Cirrhosis of the Liver Podcast and Nursing Care Plan

Cirrhosis

Cirrhosis of the Liver Podcast and Nursing Care Plan

What is Cirrhosis

Cirrhosis is the result of damage to the liver. Remember that the liver is responsible for taking out harmful substances from the body. When the patient has a liver disease of other liver disorder, this can result in cirrhosis which is a late stage of fibrosis (scarring) of the liver. Once cirrhosis has occurred in response to the damage to the liver, it can not be reversed. However, if cirrhosis is caught early and treated, the damage can be limited. But if cirrhosis continues to progress, more scar tissue will form, which will compromise the liver function of removing toxins, etc. If cirrhosis is allowed to advance it can become life threatening.

Sign and Symptoms

Usually cirrhosis can be asymptomatic (no signs or symptoms) until the damage to the liver is advanced. When this happens, the patient might exhibit:

  • Bleeding
  • Fatigue
  • bruising
  • Itchy skin
  • Jaundice
  • Nausea
  • Lower extremity swelling
  • Loss of appetite
  • Confusion
  • Spider type blood vessels on the skin
  • Varices
  • Ascities

 

Cirrhosis

 

 What causes cirrhosis

When the liver is injured, it will try to repair itself. This repairing process causes scar tissue to form. As many years of damage from disease or illness occurs, more and more scar tissue is produced, the liver function becomes compromised and worsens.  In later stages of cirrhosis, the liver no longer functions well.

The healthcare provider will try to find the underlying cause of cirrhosis to prevent further damage to the liver. Some factors that can contribute to cirrhosis are:

  • Hepatitis B and /or Hepatitis C
  • Chronic alcohol abuse
  • Nonalcoholic fatty liver disease (fat accumulating in the liver).
  • Primary sclerosing cholangitis (scarring and hardening of the bile ducts).
  • Primary biliary cirrhosis (destruction of the bile ducts).

Other causes of cirrhosis may be inherited. Here are some but not all of these conditions:

  • Hemochromatosis (iron buildup in the body)
  • Cystic fibrosis
  • Biliary atresia (bile ducts that form poorly)

It is important to note that a patient may have more than one cause of cirrhosis.

* Crytogenic cirrhosis is a type of cirrhosis of unknown etiology.

 Complications from Cirrhosis

The complications that develop from cirrhosis are usually related to blood flow, these include:

  • Portal hypertension: High blood pressure in the veins that supply the liver. When blood flow through the liver is compromised, there is increasing pressure in the vein that brings blood from the intestines and spleen to the liver.
  • Edema & Ascites: This is fluid accumulation in the legs (edema) and abdomen (ascites) from the portal hypertension. But, edema and ascites can also develop from the liver being so scarred that it can not make enough blood proteins such as albumin.
  • Splenomegaly (enlarged spleen)
  • Bleeding: Because portal hypertension can divert blood into smaller veins, these veins can become stressed by the additional load causing them to burst.  This can result in serious bleeding. This pressure can also cause veins to enlarge (varices) and become life threatening especially if this occurs in the esophagus (esophageal varices) and abdomen (gastric varices). Because the liver is compromised, it is unable to make enough clotting factors, which may result in ongoing bleeding.
  • Jaundice: Here the liver is not able to remove bilirubin (a blood waste product), The skin and whites of the eyes can turn yellow as a result.  The urine may also become darker.
  • Malnutrition: The scarring from cirrhosis impedes the bodies processing of nutrients, this can lead to weight loss and weakness.
  • Infection: Due to the cirrhosis, the patient may have trouble fighting infections. Bacterial peritonitis can result from ascites which is a serious infection.
  • Hepatic Encephalopathy (built up toxins in the brain): Since the damaged liver is unable to remove toxins from the blood, the toxins can accumulate in the brain and cause mental confusion and difficulty in concentration.
  • Fractures: increased risk of fractures due to the loss of bone strength.
  • Bile duct stones and Gallstones: this is due to the blockage of bile which leads to irritation, creation of stones and infection.
  • Increased risk of liver cancer

Diagnosis

Laboratory tests:

  • LFT – Liver Function Test: This test will determine if there is excess enzymes in the patients blood.
  • Clotting factors: to check bloods ability to clot.
  • Kidney Function: Mainly checked for excess in creatinine.
  • Imaging tests: CT, MRI, and ultrasound may be done to assess the liver.

Treatments

Treatment is aimed at slowing the progression of developing scar tissue in the liver and to the symptoms and complications. Depending on the extent of the damage, hospitalization may be required.

Some of the underlying causes that will need to be addressed/treated include:

  • Weight loss: this can help patients diagnosed with nonalcoholic fatty liver disease.
  • Alcohol dependency treatment: Patients should not drink alcohol with cirrhosis.
  • Medications: may help stop liver damage brought on by Hepatitis (namely B&C). Medications may also help slow down the progression of cirrhosis.
  • Ascites and edema: may be manged with a low-sodium diet. If ascites severe enough, the patient may require additional procedures or surgery to remove the fluid and relieve pressure.
  • Blood pressure medications: to combat portal hypertension.
  • Endoscopy: this is a possibility as esophageal and gastric varices can develop.
  • Antibiotics: for any infections that may arise.
  • Blood and ultrasound exams: to assess for liver damage and/or signs of liver cancer.
  • Medications: to help reduce the amount of toxins that may result in hepatic encephalopathy due to reduced liver function.
  • Liver transplant surgery: for advanced cases when the liver no longer functions.

**** Cirrhosis is one of the main reasons for a liver transplant.

Nursing Care Plan

Nursing Diagnosis

1. Imbalanced Nutrition: Less than body requirements related to malabsorption.

Desired outcomes:

Within 24 hours of hospital discharge, the client is able to demonstrate progress towards adequate nutritional status as evidenced by progressive weight gain.

InterventionsRationals
InterventionsRationals
Weigh patient daily. Assess and record (I&O) intake and output.To assess adequacy of diet and measure the use of diuretic therapy if utilized.
Allow client to eat that are permitted within dietary meal plan. Explain dietary meal plan and restrictions.Sodium and fluids are restricted due to fluid retention and ascites.
Offer small and frequent meals.If ascites is present, the patient may not be able to tolerate larger meals.

2. Excess Fluid Volume: Risk for electrolyte imbalance related to compromised regulatory mechanisms with accumulation of fluid retention occurring with hepatocellular failure and portal hypertension.

Desired outcomes:

Within 1 day of discharge, client will exhibit normovolemic status as evidenced by respiratory rate between 12 -20 breaths per minute without any respiratory distress, edema at 1 or less,  and a reduction of abdominal girth.

InterventionsRationals
InterventionsRationals
Weigh patient daily. Assess and record (I&O) intake and output.To assess adequacy of diet and measure the use of diuretic therapy if utilized.
Measure abdominal girth for baseline point if reference.This will allow a comparison to observe if there is an increase or decrease in ascites. This will measure the effectiveness of medical treatments.
Assess level of edema from 1 - 4 and document findings.Edema allows health care provider assess if there is an excess on sodium intake or low serum albumin. Ascites is usually associated with low albumin levels.
Monitor vital signs q shiftThis will assess if there is any pulmonary congestion if there is a drop in resp rate. An increase in blood pressure can be associated with fluid retention.

3. Risk for bleeding related to altered clotting factors

Desired outcomes: 

Patient will be free of occult or frank bleeding and will exhibit hemodynamic stability by maintaining a pulse of less than 100 beats per minute. A systolic blood pressure of at least 90 mmhg and a respiratory rate if 12-20 breaths per minute.

InterventionsRationals
InterventionsRationals
Monitor vital signs for indicators of bleeding or hemorrhage.Tachypnea, hypotension, and tachycardia may be associated with bleeding or hemorrhage. This can occur with anticoagulant therapy and will need prompt intervention.
At the minimum of every eight hours, inspect for any wounds that may have resulted from invasive procedures. Also check the oral mucosa and nares.This assessment will determine if there is any bleeding from anticoagulant therapy. Notify the physician immediately.
If patient is on heparin, monitor the PTT (partial thromboplastin time)Need to ensure that the PTT stays within the therapeutic range of 1.5-2.50 X control.
If patient is on Coumadin, monitor the PT (prothrombin time).Need to ensure that the PT stays within the therapeutic range of 1.5-2.50 X control, or INR value of 2.0-3.0.

Other nursing diagnosis:

Knowledge deficit

Disturbed body image/ Self esteem

Risk for acute confusion

 

Disclaimer:

Please follow your facilities infection control guidelines. The medical information on this site is provided as an information resource only, and is not to be used or relied on for any diagnostic or treatment purposes. This information is not intended to be nursing education and should not be used as a substitute for professional diagnosis and treatment.

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Anna C. RN-BC, BSN, PHN, CMSRN Anna began writing extra materials to help her BSN and LVN students with their studies. She takes the topics that the students are learning and expands on them to try to help with their understanding of the nursing process. She is a clinical instructor for LVN and BSN students along with a critical care transport nurse.

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