent skin care; avoid use of soaps and alcohol-based lotions.

5. Massage every 2 h with emollients; turn every 2 h.

6. Recommend avoiding use of harsh detergents.

7. Assess skin integrity every 4-8 hrs.

1. Assists in determining appropriate interventions.

2. Provides baseline for detecting changes and evaluating effectiveness of interventions.

3. Prevents skin excoriation and infection from scratching.

4. Removes waste products from skin while preventing dryness of skin.

5. Promotes mobilization of edema.

• Exhibits intact skin without redness, excoriation, or breakdown.

• Reports relief from pruritus.

• Exhibits no skin excoriation from scratching.

• Uses nondrying soaps and lotions.

• Turns self periodically, exhibits reduced edema of dependent parts of the body.

• Exhibits decreased edema; normal skin turgor.

Nursing diagnosis: chronic and discomfort r/t enlarged liver and ascites.

Goal: increased level of comfort.

Nursing interventions

rationale Expected outcomes

1. Maintain bed rest within pt experiences abdominal discomfort.

2. Administer antispasmodic and analgesic agents as prescribed.

3. Observe, record, and report presence and character of pain and discomfort.

4. Reduce fluid and sodium intake if prescribed.

5. Encourage the use of distracting activities such as music, reading, or meditation.

1. Reduces metabolic demands and protects the liver.

2. Reduces irritability of the GI tract and decrease abdominal pain and discomfort.

3. Provides baseline to detect further deterioration of status and to evaluate interventions.

4. Removal of a ascites fluid may decrease abdominal discomfort.

5. Distraction may limit the perception of pain.

• Reports pain and discomfort if present.

• Maintains bed rest and decrease activity in presence of pain.

• Takes antispasmodic and analgesics as indicated and as prescribed.

• Reports decreased pain and abdominal discomfort.

• Reduce sodium and fluid intake to prescribed levels if indicated to treat ascites.

• Exhibits decreased abdominal girth and appropriate weight changes.

Nursing diagnosis: fluid volume excess to ascites and edema formation.

Goal: restoration of normal fluid volume.

Nursing interventions

rationale Expected outcomes

1. Restrict sodium and fluid intake if prescribed.

2. Administer diuretics, potassium, and protein supplements as prescribed.

3. Record intake and output every 1-8 h depending on response to interventions and on pt acuity.

4. Measure and record abdominal girth and weight daily.

5. Explain rationale for sodium and fluid restrictions.

1. Minimize formation of ascites and edema.

2. Promotes excretion of fluid through the kidneys and maintenance of normal fluid and electrolyte balance.

3. Indicates effectiveness of treatment and adequacy of fluid intake.

4. Monitors change in ascites formation and fluid accumulation.

5. Promotes pt`s understanding of restriction and cooperation with it.

• Consumes diet low sodium and within prescribed fluid restriction.

• Takes diuretics, potassium, and protein supplement as indicated without experiencing side effects.

• Exhibits increased urine output.

• Exhibits decreasing abdominal girth.

• Shows a decrease in ascites with decrease weight .

Nursing diagnosis: risk for imbalanced body temperature; hyperthermia r/t inflammatory process

of cirrhosis.Goal: maintenance of normal body temperatures, free from

infection.

Nursing interventions

rationale Expected outcomes

1. Record temperature regularly.

2. Encourage fluid intake.

3. Apply cool sponges or ice bag for elevated temperature.

4. Administer antibiotics as prescribed.

5. Avoid exposure to infections.

6. Keep pt at rest while temperature is evaluated.

7. Assess for abdominal pain, tenderness.

8. Use sterile technique for all invasive procedures.

1. Provides baseline to detect fever and to evaluate interventions.

2. Corrects fluid less from perspiration and fever and increases patient's level of comfort.

3. Minimize risk of further infection and further increase in body temperature.

4. Reduce metabolic rate.

• Exhibits normal temperature and reports absence of chills or sweating.

• Demonstrates adequate intake of fluid.

• Exhibits no evidence of local or systemic infection.

Health teaching:

Promoting rest Improving nutritional

status Providing skin care Reducing risk of injury

References www.cirrhosisoftheliver.us http://

www.nlm.nih.gov/medlineplus/ency/article/000255.htm

Kluwer, W., Williams, L., & Wilkins, L. (2010). Assessment and Management of Patient With Hepatic Disorders. In Smeltzer S.C., Bare B.G., Hinkle J.L., & Cheever K.H. (eds), Medical-Surgical Nursing (pp 1116-1168) (12th ed.). New York: Lippincott-Raven.