LIVER CIRRHOSIS
● a chronic, degenerative disease characterized by
replacement of normal liver tissue with diffuse fibrosis that
disrupts the structure and function of the liver
TYPES
A. Alcoholic Cirrhosis ( Laennec’s Cirrhosis)
○ Most common type of liver cirrhosis
○ Caused by chronic alcoholism
B. Postnecrotic cirrhosis
○ Late result of a previous bout of acute viral hepatitis ASSESSMENT: Clinical manifestations
C. Biliary cirrhosis S/Sx (Early)
○ Resulted from chronic biliary obstruction and ● anorexia, nausea, indigestion
infection ● aching or heaviness in right upper quadrant
○ Least common type ● weakness & fatigue
PREDISPOSING/PRECIPITATING FACTORS S/Sx (Late)
● Malnutrition ● abnormal liver function tests:
● Effects of alcohol abuse ○ ↑ bilirubin (N=0-0.9mg/dl)
● Chronic impairment of bile excretion – biliary obstruction in ○ AST (N=4.8-19U/L)
the liver and common bile duct (gallbladder stones) ○ ALT (N= 2.4-17U/L)
● Necrosis from hepatotoxins or viral hepatitis ○ Serum alkaline phosphatase (N=30-40U/L)
● Congestive heart failure ○ Ammonia (plasma) (N= 15-45umol/L)
● intermittent jaundice, pruritus
PATHOPHYSIOLOGY ● edema, ascites, prominent abdominal wall veins
● liver cell damage result in inflammation & hepatomegaly ● Ecchymosis, bleeding tendencies
● attempts at regeneration eventually result to fibrosis and a ● anemia
small nodular liver ● Infection
● hepatic function is slowly impaired ● Gynecomastia, testicular atrophy
● obstruction of venous channels blocks hepatic blood flow ● Neurologic changes
and cause portal hypertension
Assist with Paracentesis
Complications of Liver Cirrhosis ● have the client void before the procedure
1. Ascites ● high –fowlers position during the procedure
● abnormal intraperitoneal accumulation of watery fluid ● monitor pt. for hypovolemia & electrolyte imbalance
containing small amounts of protein ● observe puncture wound for leakage & signs of infection
● Due to
○ ↑ intravascular colloidal pressure 2. Hepatic Encephalopathy
● cerebral dysfunction assoc. with severe liver disease
○ ↑ capillary hydrostatic pressure
● inability of the liver to metabolize substances that can be
○ Na and H2O retention
toxic to the brain such as ammonia, which is produced by
○ Failure of the liver to metabolize aldosterone
the breakdown of protein in the intestinal tract
S/Sx
● abdominal enlargement, wt.
● fatigue
● abdominal discomfort, respiratory difficulty
Med. Mgt. (depending on severity of ascites)
✔Na+ & fluid restriction (500-1000 ml/day)
✔diuretic therapy (furosemide/ spironolactone)
✔Paracentesis – for diagnosis or when fluid volume compromise
comfort & breathing
Nursing Interventions to ↓ ascites & increase/promote comfort
✔ maintain on bed rest
✔ fluid & Na restriction
✔ monitor I/O, daily wt.
✔ measure abd. girth every shift
✔ Maintain high-Fowlers for max. respiration
✔ support abdomen with pillows
✔ administer diuretics, salt-poor albumin IV as ordered
- monitor for signs of CHF, pulmonary edema, dehydration,
electrolyte imbalance, hypersensitivity reaction
Encephalopathy 3. Esophageal Varices
S/Sx ● distention of the smaller blood vessels of the esophagus as a
● Asterixis - flapping hand tremors (early sign) result of portal hypertension – due to obstruction of venous
● LOC – lethargy progressing to coma circulation w/in the damaged liver
● mental status, confusion, disorientation ● the ↑ portal venous pressure causes blood to be forced into
● dullness, slurred speech these vessels – become tortuous and fragile
● behavioral changes, lack of interest in grooming/ appearance ● blood vessels become prone to injury by mechanical trauma
● twitching, muscular incoordination, tremors from ingestion of coarse food and acid pepsin erosion which
● Fetor hepaticus may result in bleeding
● elevated serum ammonia level ● bleeding may also occur as a result of coughing, vomiting,
sneezing, straining at stool or any physical exertion that
Hepatic Encephalopathy abdominal venous pressure
Interventions:
a. ↓ ammonia production S/Sx:
● ↓ dietary protein to 20-40 g/day, maintain adequate calories ▪ ● upper GI bleeding (hematemesis) - melena
● ↓ ammonia formation in the intestine – give laxative, enema ● massive hemorrhage
as ordered and Neomycin - ↓ bacterial ammonia production ● signs/symptoms of hypovolemic shock
b. Protect pt. from injury Med. Mgt.
● side rails up ✔ find the source of bleeding – esophagoscopy, angiography
● turning to side ✔ control bleeding
● assess mental status, LOC a. Gastric lavage, administration of antacid via NGT
● proper positioning (semi-Fowler’s) b. Surgical bypass procedures (splenorenal shunt)
● prevent aspiration c. Variceal band ligation (esophageal variceal ligation (EVL)
d. Endoscopic sclerotherapy or injection sclerotherapy
c.Prevent further episodes of encephalopathy e. Balloon tamponade
● low protein diet ● insertion of Sengstaken–Blakemore tube with
● prescribed medications gastric and esophageal balloon that are inflated to
● avoid constipation ( to ammonia production by bacteria in stop bleeding
the GIT)
● early signs of encephalopathy (restlessness, slurred speech,
dec. attention span)
POSSIBLE NURSING DIAGNOSES
● Activity intolerance R/T fatigue, lethargy, and malaise
● Imbalanced nutrition R/T abdominal distention and
discomfort, and anorexia
● Impaired skin integrity R/T pruritus from jaundice and
edema
● High risk for injury R/T altered clotting mechanisms and
altered LOC
● Disturbed body image R/T changes in appearance, sexual
dysfunction, and role function
● Chronic pain R/T enlarged tender liver and ascites
● Fluid volume excess R/T ascites and edema formation
● Ineffective breathing pattern R/T restriction of thoracic
excursion secondary to ascites and abdominal distention
NURSING INTERVENTIONS
1. Reduce metabolic demands on the liver
● provide bed rest
● eliminate ingestion of toxic substances to the liver: sedatives
opiates, alcohol, acetaminophen
● ↓ activities
2. Provide adequate nutrition & hydration
● Low – protein, high-carbohydrate, high calorie, sodium-
restricted diet
● multiple vitamin therapy
● restrict fluids & sodium if there is edema or ascites
● provide mouth care before meals
● monitor I/O, daily wt.
3. Prevent infection
● encourage good personal hygiene
● reverse isolation
● assess for signs of infection esp. urinary
● encourage deep breathing/position changes
4. Protect pt. from bleeding
● monitor urine, stool, gums, skin for signs of bleeding/
bruising
● avoid injections, apply pressure to venipuncture sites for at
least 5 mins.
● Monitor prothrombin time, bleeding time
● Teach pt. to use soft toothbrush, avoid constipation
● Prevent scratching from pruritus, proper skin care
● Administer Vit. K as ordered
