Cirrhosis of the Liver Flashcards
Functions of the Liver
- Detoxification
- Production
- Metabolism
- Storage
- Endocrine function
- Excretion of bile
Define cirrhosis
- Chronic, progressive disease
- Destruction of the liver parenchymal cells
- Liver attempts to regenerate following inflammation; scar tissue develops in place of functioning cells
- Eventually, irregular and disorganized liver regeneration, poor cellular nutrition, and hypoxia (from inadequate blood flow and scar tissue) result in decreased functioning of the liver.
- The development of cirrhosis is an insidious, prolonged course, usually after decades of chronic liver disease.
- Cirrhosis (combined with chronic liver diseases) is ranked as the eighth leading cause of death in the United States.
- Cirrhosis is twice as common in men as in women.
Etiology and Pathophysiology
- Biliary causes of cirrhosis include primary biliary cirrhosis and primary sclerosing cholangitis. Primary sclerosing cholangitis is a chronic inflammatory condition affecting the liver and bile ducts that is frequently found in men.
- Cardiac cirrhosis includes a spectrum of hepatic derangements that result from long-standing, severe right-sided heart failure. The treatment is aimed at managing the patient’s underlying heart failure.
Clinical Manifestations - Early Signs
Anorexia or weight loss due to decreased appetite
Dyspepsia or heartburn
Flatulence/abdominal pain
Nausea/vomiting
Change in bowel habits
Fever
Lassitude or extreme fatigue. Client will have no energy, nor desire, for activity
Enlarged liver or spleen
Clinical Manifestations - Late Signs
Some common clinical manifestation in the late stages of cirrhosis are similar to early stages, but have become more progressive.
- Anorexia
- Dyspepsia
- N/V
- Abdominal pain
- Fetor hepaticus, other wise known as “the breath of death”, which is foul and can often times smell like feces
- Varices, including Esophageal, Gastric, and Hemorrhoid which are dilated veins caused by elevated pressure in the portal venous system. Bleeding is the biggest concern in varices due to increased risk for varices abrasion.
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Hematemesis which is blood in the vomit
Cirrhosis of the Liver - Late Signs
Integumentary:
- Jaundice: Decreased ability of liver cells to conjugate and excrete bilirubin
- Spider angiomas: Small dilated blood vessels with bright red center and spiderlike branches; Nose, cheeks, upper trunk, neck, shoulders
- Palmar erythema: Red area on palms of bands that blanches with pressure
- Purpura Petechiae
Hematologic:
- Anemia
- Thrombocytopenia
- Leukopenia
- Coagulation disorders
- Splenomegaly
Metabolic:
- Potassium deficiency
- Hyponatremia/hypernatremia
- Hypoalbuminemia
Cardiovascular:
- Portal hypertension: caused by an increase in venous pressure leading to blood flow obstruction in and out of the liver
- Fluid retention
- Peripheral edema
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- Ascites: the accumulation of fluid in the peritoneal or abdominal cavity, presenting a protuberant abdomen; manifested by abdominal distention with weight gain; abdominal striae with distended abdominal wall veins may be present.
Reproduction:
- Amenorrhea
- Testicular atrophy
- Gynecomastia or enlarged mammary glands in males
- Impotence
Neurologic:
- Hepatic encephalopathy: a neuropsychiatric condition due to excessive ammonia buildup in the blood. It can lead to such conditions as insomnia, mental status changes, inappropriate behaviors, and trouble concentrating, to name a few
- Peripheral neuropathy: the inability to of the client to hold both upper extremities in the fully extended position for a period of time. If you instruct client to do a Frankenstein pose and hold.. The hands will begin flapping
- Asterixis
Lab Findings for the Liver
Expected findings - ↑ or ↓
AST (SGOT), ALT (SGPT), GGT
Albumin
Protein
Ammonia (NH3)
PT
Billirubin
Nursing Assessment
- Past health history: chronic alcoholism, viral hepatitis
- Physical examination
- Medications
- Weight loss
- Jaundice or yellowing of skin due to deposits of bilirubin in the blood
- Abdominal distention
- Nausea/vomiting
- Altered mentation
- Right upper quadrant pain
- Abnormal laboratory values
Nursing Diagnoses
- Imbalanced nutrition: Less than body requirements
- Impaired skin integrity
- Ineffective breathing pattern
- Excess fluid volume
- Dysfunctional family processes: Alcoholism
Nursing Management Planning
- Relief of discomfort
- Minimal to no complications
- Return to as normal a lifestyle as possible
- Protein supplements for protein-calorie malnutrition
- Low-sodium diet for patient with ascites and edema
- Anorexia is a major concern in cirrhosis. Clients have minimal to no appetite, so the use of appetite stimulants and small portion, high calorie, and high protein meals is important.
Nursing Management Implementation
- Providing education on alcohol cessation
- Treat alcoholism—ABSTAIN- abstinence is the best treatment, especially in early stages
Identify hepatitis early and treat - Stress importance of adequate nutrition
AND - Identify biliary disease early and treat
Nutritional Therapy
Diet for patient without complications:
- High in calories (3000 cal/day)
- ↑ Carbohydrate
- Moderate to low fat
- Protein restriction rarely justified
- Soft diet
- Small frequent meals
- Encouraging a soft diet is also important to reduce the risk of developing bleeding esophageal varices
Nursing Implementation
Acute Interventions include:
- Rest to reduce fatigue by encouraging naps
- Oral hygiene to reduce fetor hepaticus odor
- Between-meal nourishment
- Dietary restrictions explained: Low sodium, high calorie, adequate protein
- Medication therapy
- Monitor for fluid and electrolyte disturbances & bleeding disorders
- Accurate I/Os
- Daily weights to assess for increase fluid retention
- Abdominal girth measurement to assess for increased fluid retention. A simple tape measure is all that it is required and part of cirrhosis nursing management
- Extremities measurement for fluid retention and elevation of lower extremities to reduce edema
- Relief of dyspnea: Place client in Semi- or high Fowler’s position to reduce diaphramic pressure on thoracic cavity
- Appropriate skin care, such as: a Special mattress or a Turning schedule, at least every 2 hours
- Hepatic encephalopathy: maintain safe environment, assess carefully; level of responsiveness (Levels of consciousness and behavior disturbances can change on a daily basis and are proportionate to levels of fluid retention and stage of cirrhosis); Sensory and motor abnormalities
- Ambulatory and home care: Supportive measures, proper diet, rest
- Avoidance of hepatotoxic OTC drugs: acetaminophen, and abstinence from alcohol; abstinence from alcohol is important and results in improvement in most patients. Achieving abstinence from alcohol is difficult for some patients. Explore your own attitude regarding the patient whose cirrhosis is attributed to alcohol abuse.
- Abstinence from alcohol
- The patient with cirrhosis may be faced with a prolonged course and the possibility of serious, life-threatening problems and complications. The patient and caregiver need to understand the importance of continuous health care and medical supervision.
- Care should be given without rejection and moralizing. Treat the patient with a caring attitude.
Nursing Evaluation
- Maintain food and fluid intake adequate to meet nutritional needs
- Maintain skin integrity with relief of edema and pruritus
- Experience normalization of fluid balance as a result of medical and nursing interventions
- Acknowledge and get treatment for a substance abuse problem
