- Comprehend the pathophysiology of cirrhosis, including the structural changes in the liver and the implications for overall health.
- Recognize and assess the various risk factors contributing to the development of cirrhosis, such as chronic alcohol consumption, viral hepatitis, or nonalcoholic fatty liver disease.
- Learn to identify the clinical manifestations of cirrhosis, including signs of liver dysfunction such as jaundice, ascites, and hepatic encephalopathy.
- Understand preventive measures and interventions to minimize complications associated with cirrhosis, such as variceal bleeding, hepatic encephalopathy, and hepatorenal syndrome.
- Develop a holistic approach to care that addresses not only the physiological aspects of cirrhosis but also the psychosocial impact on the patient and their family.
Pathophysiology of Cirrhosis
- Liver Fibrosis:
- Cirrhosis is characterized by extensive scarring (fibrosis) of the liver tissue, disrupting its normal architecture and impairing function.
- Prolonged exposure to various insults, such as chronic alcohol abuse, viral hepatitis, or fatty liver disease, leads to continuous liver injury and inflammation.
- The liver attempts to repair itself by forming regenerative nodules. However, this process contributes to the development of a nodular, lumpy texture in the liver.
- Progressive fibrosis disrupts the normal blood flow through the liver, leading to increased pressure in the portal vein (portal hypertension).
- As cirrhosis advances, hepatocytes (liver cells) are replaced by scar tissue, impairing the liver’s ability to perform vital functions, such as detoxification, synthesis of proteins, and storage of glycogen. This results in systemic complications affecting multiple organ systems.
Etiology of Cirrhosis
- Alcohol Abuse:
- Chronic and excessive alcohol consumption is a leading cause of cirrhosis, causing direct damage to liver cells.
- Chronic infection with hepatitis B or C viruses can lead to persistent inflammation and scarring of the liver.
- Accumulation of fat in the liver, often associated with obesity and metabolic syndrome, can progress to cirrhosis.
- Conditions like autoimmune hepatitis, primary biliary cirrhosis, and primary sclerosing cholangitis involve the immune system mistakenly attacking liver cells, leading to cirrhosis.
- Inherited conditions, such as hemochromatosis (excessive iron absorption) or Wilson’s disease (copper accumulation), can contribute to cirrhosis.
Desired Outcome for Cirrhosis
- Manage Symptoms:
- Alleviate symptoms such as fatigue, abdominal pain, and jaundice to improve the patient’s overall well-being.
- Minimize the risk of complications, including portal hypertension, ascites, and hepatic encephalopathy, through proactive management.
- Implement strategies to slow the progression of cirrhosis and preserve liver function.
- Address malnutrition and optimize nutritional intake to support liver function and overall health.
- Improve the patient’s quality of life by addressing physical, emotional, and social aspects of living with cirrhosis.
- Support the patient in adhering to prescribed medications to manage cirrhosis and related conditions effectively. Ensure understanding of medication regimens and address any barriers to adherence.
- Prevent fluid imbalances by closely monitoring fluid intake and output. Implement measures to manage fluid retention and prevent complications associated with fluid overload or depletion.
- Establish a regular follow-up schedule for ongoing monitoring of liver function, symptoms, and potential complications. Timely assessments allow for prompt intervention and adjustments to the care plan as needed
Cirrhosis (Liver) Nursing Care Plan
Subjective Data:
- The patient may not have symptoms
- RUQ abdominal pain
- Fatigue
- Poor appetite
- Nausea
- Itchy skin
Objective Data:
- Bruising and bleeding easily
- Confusion or memory loss
- Dependent edema
- Ascites
- Jaundice
- Dark-colored urine
- Spider-like blood vessels on the skin
- Clay-colored stool
- Asterixis (flapping hand tremor)
- Decreased reflexes
- Anemia
- Malaise
- Hepatomegaly
- Splenomegaly
Nursing Assessment for Cirrhosis
- Medical History:
- Obtain a detailed medical history, including alcohol consumption, viral hepatitis, and exposure to liver-toxic substances.
- Evaluate and document symptoms such as fatigue, abdominal pain, nausea, vomiting, and changes in bowel habits.
- Assess the patient’s nutritional status, focusing on dietary habits, weight changes, and signs of malnutrition.
- Monitor fluid balance, paying attention to the presence of ascites, edema, or other signs of fluid retention.
- Review liver function tests, including serum bilirubin, albumin, and prothrombin time, to assess the degree of liver dysfunction.
- Assess mental status for signs of hepatic encephalopathy, such as confusion, altered consciousness, or personality changes.
- Examine the skin for jaundice, bruising, and signs of pruritus, which may indicate impaired liver function.
- Perform a thorough abdominal examination to detect hepatomegaly, splenomegaly, or signs of ascites.
- Conduct a psychosocial assessment to identify stressors, coping mechanisms, and support systems. Evaluate the patient’s emotional well-being and provide resources for counseling or support groups as needed.
- Screen for current or past substance use, including alcohol, illicit drugs, or prescription medications. Assess the patient’s readiness for behavioral interventions or substance abuse treatment if applicable.
- Perform a cardiovascular assessment, focusing on blood pressure, heart rate, and signs of fluid overload or compromise. Cirrhosis can impact cardiovascular function, and early detection of related issues is crucial for comprehensive care
Implementation for Cirrhosis
- Maintain Fluid Balance
- Implement strict fluid balance monitoring to manage ascites and prevent dehydration.
- Implement fluid restriction if ordered, for example if ascites or edema is present.
- Paracentesis, liver biopsy, or other procedures may be indicated to diagnose and treat liver disease. Provide education and implement pre-procedure orders, such as NPO status and proper administer of medications.
- Collaborate with a dietitian to develop a nutrition plan based on the patient’s dietary preferences and restrictions.
- Consider enteral or parenteral nutrition if the patient is malnourished or unable to tolerate oral intake.
- Administer prescribed medications, such as diuretics, lactulose, and medications to manage complications like portal hypertension.
- Ensure compliance with medication regimens to control symptoms and prevent complications.
- Implement fall precautions or bleeding precautions, as indicated, depending on the patient’s status.
- Provide interventions to alleviate symptoms such as pruritus, fatigue, and abdominal pain.
- Administer medications as prescribed to address specific symptoms and improve the patient’s quality of life.
- Educate the patient and family about the nature of cirrhosis, treatment options, and the importance of adherence to medical recommendations.
- Provide emotional support and refer to support groups or counseling services if needed.
Nursing Interventions and Rationales
- Complete vitals and respiratory assessment
Note impaired gas exchange and compromised respiratory function Assess for decreased or labored breathing
- Monitor fluid and electrolyte balance
- Daily weights
- Assess for JVD
- Liver impairment may also affect renal function. Ascites and dependent edema may be indicators of hyponatremia.
- Increasing weight and blood pressure may indicate vascular congestion
- The decrease in weight and blood pressure may indicate the effectiveness of interventions
- Initiate bleeding precautions per facility protocol
- No straight razors
- Use a soft toothbrush and good oral hygiene
- Use stool softeners to avoid straining with bowel movements
Coagulation chemicals such as prothrombin and fibrinogen. Damage to the liver may alter the production of these chemicals and increase the risk of bleeding.
- Promote rest to conserve energy
Impaired liver function can cause the patient to be easily fatigued. Encourage rest periods and cluster care to conserve energy for nutrition and self-care.
- Assist with paracentesis as necessary
If ascites progresses, it may be necessary to perform paracentesis to drain the abdominal fluid. Assist with set-up and positioning of patient, post-procedure site assessments, and monitoring.
- Administer medications appropriately
- Diuretics
- Lactulose
- Analgesics
- Blood products
- Vitamin K
- Diuretics- are often given to manage the accumulation of fluid and edema
- Lactulose- a man-made sugar that is given to help reduce the amount of ammonia in the blood and prevent hepatic encephalopathy
- Analgesics- given to manage pain; avoid acetaminophen
- Blood products- excessive bleeding and complications following surgery may require blood transfusions
- Vitamin K- helps to promote clotting and avoid complications from bleeding
- Provide adequate nutrition and education, encourage lifestyle changes
Malnutrition is often a complication of liver disease but may go unnoticed due to an increase in weight. Encourage and educate patients to maintain a diet low in sodium and fat. Avoid alcohol, seek treatment for alcohol dependence.
Evaluation for Cirrhosis
- Assessment of Symptom Control:
- Evaluate the effectiveness of interventions in managing symptoms such as ascites, hepatic encephalopathy, and fatigue.
- Monitor the patient’s reported comfort level and adjust interventions as needed.
- Assess changes in the patient’s nutritional status and weight.
- Review dietary adherence and the impact on nutritional parameters.
- Evaluate the patient’s fluid balance and assess for improvements in edema and ascites.
- Monitor electrolyte levels and adjust interventions accordingly.
- Assess the patient’s adherence to prescribed medications for cirrhosis management.
- Evaluate any side effects or complications related to medication regimens.
- Evaluate the patient’s emotional well-being and assess for signs of depression or anxiety.
- Explore the patient’s support system and the effectiveness of support services provided.
References
- https://www.mayoclinic.org/diseases-conditions/cirrhosis/symptoms-causes/syc-20351487
- https://aasldpubs.onlinelibrary.wiley.com/doi/full/10.1002/cld.526
- https://www.niddk.nih.gov/health-information/liver-disease/cirrhosis/treatment
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Transcript
Hey guys, we're going to talk about cirrhosis and putting this into a nursing care plan. Alright, so first you have to collect all your information and all this is, is just your assessment, your gathering of your data. That's all this is.
So, our subjective data is coming from the patient. So, a patient with cirrhosis might complain of right upper quadrant pain. They might be super tired and complain of fatigue and they might have a poor appetite. They might have some nausea or itchy skin.
Now, the nurse is going to go on and get her objective data. So, her observations, her assessment pieces. So, perhaps we noticed some easily bruised skin, confusion, some memory problems or lots of edema, dependent edema, and that horrible ascites that occurs from all that extra fluid. We might notice them to be jaundice, right? That liver is having some liver problems and with cirrhosis, that jaundice that high bilirubins happens. I had a patient once that was literally as yellow as a highlighter from cirrhosis. So, she just glowed. So, jaundice is a big one. They might have some dark colored urine happening, or the super clay colored stool.
Alright, so all of these are things that we would see or observe on our assessment as a nurse on a patient with cirrhosis. Now, we're going to take this data and we're going to analyze it. So, analyze the information to help us diagnose and prioritize. So, what's the problem? Well, for our hypothetical patient, we can say that the lab work is off. Maybe we're seeing some high ammonia levels and then we also on our patient, see some horrible ascites. Our problem is also that our patient is an alcoholic, why not? We'll just add that to it. Okay, so that's our problem. What needs to be improved? What we need to do is improve the ammonia levels right? Those high ammonia levels are going to cause some confusion and not be good for the patient. We need to improve the swelling, that ascites, which is so uncomfortable for the patient and perhaps offer some education on alcohol and other items to help this patient. So, what's our priority? Well, our priority again, cirrhosis is there, it has already happened, but we can prevent further damage and then bring our ammonia levels down.
Okay, so now ask yourself the how questions. So, how do we know it is a problem? So, this is where you link your data. So, always with any care plan, you're going to link the data, link your assessment findings here. So, our data that we've linked, the ascites, we have the lab work showing the ammonia levels, we see jaundice, things like that. So, we're linking our data together.
How are we going to address it? So, we're going to monitor. Monitor some lab work, monitor the fluid electrolyte balance. We're going to give some diet education, we can give some meds to help. So, for instance, the diuretics that are often given to manage that accumulation of the fluid and edema, lactulose, which is that sugary drink that they will drink to get their ammonia levels out of their bloodstream and lower them ammonia, so those things are just some things that we can do to address the problem. And how am I going to know that it gets better? Well, because it's kind of a chronic thing, right? We're not going to completely cure this patient, but we can reduce the symptoms. So, things like the ammonia will come down. The ascites maybe will improve depending on whatever we're tackling as our problem. We'll know it gets better because that will get better. So, we're going to reduce the symptoms and prevent worsening of the problem.
Alright, let's translate. So, our high level nursing concepts. So, there are so many for this one. I think for cirrhosis, so the ones I'm gonna pick are lab values, fluid balance, and then I always love some patient education. Alright, let's look into this. So, we're going to take our nursing care plan, form, whatever you use, you got your problems, your priorities, the assessment pieces from the patient, and that you have assessed your intervention to fix this data. Your why, your rationale as to why this intervention should work and then what you expect to see happen.
Alright, so we have lab values, fluid balance and patient education. So, first our lab values. So, for this patient, we have high ammonia and we are noting that the patient is also anemic. So, we can give some lactulose, right? That's going to help bring down the ammonia levels and then put some iron into the diet or give iron supplements.
Now, our rationale… So, our why, well, the lactulose is going to remove excess ammonia and then put some iron into the diet, giving some iron supplements needed for red blood cell production. Our expected outcomes. We are going to have ammonia levels lowered and the anemia improves so our lab values will look better. Our fluid balance. So, this patient had data of some edema and some ascites occurring. Our interventions. Some diuretics to get rid of that fluid, daily weights and maybe a paracentesis, of course, if the provider orders, we're not just going to stick a needle in the belly, but we can assist. So our rationale… The diuretics will remove the excess fluid. We can do daily weights to monitor this progress and then the paracentesis to reduce ascites. So overall, our expected outcome for this will be to improve the edema Siamese and improve the vascular congestion occurring.
Our patient education… So this patient, we said that they are an alcoholic and they're malnourished, right? Well, one, if you're an alcoholic you're usually malnourished. Then two, these patients just, you know, they have that loss of appetite and even though they're super swollen and can be overweight, that doesn't mean that they're well-nourished.
So, our interventions. We might need to talk about some rehab or dependency education on the importance of not drinking, because we want to prevent further problems, and a low sodium and low fat diet. The rationale is, because this is going to prevent further damage, right? So, our expected outcomes as always with patient education is what the patient is going to verbalize or demonstrate and understand.
Alright, let's look at our key points here for care plans. So, first collect your information. This is going to be your assessment data that's subjective, and the objective data. Then you're going to analyze, that's going to help you diagnose and prioritize, ask your how questions so you can plan, implement and evaluate, and then translate. So, our concise terms, our concepts, and then use whatever form you prefer, so that you can transcribe and get it all on paper.
Alright guys, that was it for cirrhosis. Check out all our nursing care plans that we have available and the awesome videos on NURSING.com. Now, go out and be your best selves today and as always, happy nursing!
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