The liver is an important body organ that carries out a variety of crucial tasks, such as:
- Production of blood proteins that support the immune system, deliver oxygen, and help in blood coagulation
- Bile production which aid in food digestion
- Glucose storage in the form of glycogen
- Removal of hazardous elements from the bloodstream, such as alcohol and narcotics, from the body
- Cholesterol production and saturated fat breakdown
Liver failure happens when the liver is incapable of carrying out the above functions. Liver failure is a potentially fatal emergency that must be treated immediately.
Elevated liver biochemistry, coagulopathy, and hepatic encephalopathy without underlying chronic liver disease are the hallmarks of acute liver failure (ALF).
Less than 10 cases of ALF occur annually per million people in the developed world. Each year, there are roughly 2800 new cases of ALF in the United States. Young individuals are frequently affected by acute liver failure. It ais also more common in developing nations.
Signs and Symptoms of Liver Failure
Liver failure symptoms may include:
- nausea
- appetite loss
- fatigue
- diarrhea
- jaundice (as manifested by yellow discoloration of skin and eyes)
- weight loss
- easy bleeding or bruising
- pruritus
- edema (as manifested by leg swelling)
- ascites (abdominal fluid accumulation)
These symptoms are nonspecific to hepatic failure and may be associated with other conditions. Some patients with liver failure are asymptomatic until it has progressed to a fatal stage which can manifest as feeling disoriented, drowsy, or slipping into a coma.
Jaundice is also a common clinical presentation. Encephalopathy can also occur secondary to toxin accumulation in the brain and can manifest as impaired cognitive ability, sleepiness, and lack of concentration. Possible complications include splenomegaly, renal failure, gastrointestinal bleeding, and hepatic carcinoma.
Types of Liver Failure
- Acute Liver Failure. In acute liver failure or ALF, the decline in liver function occurs suddenly in weeks or even days without warning. Drug-induced liver injury is the most frequent cause of acute liver failure in the United States and Western Europe, but viral hepatitis is still the most common cause in underdeveloped nations. About 2800 cases of ALF are reported each year in the US, with acetaminophen serving as the primary trigger.
- Chronic Liver Failure. Compared to acute liver failure, chronic liver failure or CLF occurs more gradually. Before the patient experience any symptoms, it could take months or even years. Cirrhosis, which develops when normal liver tissue is replaced with scar tissue, frequently leads to chronic liver failure. Cirrhosis is most frequently brought on by hepatitis C infection, excessive alcohol consumption, or nonalcoholic fatty liver. Scar tissue formation is secondary to an inflammatory process happening in the liver, thereby gradually losing its function.
Risk Factors to Liver Failure
The group of people most at risk for liver failure includes:
- Those who have chronic hepatitis caused by Hepatitis B or C
- Chronic alcoholics
- Those who have an underlying or acquired medical conditions that increase the risk of liver failure, such as:
- Hemochromatosis (in which the body absorbs excessive amounts of iron from food)
- Non-alcoholic fatty liver disease (NAFLD)
- Autoimmune disease (condition where autoantibodies attack the liver)
- Wilson disease (condition wherein the body is incapable of copper removal).
Causes of Liver Failure
- Causes of Acute Liver Failure
Acute liver failure, also known as fulminant hepatic failure, can occur in the absence of pre-existing liver disease. Acetaminophen overdose is the most frequent cause of abrupt liver failure in the United States. Acute liver failure can also result from:
- certain prescription drugs
- a few dietary supplements
- Hepatitis viruses, including hepatitis A, B, and C, are viral illnesses.
- toxins
- specific autoimmune conditions
- Existing hereditary liver disease
- Causes of Chronic Liver Failure
Long-term inflammation that results in the scarring of healthy liver tissues (fibrosis) causes chronic liver failure. The majority of healthy liver tissues are replaced by scar tissue, which is known as cirrhosis.
While some of the causes of hepatic inflammation are associated with underlying medical disorders, other causes of hepatic inflammation can be more challenging to identify. These might include the following:
- Hepatitis C infection
- Excessive alcohol consumption
- Nonalcoholic fatty liver disease
Complications of Liver Failure
- Complications of Acute Liver Failure
- Cerebral edema (a surplus of fluid in the brain). Excess hydration can lead to pressure buildup in the brain leading to seizures, severe mental confusion, and disorientation.
- Bleeding and clotting disorders. One of the liver’s functions is to produce clotting factors that aid in coagulation. With an impaired liver function, these clotting factors are insufficiently produced thereby making the individual susceptible to developing bleeding disorders (e.g., gastrointestinal bleeding).
- Infections. Acute liver failure patients are more susceptible to infections, especially those of the hematologic, respiratory, and urinary systems.
- Renal failure. Acetaminophen overdose impairs both the liver and kidneys. Liver failure is subsequently followed by renal failure.
- Complications of Chronic Liver Failure
- Variceal bleeding
- Ascites and spontaneous bacterial peritonitis (SBP)
- Hepatic encephalopathy
- Hepatorenal syndrome
- Hepatopulmonary syndrome
- Hepatocellular carcinoma (HCC)
Diagnosis of Liver Failure
- Comprehensive history taking and Physical examination. Identify any history of alcohol abuse, genetic irregularities, or other medical conditions.
- Liver function tests. Liver function tests are blood tests used to monitor and identify liver damage or illness by measuring the levels of specific proteins and enzymes in the blood.
- Biopsy. To assess liver disease, a biopsy is frequently utilized as a test wherein a small portion of the liver is extracted as a sample, processed, and examined in the laboratory
Treatment for Liver Failure
- Treatment for Acute Liver Failure
These individuals frequently pass away from the complications of acute liver failure, which is a complicated condition. Patient management in the intensive care unit is required before moving them to a facility with liver transplant capabilities. Along with the diagnostic process, treatment should start as soon as possible.
- Medications. The treatment must target the underlying cause; for instance, N-acetylcysteine (NAC) should be given for acetaminophen poisoning, antivirals for acute hepatitis B, steroids for autoimmune flare-ups, penicillamine for Wilson’s disease, and penicillin for mushroom poisoning. NAC has also demonstrated efficacy in non-acetaminophen acute liver failure. Dextrose infusion should be used to avoid hypoglycemia in patients with ALF.
- Prevention of cerebral edema. Regardless of the cause, preventing cerebral edema is the cornerstone of ALF treatment. To do this, one can use head elevation, mannitol, hyperventilation, and cerebro-protective techniques.
- Close monitoring. Intracranial pressure (ICP) monitoring with pressure monitors is employed in some cases of liver failure. Renal failure, metabolic acidosis, coagulopathy, and hypoglycemia are further complications of liver failure that need to be closely monitored. Coagulopathy should only be treated if the patient requires an invasive operation or there is ongoing bleeding. In order to prevent multiorgan failure until recovery or liver transplant, ALF is managed with strong supportive treatments.
- Treatment for Chronic Liver Failure
The aim of treatment in CLF is to halt the spread of the illness and its complications, and this calls for a multidisciplinary strategy. The major management tenets include the elimination of underlying causes, control of portal hypertension, and individualized therapy for each condition. Most patients with chronic liver disease have one of the consequences upon presentation. These may include:
- Esophageal varices. Bleeding from varices is one of the fatal consequences of CLF, and treatment involves vigorous fluid resuscitation, vasopressors (octreotide, terlipressin), and endoscopy. The standard treatments for variceal bleed in an emergency are endoscopic band ligation and injectable sclerotherapy.
- Hepatic encephalopathy. The main goal of treatment for hepatic encephalopathy is to deal with the contributing variables. With the help of rifaximin and lactulose, patients with hepatic encephalopathy typically experience improvements.
- Hepatorenal syndrome. To reverse acute kidney injury in CLF, the main objective is to address the underlying causes. The intensity and location of the patient influence the treatment options. Norepinephrine, terlipressin, midodrine, and octreotide with albumin infusion are all possible treatment options.
- Hepatocellular carcinoma (HCC). The management of HCC is based on the Barcelona clinic’s stage approach for liver cancer, which includes:
- Resection and ablation at the initial stage (single HCC lesion)
- Transarterial chemoembolization and radio-embolization are intermediate stages
- Sorafenib for metastatic illness
Nursing Considerations on Liver Failure
Supporting body systems, controlling symptoms of decreasing liver function, providing emotional support, and avoiding the worsening of cerebral edema are the main nursing care goals for patients with liver failure.
- Monitor the signs and symptoms, blood pressure, volume status, coagulation tests, and level of consciousness.
- Maintain a 30-degree elevation in the bed’s head while the patient’s head is in a neutral position.
- Reduce stimulation, such as repeated suctioning.
- Assess for the presence of hypoxia and hypercapnia; treat these symptoms as directed and appropriate.
- Use a cooling blanket, fan, or both to aggressively combat fever.
- Monitor for infection-related symptoms and possible sepsis; give antibiotics as directed.
- Continue to closely monitor the patient’s blood glucose levels for any signs of hypo- or hyperglycemia.
- Deliver nutritional assistance as directed.
ICP monitoring is necessary for patients whose acuity level necessitates it (such as those in an intensive care unit with grade 3 or 4 hepatic encephalopathies).
Nursing Diagnosis for Liver Failure
Liver Failure Nursing Care Plan 1
Nursing Diagnosis: Excess Fluid Volume related to compromised regulatory system [e.g., syndrome of inappropriate antidiuretic hormone (SIADH), decreased plasma proteins, malnutrition, and excessive fluid/sodium intake secondary to liver failure as evidenced by weight increase, anasarca and edema, increases in urine specific gravity, oliguria, and intake that is higher than output, dyspnea, pleural effusion and adventitious breath noises, changes in BP and CVP, positive hepatojugular reflex or JVD, altered amounts of electrolytes, alteration in mental state, and excessive fluid/sodium intake
Desired Outcome: The patient will demonstrate a stable fluid volume, balanced I&O, stable weight, vital signs within the patient’s normal range, and absence of edema.
| Nursing Interventions for Liver Failure | Rationale |
| Take note of the patient’s input and output – I&O measurements, daily weights, and a weight gain of more than 0.5 kg/day. | To evaluate the state of the circulating blood volume, the emergence or disappearance of fluid changes, and the response to the therapeutic regimen. Positive weight gain and balance often indicate ongoing fluid retention. Note: Hepatorenal syndrome can occur from decreased circulation volume (fluid shifts), which can directly impair renal function and urine output. |
| Monitor the patient’s blood pressure (and CVP if available). Note for signs of JVD and abdominal vein distention. | Although fluid transfers out of the vascular area can prevent BP rises from happening, fluid volume excess is typically associated with it. Vascular congestion is linked to stomach and external jugular vein distension. |
| Assess the patient’s respiratory status. Note the presence of increased respiratory rate (tachypnea) and shortness of breath (dyspnea). | This is a sign of pulmonary obstruction. |
| Auscultate the patient’s lungs and listen for developing adventitious noises as well as reduced breath sounds. | Consolidation, poor gas exchange, and problems may occur when lung congestion increases. |
| Observe and monitor for cardiac dysrhythmias. Observe the development of the S3/S4 gallop rhythm by auscultating the heartbeat. | Electrolyte imbalance, reduced coronary arterial perfusion, and HF may all be precipitating factors. |
| Analyze the extent of peripheral edema. | Contributory factors leading to fluid shift into tissues include sodium and water retention, decreased albumin, and increased antidiuretic hormone (ADH). |
| Measure the patient’s abdominal girth. | It reflects the buildup of fluid (ascites) caused by the leakage of plasma proteins or fluid into the peritoneal cavity. Note: An excess of fluid might constrict circulation, resulting in a deficit (signs of dehydration). |
| When ascites is present, promote bed rest. | It may encourage diuresis brought on by recumbency. |
| Monitor the patient’s serum electrolytes and albumin levels (particularly potassium and sodium). | Edema develops as a result of decreased serum albumin’s impact on the osmotic pressure of plasma colloid. Different electrolyte shifts/imbalances may result from decreased renal blood flow, higher levels of ADH and aldosterone, and the use of diuretics (to lower total body water). |
| Monitor the patient’s serial chest radiographs. | Pleural effusions, pulmonary edema, and vascular congestion are common. |
| Limit sodium and fluid consumption as necessary. | To reduce fluid retention in extravascular areas, sodium intake may be decreased. Dilutional hyponatremia may require fluid restriction to be treated. |
| Use plasma expanders and salt-free albumin as directed. | Albumin can be used to raise the colloid osmotic pressure in the vascular compartment, increasing effective circulating volume and reducing ascites development by drawing fluid into the vascular space. |
Liver Failure Nursing Care Plan 2
Imbalanced Nutrition: Less than Body Requirements
Nursing Diagnosis: Imbalanced Nutrition: Less Than Body Requirements related to inability to metabolize or digest foods due to an inadequate diet, early satiety, anorexia, nausea/vomiting, indigestion (ascites), and abnormal bowel movements secondary to liver failure as evidenced by weight loss, alterations in bowel movements and sounds, atrophy or poor muscular tone, and imbalances in nutritional studies
Desired Outcomes:
- The patient will demonstrate progressive weight gain toward the desired outcome using patient-appropriate laboratory value normalization,.
- The patient will no longer exhibit any signs of malnutrition.
| Nursing Interventions for Liver Failure | Rationale |
| Determine the patient’s dietary intake by calorie count monitoring. | This provides crucial data on intake, requirements, and deficits. |
| As directed, determine the patient’s weight. Compare the measurements of the skinfolds, recent weight history, and fluid status changes. | In light of edema and/or ascites, it could be challenging to use weight as a direct measure of nutritional status. Skinfold measurements are helpful in determining changes in subcutaneous fat stores and muscle mass. |
| Encourage the patient to eat by outlining the benefits of various diets. If the patient is easily fatigued, feed them or have the SO help them. Include the patient in meal preparation so that his or her food preferences can be taken into account. | Diet and nutrition improvements are essential for healing. If family members are involved, and favorite foods are included as much as feasible, the patient may eat better. |
| Encourage the patient to consume all of their meals, including any supplementary feedings. | Because of nausea, widespread weakness, or malaise, the patient may pick at their food or take only a few bites. |
| Serve the patient small, frequent meals. | Increased intra-abdominal pressure and ascites may contribute to a poor ability to tolerate larger meals (if present). |
| If permitted, offer salt replacements; avoid those that include ammonium, if allowed. | Ammonia increases the risk of encephalopathy while salt substitutes improve the flavor of food and help increase appetite. |
| Limit the patient’s intake of foods that are excessively hot, cold, gas-producing, spicy, or caffeine-containing. | Reduces stomach irritation, diarrhea, and discomfort in the abdomen that could affect oral intake. |
| If necessary, suggest soft foods and steer clear of roughage. | Advanced cirrhosis patients may experience esophageal varices-related bleeding. |
| Encourage regular oral hygiene, particularly before meals. | Anorexia is exacerbated by the patient’s propensity for sore and/or bleeding gums and poor breath. |
| Encourage uninterrupted rest times, particularly before meals. | Energy conservation encourages cellular regeneration and lowers the metabolic demands placed on the liver. |
| Encourage people to stop smoking. Inform people about the potential drawbacks of smoking. | Reduces excessive stomach stimulation, danger of irritation, and bleeding potential. |
| Monitor the following laboratory tests: serum glucose, pre- and albumin, total protein, and ammonia. | Reduced gluconeogenesis, low glycogen reserves, or insufficient ingestion can all lead to lower glucose levels. Reduced hepatic synthesis, poor metabolism, or loss into the peritoneal cavity could all contribute to low protein levels (ascites). Restricting protein consumption may be necessary to lower ammonia levels and avoid potentially fatal consequences. |
| Monitor the patient’s NPO status whenever necessary. | In order to lessen the burden on the liver and the formation of ammonia and urea in the GI tract, GI rest may initially be necessary in critically ill patients. |
Liver Failure Nursing Care Plan 3
Nursing Diagnosis: Ineffective Breathing Pattern related to collection of intra-abdominal fluid (ascites), reduced lung expansion, the buildup of secretions, reduced energy, and weariness secondary to liver failure
Desired Outcome: The patient will maintain an efficient breathing pattern, be free of cyanosis and dyspnea, and have satisfactory ABG and vital capacity readings.
| Nursing Interventions for Liver Failure | Rationale |
| Monitor the patient’s breathing depth, pace, and exertion. | Hypoxia and/or fluid buildup in the belly may cause rapid, shallow breathing or dyspnea to manifest. |
| Auscultate the patient’s lungs and observe the presence of crackles, wheezes, and rhonchi. | These may be a sign of difficulties arising. A buildup of fluids or secretions may be indicated by the presence of atypical breath sounds. Atelectasis is indicated by reduced or absent noises. |
| Examine alterations in consciousness. | Alterations in mentation could be caused by hypoxia and respiratory failure, which frequently come along with a hepatic coma. |
| Maintain an elevated bed head. Take a side position. | This reduces the danger of aspirating secretions while facilitating breathing by relieving strain on the diaphragm. |
| Encourage regular shifting of positions, deep breathing exercises, and coughing drills. | Aids in lung expansion and secretion mobilization. |
| Observe the temperature. Take note of the presence of chills, increased coughing, and changes to the color and nature of sputum. | Indicates the beginning of an infection, particularly pneumonia. |
| Monitor the patient’s vital capacity measures, chest x-rays, pulse oximetry, and serial ABGs. | Reveals modifications in respiratory condition and the emergence of pulmonary problems. |
| As directed, give extra oxygen. | Mechanical ventilation may be necessary to treat or prevent hypoxia if breathing and oxygenation are insufficient. |
| Give a respiratory adjunct demonstration and offer assistance. | Lowers atelectasis occurrence and increases secretion mobilization. |
Liver Failure Nursing Care Plan 4
Nursing Diagnosis: Disturbed Body Image related to biophysical modifications or altered appearance, prognosis uncertainty and modifications to role function, individual susceptibility, and a self-destructive attitude (alcohol-induced disease) secondary to liver failure as evidenced by expression of lifestyle modification or restriction, apprehension of others’ judgment or response, negative thoughts regarding one’s appearance or ability, and the sensation of being helpless, despairing or powerless.
Desired Outcomes:
- The patient will declare their acceptance of changes and of themselves in the here and now.
- The patient will determine their feelings and coping mechanisms for a negative self-perception.
| Nursing Interventions for Liver Failure | Rationale |
| Encourage the expression of worries and fears by talking about the circumstance. Describe the connection between the disease’s nature and its symptoms. | When the cause is linked to alcohol or other drug usage, the patient may feel guilty as well as particularly sensitive to physical changes in their body. |
| Support and encourage the patient; give care with a positive demeanor. | Caretakers must make every effort to make the patient feel appreciated as a person since they occasionally allow judgmental feelings to interfere with patient care. |
| Encourage family or carer to express emotions verbally, visit without restriction, and take part in caring. | Family members may be afraid of the patient’s approaching death and may feel responsible over the patient’s condition. They need unrestricted access to patients as well as nonjudgmental emotional support. Participation in care fosters trust between staff, patients, and carer and makes them feel productive. |
| Help the patient or carer adjust to the change in appearance by recommending attire that will not draw attention to the change in look (color of clothes, etc). | Jaundice, ascites, and ecchymotic regions may give the patient an unpleasant aspect. Supporting a patient might help them feel more confident and in control of their situation. |
| Consult the assistance programs. Assistance may come from therapists, mental resources, social services, clergy, and alcohol treatment programs. | Additional professional resources may be needed due to the illness’s increased vulnerability and concerns. |
Liver Failure Nursing Care Plan 5
Nursing Diagnosis: Deficient Knowledge related to lack of awareness/recall, incorrect information interpretation, and lack of experience with information sources secondary to liver failure as evidenced by questions, information requests, and statements of misconceptions, incorrect execution of instructions or the emergence of avoidable difficulties.
Desired Outcomes:
- The patient will explain his/her understanding of the disease’s course, prognosis, and complications.
- The patient will link the symptoms to the underlying causes.
- The patient will determine/start the necessary lifestyle modifications, and take part in the care.
| Nursing Interventions for Liver Failure | Rationale |
| Review the disease’s course, its prognosis, and its outlook. | This offers a knowledge base so the patient can make educated decisions. |
| Refer the patient to a nutritionist or dietitian. | Patients with cirrhosis require regular monitoring and dependable nutritional advice. |
| Stress the value of abstaining from alcohol. If necessary, identify local alcohol rehabilitation centers. | The main factor contributing to the cirrhosis epidemic is alcohol. |
| The importance of using only medications prescribed or approved by a healthcare professional who is knowledgeable about the patient’s history should be explained to the patient along with the altered effects of medications due to cirrhosis. | Some medications are hepatotoxic (especially narcotics, sedatives, and hypnotics). Additionally, a damaged liver is less able to digest all medications, which might increase the cumulative effect and/or aggravate bleeding tendencies. |
| Review the process for keeping a peritoneovenous shunt operating when one is present. | After inserting a Denver shunt, the patient must periodically pump the chamber to keep the device open. Patients with a LeVeen shunt may do a Valsalva technique or wear an abdominal binder to keep the device functioning. |
| Help the patient find a support person (s). | Support networks are crucial for maintaining behavior changes due to the length of recovery, risk of relapse, and sluggish convalescence. |
| Emphasize the importance of follow-up care and therapeutic regimen adherence. | Because of its chronic nature, the disease may develop potentially fatal consequences. gives the chance to assess the success of the regimen, including the patency of the shunt if one is being utilized. |
| Talk about the limitations on salt substitutes and sodium as well as the need of reading food and OTC medicine labels. | This reduces the production of ascites and edema. Other electrolyte imbalances could be caused by using replacements excessively. Alcohol or sodium may be present in food, over-the-counter, and/or personal care items (such as some mouthwashes and antacids). |
Nursing References
Ackley, B. J., Ladwig, G. B., Makic, M. B., Martinez-Kratz, M. R., & Zanotti, M. (2020). Nursing diagnoses handbook: An evidence-based guide to planning care. St. Louis, MO: Elsevier. Buy on Amazon
Gulanick, M., & Myers, J. L. (2022). Nursing care plans: Diagnoses, interventions, & outcomes. St. Louis, MO: Elsevier. Buy on Amazon
Ignatavicius, D. D., Workman, M. L., Rebar, C. R., & Heimgartner, N. M. (2020). Medical-surgical nursing: Concepts for interprofessional collaborative care. St. Louis, MO: Elsevier. Buy on Amazon
Silvestri, L. A. (2020). Saunders comprehensive review for the NCLEX-RN examination. St. Louis, MO: Elsevier. Buy on Amazon
