5 Essential Nursing Care Plans for Cirrhosis of Liver: Diagnoses and Interventions

Liver cirrhosis represents the advanced stage of liver disease, characterized by irreversible scarring that disrupts normal liver function. This condition arises from various chronic liver diseases, with common causes including prolonged alcohol abuse, non-alcoholic fatty liver disease linked to obesity and diabetes, and hepatitis infections. As a critical organ, the liver performs numerous vital functions, such as metabolism, detoxification, digestion, vitamin and mineral storage, and the production of clotting factors. When cirrhosis compromises these functions, severe complications like edema, ascites, splenomegaly, bleeding risks, infections, malnutrition, and hepatic encephalopathy can emerge.

Nurses play a pivotal role in the comprehensive care of patients with liver cirrhosis. Their responsibilities extend across symptom management, encompassing procedures like paracentesis, managing cognitive impairments from hepatic encephalopathy, ensuring adequate nutrition, and preparing patients for potential liver transplantation. Furthermore, patient education and emotional support are integral to helping individuals and their families navigate the complexities of living with cirrhosis and managing its associated complications.

This article delves into five essential nursing care plans tailored to address the most critical nursing diagnoses in patients with liver cirrhosis. These plans are designed to guide nurses in providing evidence-based care, optimizing patient outcomes, and enhancing their quality of life.

Nursing Assessment for Cirrhosis of Liver

Effective nursing care begins with a thorough assessment to gather subjective and objective data. This involves reviewing the patient’s health history, conducting a physical examination, and analyzing diagnostic findings.

Health History Review

1. Initial and Worsening Symptoms: Early symptoms of cirrhosis are often vague, including anorexia, fatigue, nausea, fever, weakness, and unintended weight loss. As liver function declines, more pronounced symptoms emerge, such as changes in mental status, easy bruising and bleeding, pruritus, jaundice, light-colored stools, and blood in the stool.

2. Abdominal Pain Characteristics: Patients may describe pain as sharp or dull throbbing in the right upper abdomen. Pain can also be generalized abdominal discomfort due to liver and spleen enlargement and ascites.

3. Risk Factor Identification: Modifiable risk factors are crucial to assess:

• Obesity: A major contributor to fatty liver disease.
• Sedentary lifestyle: Increases the risk of non-alcoholic fatty liver disease (NAFLD).
• Diet: High-fat diets and consumption of raw or undercooked meat or seafood can elevate risk.
• Smoking: Accelerates cirrhosis progression in hepatitis B and worsens fibrosis in hepatitis C.
• Alcohol consumption: A leading cause of hepatitis and subsequent cirrhosis.

4. Hepatitis History: Prior hepatitis B or C infections are significant, as they are common precursors to cirrhosis.

5. Medical History and Other Potential Causes: Beyond alcohol, fatty liver disease, and hepatitis, other causes include:

• Medications (e.g., methotrexate, isoniazid)
• Autoimmune hepatitis
• Cholestasis (primary biliary cholangitis, primary sclerosing cholangitis, biliary atresia, Alagille syndrome)
• Metabolic disorders (hemochromatosis, Wilson’s disease, alpha-1 antitrypsin deficiency, inherited glucose metabolism disorders)
• Cystic fibrosis
• Infections (syphilis, brucellosis)
• Chronic heart failure
• Amyloidosis

Physical Examination Findings

1. Comprehensive Physical Assessment: Key findings include:

• General: Fever, fatigue, weight loss, muscle wasting (cachexia).
• CNS: Decreased mentation and memory.
• HEENT: Jaundice (yellowish sclera).
• Respiratory: Decreased oxygen saturation, rapid breathing (hyperventilation).
• Gastrointestinal: Anorexia, nausea, portal hypertension signs (ascites, enlarged liver/spleen, abdominal vein swelling, blood in stool).
• Genitourinary: Dark urine, light-colored/greasy stools (steatorrhea).
• Reproductive: Reduced libido, gynecomastia, testicular atrophy (men), premature menopause (women).
• Hematologic: Bruising, bleeding, anemia, pancytopenia.
• Lymphatic: Peripheral edema.
• Integumentary: Jaundice, pruritus, palmar erythema, spider angiomas.

2. Liver Palpation: May reveal enlargement, tenderness, and masses.

3. Compensation Status: Distinguish between compensated (often asymptomatic) and decompensated cirrhosis (with overt symptoms of liver failure and portal hypertension).

Diagnostic Procedures

1. Blood Tests: Assess liver function indicators:

• Elevated liver enzymes (AST, ALT).
• Elevated bilirubin.
• Creatinine (kidney function).
• Complete blood count (CBC) for cytopenias.
• Hepatitis viral serology.
• Prolonged prothrombin time (PT/INR).

2. Liver Markers: Gamma-glutamyl transferase (GGT) elevation suggests liver or bile duct damage.

3. Hepatic Function Indicators: PT and serum albumin levels reflect liver synthetic function.

4. Imaging Scans:

• CT scan: Detects lesions and tumors.
• Ultrasound: Identifies nodules and increased echogenicity.
• Doppler ultrasound: Evaluates hepatic, portal, and mesenteric vein patency.
• MRI: Visualizes iron and fat deposition.
• Transient elastography (Fibroscan): Measures liver stiffness (fibrosis).
• ERCP: Assesses bile duct issues.
• Upper endoscopy: Detects varices and bleeding in the upper GI tract.

5. Liver Biopsy: Gold standard for diagnosis, grading (inflammation), and staging (fibrosis) of cirrhosis.

5 Nursing Care Plans for Cirrhosis of Liver

Based on common complications and patient needs in liver cirrhosis, here are five crucial nursing care plans:

1. Nursing Care Plan for Acute Confusion related to Hepatic Encephalopathy

Nursing Diagnosis: Acute Confusion

Related to: Hepatic encephalopathy (HE) secondary to liver cirrhosis, ammonia accumulation.

As evidenced by: Confusion, agitation, slurred speech, lethargy, impaired decision-making, lack of coordination, difficulty concentrating.

Expected Outcomes:

• Patient will maintain orientation to person, place, and time.
• Patient will demonstrate improved cognitive function as evidenced by clear communication and appropriate responses.
• Patient will adhere to treatment plan to manage hepatic encephalopathy.

Assessments:

1. Monitor Neurological Status Regularly: Assess level of consciousness using Glasgow Coma Scale (GCS), orientation, memory, and presence of asterixis (liver flap).
2. Evaluate Serum Ammonia Levels: Track ammonia levels as indicators of HE severity, noting trends and correlations with mental status changes.
3. Review Liver Function Tests (LFTs): Assess bilirubin, AST, ALT, albumin, and PT/INR to understand the extent of liver dysfunction contributing to HE.
4. Assess for Precipitating Factors: Identify potential triggers for HE, such as infection, constipation, GI bleeding, electrolyte imbalances, and medication non-adherence.

Interventions:

1. Administer Lactulose as Prescribed: Give lactulose to promote ammonia excretion through stools. Monitor bowel movements and adjust dose to achieve 2-3 soft stools per day.
2. Implement Protein-Modified Diet: Collaborate with a dietitian to provide a diet that restricts protein intake if necessary, based on HE severity, and ensure adequate caloric intake from non-protein sources.
3. Ensure Safety Measures: Implement fall precautions, bed alarms, and side rail use as needed. Provide a safe, clutter-free environment due to altered mental status and coordination.
4. Orient Patient Frequently: Reorient patient to time, place, and person regularly. Use visual aids and familiar objects to enhance orientation.
5. Maintain Calm Environment: Reduce environmental stimuli and noise to minimize agitation and confusion. Promote rest periods and a consistent daily routine.
6. Educate Patient and Family: Explain HE, its causes, and management strategies. Teach family members to recognize early signs of HE worsening and the importance of medication adherence and dietary modifications.

:max_bytes(150000):strip_icc():format(webp)/195973_0491_NursePatientTeaching_final-088cb40000e14a9ca35414514b96a856.jpg)
Alt Text: A nurse is explaining medication instructions to a patient to ensure they understand their treatment plan for managing cirrhosis.

2. Nursing Care Plan for Ineffective Breathing Pattern related to Ascites and Hepatomegaly

Nursing Diagnosis: Ineffective Breathing Pattern

Related to: Ascites, hepatomegaly, and increased intra-abdominal pressure secondary to liver cirrhosis.

As evidenced by: Dyspnea, tachypnea, orthopnea, decreased oxygen saturation, use of accessory muscles for breathing.

Expected Outcomes:

• Patient will demonstrate a respiratory rate within normal limits (12-20 breaths per minute).
• Patient will maintain oxygen saturation ≥95% on room air or supplemental oxygen as needed.
• Patient will report reduced dyspnea and improved breathing comfort.

Assessments:

1. Monitor Respiratory Rate, Depth, and Effort: Assess breathing pattern, noting tachypnea, shallow breaths, labored breathing, and use of accessory muscles.
2. Auscultate Breath Sounds: Listen for adventitious breath sounds such as crackles or diminished breath sounds, indicating fluid overload or atelectasis.
3. Measure Oxygen Saturation (SpO2): Continuously or intermittently monitor SpO2 to detect hypoxemia.
4. Assess for Orthopnea and Position of Comfort: Determine if patient experiences shortness of breath while lying flat and identify positions that ease breathing.
5. Monitor Abdominal Girth: Measure abdominal girth daily to track ascites progression and its impact on respiratory function.

Interventions:

1. Elevate Head of Bed: Position patient in a semi-Fowler’s or high-Fowler’s position to reduce pressure on the diaphragm and improve lung expansion.
2. Administer Supplemental Oxygen as Ordered: Provide oxygen therapy via nasal cannula or mask to maintain adequate oxygenation if SpO2 is below prescribed levels.
3. Encourage Deep Breathing and Coughing Exercises: Instruct patient on techniques to promote lung expansion and clear secretions, preventing atelectasis.
4. Prepare for Paracentesis if Indicated: Assist with paracentesis to remove ascitic fluid, thereby reducing intra-abdominal pressure and improving diaphragmatic excursion.
5. Administer Diuretics as Prescribed: Give diuretics to reduce fluid overload and ascites, easing respiratory distress. Monitor electrolytes and renal function closely.
6. Provide Rest Periods: Ensure adequate rest to reduce oxygen demand and fatigue, which can exacerbate dyspnea.

:max_bytes(150000):strip_icc():format(webp)/GettyImages-1292857292-0d500858690a4b71a9602f48f00a2c37.jpg)
Alt Text: A nurse is helping a patient adjust their position in bed to a more upright sitting position to facilitate easier breathing due to complications from liver cirrhosis.

3. Nursing Care Plan for Risk for Impaired Skin Integrity related to Edema, Ascites, and Jaundice

Nursing Diagnosis: Risk for Impaired Skin Integrity

Related to: Edema, ascites, jaundice (bile salt deposition), and poor nutritional status secondary to liver cirrhosis.

As evidenced by: (Risk diagnosis – no evidence, but risk factors present: edema, ascites, jaundice, pruritus).

Expected Outcomes:

• Patient will maintain intact skin without signs of breakdown (redness, blistering, open areas).
• Patient will demonstrate understanding of skin protection measures.
• Patient will report reduced pruritus and discomfort.

Assessments:

1. Perform Daily Skin Assessment: Inspect skin for color changes (jaundice), edema, dryness, lesions, and signs of breakdown, particularly in pressure areas and edematous sites.
2. Evaluate for Pruritus: Assess the presence, severity, and distribution of itching. Note any skin excoriation from scratching.
3. Monitor Edema and Ascites: Assess and document the extent of peripheral edema and ascites. Measure abdominal girth regularly.
4. Assess Nutritional Status: Evaluate dietary intake, albumin levels, and signs of malnutrition, which can compromise skin integrity.

Interventions:

1. Implement Pressure Relief Measures: Use pressure-redistributing mattresses and cushions. Turn and reposition patient frequently (every 2 hours) to prevent pressure ulcers, especially in edematous areas.
2. Maintain Skin Hygiene: Provide gentle skin care using mild, pH-balanced cleansers. Avoid harsh soaps and hot water. Pat skin dry instead of rubbing.
3. Apply Emollients and Moisturizers: Apply non-irritating, fragrance-free moisturizers to keep skin hydrated, especially after bathing.
4. Manage Pruritus:
   • Keep skin cool with cool compresses or tepid baths.
   • Administer antipruritic medications (e.g., antihistamines, cholestyramine) as prescribed.
   • Advise patient to avoid scratching and keep nails short and clean.
   • Suggest loose, cotton clothing to minimize skin irritation.
5. Prevent Skin Trauma: Handle patient gently during transfers and procedures to avoid skin tears. Protect edematous limbs from injury.
6. Promote Adequate Nutrition and Hydration: Encourage a balanced diet rich in protein and vitamins to support skin health. Ensure adequate fluid intake unless contraindicated.

:max_bytes(150000):strip_icc():format(webp)/174157188-56a9d34a5f9b58b7d0ffc340.jpg)
Alt Text: A nurse is conducting a skin assessment on a patient’s arm, carefully checking for any indicators of skin integrity issues related to liver cirrhosis complications.

4. Nursing Care Plan for Ineffective Tissue Perfusion (Hepatic) related to Liver Damage

Nursing Diagnosis: Ineffective Tissue Perfusion (Hepatic)

Related to: Liver damage, scarring, and altered blood flow secondary to cirrhosis.

As evidenced by: Jaundice, ascites, elevated liver enzymes (initially), prolonged PT/INR, decreased albumin, variceal bleeding, hepatic encephalopathy.

Expected Outcomes:

• Patient will demonstrate stable vital signs and hemodynamic status.
• Patient will exhibit laboratory values within acceptable limits for liver function (or baseline).
• Patient will be free from complications of ineffective hepatic perfusion (e.g., variceal bleeding, encephalopathy).

Assessments:

1. Monitor Vital Signs and Hemodynamic Status: Regularly assess blood pressure, heart rate, and signs of hypovolemia or fluid overload.
2. Review Liver Function Tests (LFTs) and Coagulation Studies: Track trends in AST, ALT, bilirubin, albumin, PT/INR, and platelet count to monitor liver function and bleeding risk.
3. Assess for Signs of Hepatic Decompensation: Monitor for worsening jaundice, ascites, edema, encephalopathy, and variceal bleeding.
4. Assess for Signs of Bleeding: Observe for bruising, petechiae, bleeding gums, epistaxis, melena, hematemesis, and monitor hemoglobin and hematocrit levels.
5. Evaluate Fluid Balance: Monitor intake and output, daily weights, and assess for edema and ascites to manage fluid overload.

Interventions:

1. Administer Medications as Prescribed:
   • Diuretics (e.g., spironolactone, furosemide) to manage ascites and edema.
   • Beta-blockers (e.g., propranolol, nadolol) to reduce portal hypertension and prevent variceal bleeding.
   • Lactulose to manage hepatic encephalopathy.
   • Vitamin K to correct coagulopathies.
2. Monitor and Manage Fluid and Electrolyte Balance: Closely monitor serum electrolytes, especially sodium and potassium, and replace as needed. Restrict sodium intake as prescribed.
3. Prevent and Manage Bleeding:
   • Initiate bleeding precautions.
   • Administer blood products (platelets, fresh frozen plasma) as ordered for significant bleeding or coagulopathy.
   • Prepare for procedures to manage variceal bleeding (e.g., endoscopic band ligation, sclerotherapy, TIPS).
4. Optimize Nutritional Support: Provide a diet that is appropriate for liver disease, often low in sodium and potentially protein-modified depending on encephalopathy status. Ensure adequate caloric intake and vitamin supplementation.
5. Monitor Mental Status and Manage Encephalopathy: Assess neurological status frequently. Implement interventions for acute confusion as described in care plan #1.
6. Prepare for Liver Transplant Evaluation if Indicated: For patients with end-stage liver disease, assess candidacy and prepare for referral to a transplant center.

:max_bytes(150000):strip_icc():format(webp)/GettyImages-1255410828-5a15921b0c615e0037495618.jpg)
Alt Text: A healthcare professional is reviewing liver function test results on a digital tablet, analyzing data related to a patient’s cirrhosis condition.

5. Nursing Care Plan for Dysfunctional Family Processes: Alcoholism related to Alcoholic Cirrhosis

Nursing Diagnosis: Dysfunctional Family Processes: Alcoholism

Related to: Chronic alcohol abuse leading to alcoholic liver cirrhosis.

As evidenced by: Patient’s history of heavy alcohol use, denial of addiction, physical complications of cirrhosis (ascites, jaundice, malnutrition), and potential psychosocial issues (anxiety, depression, family conflicts, financial problems).

Expected Outcomes:

• Patient will acknowledge the impact of alcohol use on liver health and family processes.
• Patient will verbalize intent to engage in alcohol cessation and treatment.
• Patient will participate in rehabilitation programs and support groups.
• Family members will demonstrate understanding of alcoholism as a disease and engage in supportive behaviors.

Assessments:

1. Assess Alcohol Use History: Obtain a detailed history of alcohol consumption patterns, duration, and consequences. Use validated screening tools (e.g., AUDIT, CAGE).
2. Identify Stage of Change: Determine the patient’s readiness to change drinking behavior (precontemplation, contemplation, preparation, action, maintenance).
3. Evaluate for Alcohol Withdrawal Symptoms: Monitor for signs and symptoms of alcohol withdrawal syndrome (AWS), including tremors, anxiety, diaphoresis, tachycardia, hypertension, seizures, and delirium tremens (DTs). Use CIWA-Ar scale for assessment.
4. Assess Family Dynamics and Support System: Evaluate the impact of patient’s alcoholism on family relationships, roles, and functioning. Identify available social support and resources.
5. Monitor for Co-occurring Mental Health Conditions: Assess for anxiety, depression, and other mental health issues that may co-exist with alcoholism.

Interventions:

1. Manage Alcohol Withdrawal: Administer benzodiazepines (e.g., lorazepam, diazepam) as per protocol to manage AWS symptoms and prevent complications like seizures and DTs. Monitor vital signs and withdrawal severity closely.
2. Provide Motivational Interviewing and Counseling: Use motivational interviewing techniques to enhance patient’s readiness to change. Provide individual and/or group counseling to address addiction, coping skills, and relapse prevention.
3. Refer to Addiction Treatment Programs: Connect patient with inpatient or outpatient rehabilitation programs, Alcoholics Anonymous (AA), and other community resources for ongoing support.
4. Educate Patient and Family about Alcoholism: Provide education on the nature of alcoholism as a chronic disease, its effects on the liver and family, and the importance of abstinence and treatment.
5. Involve Family in Treatment Process: Encourage family members to participate in family therapy, Al-Anon, and other support groups to address codependency, improve communication, and support patient recovery.
6. Coordinate Multidisciplinary Care: Collaborate with physicians, social workers, dietitians, and mental health professionals to provide holistic care addressing physical, psychological, and social aspects of alcoholism and cirrhosis.
7. Prepare for Liver Transplant Evaluation (if applicable): For patients with end-stage alcoholic cirrhosis, assess transplant eligibility and emphasize the requirement of sustained alcohol abstinence for transplant consideration.

:max_bytes(150000):strip_icc():format(webp)/GettyImages-122289422-56a9d7b05f9b58b7d0ffc77e.jpg)
Alt Text: A support group meeting is in progress, where individuals affected by addiction are sharing and supporting each other in their recovery journeys.

Conclusion

These five nursing care plans represent essential frameworks for managing patients with liver cirrhosis. By addressing acute confusion from hepatic encephalopathy, ineffective breathing patterns due to ascites, risks to skin integrity, impaired hepatic tissue perfusion, and dysfunctional family processes related to alcoholism, nurses can significantly impact patient outcomes and quality of life. Utilizing these care plans in conjunction with ongoing assessment and individualized interventions ensures comprehensive and compassionate care for individuals navigating the complexities of liver cirrhosis. Continuous education, patient advocacy, and collaborative teamwork remain paramount in optimizing care for this challenging patient population.