Liver cirrhosis represents the irreversible scarring of the liver resulting from various liver diseases. This progression signifies a serious and complex condition, with alcoholic liver disease, fatty liver disease, and hepatitis being among the most prevalent underlying causes. Years of excessive alcohol consumption, fat accumulation often linked to obesity and diabetes, and viral hepatitis infections can all lead to chronic liver damage and ultimately cirrhosis. The liver’s crucial role in metabolism, detoxification, digestion, vitamin and mineral storage, and blood clotting underscores the severity of cirrhosis and its wide-ranging impact on bodily functions.
Complications of liver cirrhosis are extensive and include edema, ascites, splenomegaly, bleeding risks due to portal hypertension, infections, malnutrition, and hepatic encephalopathy, a condition arising from toxin buildup affecting brain function. Nurses play a pivotal role in managing these complex complications, providing critical care and support throughout the patient’s journey.
Nursing Process
Managing liver cirrhosis, particularly when stemming from alcoholic hepatitis, demands a comprehensive and multifaceted approach. Nurses are integral to this process, focusing on symptom management, which may involve procedures like paracentesis for ascites, addressing cognitive changes in hepatic encephalopathy, ensuring optimal nutrition, and preparing patients who may be candidates for liver transplantation. Education and emotional support are crucial components of nursing care, helping patients and their families navigate the challenges of living with cirrhosis and its complications, especially when related to alcohol dependence.
Nursing Assessment
The cornerstone of effective nursing care begins with a thorough nursing assessment. This involves systematically gathering physical, psychosocial, emotional, and diagnostic data to create a holistic picture of the patient’s condition. Understanding both subjective and objective data is vital in formulating appropriate nursing diagnoses and interventions for patients with liver cirrhosis, particularly those with alcoholic hepatitis.
Review of Health History
1. Document General Symptoms. Early symptoms of liver cirrhosis are often subtle and nonspecific. However, as liver function declines, characteristic signs and symptoms emerge. These can include coagulopathy, reflecting impaired hepatic synthetic function; variceal bleeding due to portal hypertension; and hepatic encephalopathy, indicating compromised liver detoxification capacity. Initial manifestations may present as:
- Anorexia
- Fatigue
- Nausea
- Fever
- Weakness
- Unintended weight loss
2. Identify Signs of Worsening Cirrhosis. As liver cirrhosis progresses, more pronounced symptoms develop, signaling advanced liver dysfunction. Late-stage symptoms include:
- Changes in mentation, such as confusion or disorientation, indicative of hepatic encephalopathy.
- Easy bruising and bleeding, reflecting impaired coagulation factor production.
- Pruritus (itchy skin), caused by bile salt accumulation.
- Jaundice, a yellowing of the skin and eyes due to bilirubin buildup.
- Light-colored stools, indicating bile flow obstruction.
- Blood in the stool, potentially from gastrointestinal bleeding due to varices.
3. Investigate Abdominal Pain. Abdominal pain associated with liver cirrhosis is often described as a sharp or dull throbbing sensation localized in the right upper quadrant, just below the ribs. Beyond ascites, the enlargement of the liver and spleen (hepatosplenomegaly) common in cirrhosis can contribute to generalized abdominal pain and discomfort. It’s crucial to differentiate this pain and assess its characteristics to inform appropriate pain management strategies.
4. Identify Risk Factors. Modifiable risk factors play a significant role in the development and progression of liver cirrhosis. Identifying and addressing these factors is key to preventative care and slowing disease progression. Key risk factors include:
- Obesity: A major contributor to non-alcoholic fatty liver disease (NAFLD), which can progress to cirrhosis. Obesity-related liver disease is increasingly common and often reversible in early stages, highlighting the importance of weight management.
- Sedentary lifestyle: Lack of physical activity elevates the risk of NAFLD, emphasizing the need for promoting regular exercise.
- Diet: Diets high in fats and consumption of raw or undercooked meat or seafood can increase the risk of liver disease and subsequent cirrhosis. Dietary counseling is crucial for patients at risk.
- Smoking: Smoking accelerates the progression of cirrhosis, particularly in individuals with hepatitis B or chronic hepatitis C. Smoking cessation is vital for liver health.
- Alcohol consumption: Excessive alcohol intake is a leading cause of liver disease, progressing from alcoholic hepatitis to cirrhosis. Understanding the patient’s alcohol history is paramount in assessing risk and guiding interventions. Alcohol abuse is a primary driver of alcoholic hepatitis and subsequent cirrhosis.
5. Check for Hepatitis History. Viral hepatitis, particularly hepatitis B and C, are significant causes of cirrhosis. A history of hepatitis infection is a critical risk factor to identify. Progression from chronic hepatitis to cirrhosis underscores the importance of early detection and management of viral hepatitis.
6. Obtain Medical History. Beyond the primary causes, a detailed medical history can reveal other contributing factors to liver cirrhosis. These include:
- Medications: Certain drugs like methotrexate or isoniazid can be hepatotoxic.
- Autoimmune hepatitis: An autoimmune condition attacking the liver.
- Cholestasis: Conditions affecting bile flow:
- Primary biliary cholangitis (PBC): Destruction of bile ducts.
- Primary sclerosing cholangitis (PSC): Hardening and scarring of bile ducts.
- Biliary atresia: Poorly formed bile ducts in infants.
- Alagille syndrome: Genetic disorder causing bile accumulation due to limited bile ducts.
- Metabolic disorders:
- Hemochromatosis: Iron overload.
- Wilson’s disease: Copper accumulation in the liver.
- Alpha-1 antitrypsin deficiency.
- Inherited glucose metabolism disorders (galactosemia, glycogen storage disease).
- Cystic fibrosis: Genetic disease causing thick mucus buildup, affecting the liver.
- Infections: Syphilis or brucellosis can, in rare cases, lead to liver damage.
- Chronic heart failure: Can cause liver congestion and damage.
- Amyloidosis: Abnormal protein buildup in the liver.
Physical Assessment
1. Conduct a Thorough Physical Exam. A comprehensive physical examination is crucial for identifying the diverse manifestations of liver cirrhosis. Key findings to note include:
- General: Fever, fatigue, unintended weight loss, muscle wasting (cachexia), reflecting the systemic impact of cirrhosis.
- CNS: Decreased mentation and memory, signs of hepatic encephalopathy.
- HEENT: Jaundice, evident as yellowish sclera (icterus) of the eyes.
- Respiratory: Decreased oxygen saturation, ventilation-perfusion mismatch, reduced pulmonary diffusion capacity, and rapid breathing (hyperventilation), potentially indicating hepatopulmonary syndrome or ascites-related breathing difficulty.
- Gastrointestinal: Loss of appetite, nausea, portal hypertension signs (ascites, esophageal varices), enlarged liver and spleen (hepatosplenomegaly), distended abdominal veins (caput medusae), ascites (fluid accumulation in the abdomen), blood in the stool (melena or hematochezia).
- Genitourinary: Brownish or orange urine, light-colored stools, greasy stools (steatorrhea), reflecting bilirubin and bile flow abnormalities.
- Reproductive: Decreased libido, gynecomastia (enlarged breasts) and testicular atrophy in men, premature menopause in women, due to hormonal imbalances.
- Hematologic: Easy bruising and bleeding, folate deficiency anemia, hemolytic anemia, hypersplenism (overactive spleen causing pancytopenia – low red blood cells, white blood cells, and platelets).
- Lymphatic: Edema, particularly in the lower extremities, due to fluid retention and decreased oncotic pressure.
- Integumentary: Jaundice (yellowish skin), pruritus (itchy skin), palmar erythema (redness of palms), telangiectasia or spider angioma (spider-like blood vessels on the skin).
Comprehensive physical examination findings in a patient with cirrhosis, including jaundice and ascites.
2. Palpate the Liver. Liver palpation may reveal enlargement (hepatomegaly), tenderness, and potentially palpable masses or nodules, indicative of cirrhosis-related changes in liver texture and size.
3. Assess for Compensation Status. Cirrhosis can be categorized as compensated or decompensated, impacting symptom presentation and disease stage. Patients with compensated cirrhosis may be asymptomatic, with the condition often detected incidentally through lab work, physical exams, or imaging. In contrast, decompensated cirrhosis manifests with overt signs and symptoms due to liver failure and portal hypertension, requiring immediate and intensive medical management.
Diagnostic Procedures
1. Collect Blood Samples. Blood tests are essential for evaluating liver function and identifying markers of liver disease. Key lab tests include:
- Elevated liver enzymes (AST, ALT): Indicate liver cell damage.
- Elevated bilirubin levels: Reflect impaired bilirubin processing and excretion, contributing to jaundice.
- Creatinine: Assesses kidney function, crucial as renal dysfunction is a common complication.
- Complete blood count (CBC): May show low red blood cells, white blood cells, and platelets (pancytopenia), often due to hypersplenism and bone marrow suppression.
- Hepatitis virus serology: Detects hepatitis B and C infections.
- Elevated prothrombin time (PT) and International Normalized Ratio (INR): Indicate impaired coagulation factor synthesis by the liver.
2. Check Liver Markers. Gamma-glutamyl transferase (GGT) is a liver enzyme particularly sensitive to bile duct damage and alcohol-related liver disease. Elevated GGT levels can suggest liver disease or bile duct injury, though it’s not specific to cirrhosis.
3. Assess Synthetic Hepatic Function. Prothrombin time (PT) and serum albumin levels are reliable indicators of the liver’s synthetic function. Reduced albumin levels occur because the liver, the primary site of albumin synthesis, is impaired. Prolonged PT/elevated INR reflects deficiencies in coagulation factors synthesized by the liver, crucial in assessing bleeding risk.
4. Review Imaging Scan Findings. Various imaging modalities play a crucial role in diagnosing and assessing liver cirrhosis:
- Computed tomography (CT scan): Can reveal vascular lesions, tumors (hepatocellular carcinoma), and structural abnormalities in the liver.
- Ultrasound: Demonstrates liver nodules, increased liver echogenicity (brightness on ultrasound), characteristic of cirrhosis, and can assess for ascites and portal hypertension.
- Duplex Doppler ultrasound: Evaluates the patency and blood flow within hepatic, portal, and mesenteric veins, critical for assessing portal hypertension and vascular complications.
- Magnetic resonance imaging (MRI): Provides detailed liver imaging and can detect iron and fat deposition in the liver, aiding in diagnosing hemochromatosis and NAFLD.
- Transient elastography (Fibroscan): A non-invasive technique using ultrasound pulses to measure liver stiffness, correlating with fibrosis severity and cirrhosis stage.
- Endoscopic retrograde cholangiopancreatography (ERCP): Primarily used to assess bile duct abnormalities and blockages, particularly relevant in cholestatic liver diseases.
- Upper endoscopy: Visualizes the esophagus, stomach, and duodenum to detect esophageal or gastric varices, a serious complication of portal hypertension.
5. Prepare for Liver Biopsy. Liver biopsy remains the gold standard for confirming cirrhosis diagnosis, grading inflammation (hepatitis activity), and staging fibrosis severity. It provides definitive histological information crucial for prognosis and treatment planning, though it is invasive and carries risks.
Nursing Interventions
Nursing interventions are crucial in managing liver cirrhosis and its complications, aiming to improve patient outcomes and quality of life. For patients with alcoholic hepatitis leading to cirrhosis, addressing alcohol dependence is paramount alongside managing the physical manifestations of the disease.
Treat the Underlying Cause
1. Reduce Complications. Addressing the underlying cause of cirrhosis, especially in early stages, can mitigate liver damage and prevent further complications. This is particularly relevant in alcoholic hepatitis, where alcohol cessation is the most critical intervention.
2. Encourage Alcohol Dependency Treatment. For individuals with cirrhosis due to alcohol abuse, quitting alcohol is essential. Nurses should proactively suggest alcohol addiction treatment programs and resources, including counseling, support groups like Alcoholics Anonymous, and medical interventions to manage withdrawal and cravings.
3. Achieve Ideal Weight. Weight loss and blood sugar control are vital for patients with cirrhosis linked to non-alcoholic fatty liver disease. Lifestyle modifications, including dietary changes and exercise, are key components of management.
4. Control Viral Hepatitis. Antiviral medications are the mainstay of treatment for hepatitis C, and advancements have made a cure possible in many cases. Managing hepatitis B involves antiviral therapy to suppress viral replication and liver damage.
5. Manage Symptoms of Primary Biliary Cholangitis (PBC). Early diagnosis and medication for PBC can significantly slow cirrhosis progression. Other medications are used to alleviate symptoms like pruritus, fatigue, and pain associated with cholestatic liver diseases.
6. Improve Malnutrition. Malnutrition is common in cirrhosis due to anorexia, symptoms, and ascites. Nutritional support, including increased calorie and protein intake, is vital. Strategies include 5-6 small, frequent meals per day and a high-protein, carbohydrate-rich nighttime snack to prevent muscle catabolism.
7. Anticipate TPN Use. Total parenteral nutrition (TPN) may be necessary for patients who cannot meet nutritional needs orally or through tube feedings. TPN solutions provide essential nutrients, including fat emulsions to prevent fatty acid deficiency.
8. Manage Pain. NSAIDs and aspirin should be avoided in cirrhosis due to increased risk of GI bleeding and renal insufficiency. Low-dose acetaminophen is generally permitted for pain relief. Opioid analgesics can be used cautiously, considering the liver’s impaired drug metabolism.
Prevent Complications
1. Prevent Fluid Accumulation. Ascites and edema are managed through a low-sodium diet and diuretics to reduce fluid retention. Paracentesis may be required to remove large volumes of ascitic fluid for symptomatic relief.
2. Manage Portal Hypertension. Beta-blockers and nitrates are commonly used to lower portal pressure and reduce the risk of variceal bleeding. Regular monitoring for signs of portal hypertension complications is essential.
3. Control Bleeding Varices. Bleeding esophageal or gastric varices are a life-threatening complication. Band ligation or sclerotherapy are endoscopic procedures to stop or prevent variceal bleeding. Surgical shunts like transjugular intrahepatic portosystemic shunt (TIPS) or distal splenorenal shunt may be necessary to divert blood flow and reduce portal pressure in refractory cases.
4. Excrete Toxins. Lactulose is the primary medication to reduce ammonia levels in hepatic encephalopathy. It acts as a laxative, removing ammonia and toxins from the body through bowel movements. Monitoring mental status and adjusting lactulose dosage are crucial in managing HE.
5. Assist with Liver Transplantation. Liver transplantation is considered for patients with decompensated cirrhosis. While not suitable for all patients, liver transplantation significantly improves survival rates and quality of life for eligible individuals. Nurses play a crucial role in pre- and post-transplant care.
Prevent Further Liver Damage
1. Encourage Alcohol Cessation. Reinforce the absolute necessity of alcohol abstinence for all patients with cirrhosis, regardless of the initial cause. Continued alcohol use exacerbates liver damage and accelerates disease progression.
2. Limit Salt Intake. Sodium restriction is vital to minimize fluid retention and edema. Educate patients on hidden salt sources in processed foods and encourage using herbs and spices for flavoring instead of salt.
3. Assist with Meal Planning. Provide guidance on a balanced diet rich in fruits, vegetables, and lean proteins (fish, poultry, lentils). Advise against consuming raw seafood due to infection risk. Referral to a registered dietitian can be beneficial for personalized meal plans.
4. Prevent Infections. Cirrhosis impairs immune function, increasing infection susceptibility. Educate patients on infection prevention measures: avoiding sick contacts, frequent handwashing, and avoiding needle sharing. Vaccinations against pneumonia, influenza, hepatitis A, and hepatitis B are recommended.
5. Be Cautious with Medications. The cirrhotic liver metabolizes drugs less efficiently. Advise patients to consult their healthcare provider before taking any medications, including over-the-counter drugs. Avoidance of ibuprofen, aspirin, aminoglycoside antibiotics, proton-pump inhibitors, certain anticonvulsants, and some cholesterol-lowering medications may be necessary.
6. Educate on Urgent Medical Attention. Instruct patients to seek immediate medical care for:
- Signs of increased bleeding (unexplained bruising, nosebleeds, blood in stool or vomit).
- Worsening jaundice (increased yellowing of skin and eyes).
- Difficulty breathing (shortness of breath, increased respiratory rate).
- Increased swelling/ascites (rapid abdominal distention, leg swelling).
- Changes in mentation (confusion, disorientation).
- Changes in level of consciousness (drowsiness, lethargy).
Nursing Care Plans
Nursing care plans are essential tools for organizing and prioritizing care for patients with liver cirrhosis. They guide assessments and interventions, focusing on both short-term and long-term goals. Specific nursing diagnoses relevant to liver cirrhosis, particularly in the context of alcoholic hepatitis, include acute confusion, dysfunctional family processes related to alcoholism, ineffective breathing pattern, ineffective tissue perfusion, and risk for impaired skin integrity.
Acute Confusion
Hepatic encephalopathy (HE), a frequent complication of cirrhosis, arises from the liver’s inability to detoxify substances, leading to toxin buildup in the blood and affecting brain function. This is particularly relevant in alcoholic hepatitis, where liver damage is often severe and rapid.
Nursing Diagnosis: Acute Confusion
Related to:
- Hepatic encephalopathy (HE)
- Accumulation of ammonia in the blood
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 engage in lifestyle modifications to prevent HE recurrence (alcohol abstinence, medication adherence).
Assessment:
1. Monitor Serum Ammonia Levels. While ammonia levels don’t always directly correlate with HE severity, trending levels can indicate improvement or worsening of encephalopathy.
2. Review Neurological Imaging. EEG, MRI, or CT scans help rule out other causes of altered mental status, such as intracranial lesions or stroke, ensuring accurate diagnosis and targeted treatment of HE.
Interventions:
1. Administer Lactulose. Lactulose is the cornerstone of HE treatment, promoting ammonia excretion through bowel movements. Titrate dosage to achieve 2-3 soft bowel movements daily.
2. Prevent Falls and Injury. Cognitive impairment in HE increases fall risk. Implement fall precautions: bed alarm, supervised ambulation, assistance with ADLs, safe environment.
3. Reorient Frequently. Provide frequent reorientation to person, place, time, and situation to minimize confusion and maintain reality orientation. Use clear, simple communication.
4. Educate on Lifestyle Changes. Emphasize the importance of alcohol abstinence, prescribed medications, and a healthy diet in managing cirrhosis and preventing HE exacerbations.
5. Decrease Stimuli. Create a calm, quiet environment to minimize agitation and confusion. Reduce noise, limit visitors, and promote relaxation techniques.
Dysfunctional Family Processes: Alcoholism
Alcoholic liver disease, directly resulting from chronic heavy alcohol use, is a major cause of liver cirrhosis. The impact extends beyond the individual, profoundly affecting family dynamics.
Nursing Diagnosis: Dysfunctional Family Processes: Alcoholism
Related to:
- Heavy alcohol use
As evidenced by:
Physical effects of long-term alcohol use on the liver:
- Portal hypertension
- Ascites
- Jaundice
- Splenomegaly
- Poor nutrition
Emotional/psychological symptoms:
- Denial of addiction
- Anxiety/depression
- Guilt
- Social Isolation/loneliness
- Marital problems
- Financial issues
- Disrupted family roles
- Unresolved grief
- Ineffective coping
- Knowledge deficit regarding alcoholism and its consequences
Expected outcomes:
- Patient will verbalize understanding of alcohol’s long-term liver effects.
- Patient will agree to addiction rehabilitation or Alcoholics Anonymous (AA).
- Patient will articulate consequences of alcohol use and identify steps for change.
Assessment:
1. Assess for Alcohol Withdrawal. Alcohol withdrawal syndrome can be life-threatening, particularly delirium tremens (DTs), which can cause seizures. Monitor for withdrawal symptoms (tremors, agitation, tachycardia, hypertension) and administer benzodiazepines as prescribed to manage withdrawal safely, with caution to avoid worsening HE.
2. Monitor Liver Enzymes. Liver enzymes (AST, ALT, GGT) can indicate alcohol abuse. GGT is particularly sensitive to chronic alcohol consumption. However, liver enzymes may not always be elevated in advanced cirrhosis.
3. Assess Support System. Evaluate the impact of alcoholism and cirrhosis on family relationships. Assess for support from family, spouse, or friends, and identify areas of strain or dysfunction within the family system.
The importance of family support in managing chronic liver disease and promoting patient well-being.
Interventions:
1. Reduce Alcohol Cravings. Medications like disulfiram, topiramate, and baclofen can aid in alcohol addiction treatment by reducing cravings and withdrawal symptoms. Administer medications as prescribed and monitor for effectiveness and side effects.
2. Refer to Rehabilitation or AA. Address the underlying alcohol addiction through referrals to addiction counseling, inpatient or outpatient rehabilitation programs, and Alcoholics Anonymous. Provide resources and support for both the patient and family members affected by alcoholism.
3. Coordinate with Dietician. Alcoholism and cirrhosis often lead to malnutrition and nutrient deficiencies (folate, B vitamins, vitamin A, thiamine, zinc). Collaborate with a dietician for nutritional assessment and individualized dietary plans to address deficiencies and optimize nutritional status.
4. Prepare for Liver Transplantation. For end-stage alcoholic cirrhosis, liver transplantation may be the only treatment option. Assess patient candidacy for transplant and emphasize the requirement of complete and sustained alcohol abstinence to be eligible for transplantation.
Ineffective Breathing Pattern
Ascites and abdominal distention in liver cirrhosis increase pressure on the diaphragm, impairing respiratory mechanics and leading to ineffective breathing patterns. Hepatopulmonary syndrome, a complication of advanced cirrhosis, further contributes to shortness of breath and hypoxemia.
Nursing Diagnosis: Ineffective Breathing Pattern
Related to:
- Disease process of liver cirrhosis
- Ascites
- Organ enlargement (hepatomegaly, splenomegaly)
- Increased intra-abdominal pressure
- Hepatopulmonary syndrome
- Abdominal discomfort or pain
- Fatigue
- Anxiety
As evidenced by:
- Dyspnea (shortness of breath)
- Tachypnea (rapid breathing)
- Cyanosis (bluish discoloration of skin/mucous membranes)
- Orthopnea (difficulty breathing when lying flat)
- Hyperventilation
- Hypoxemia (low blood oxygen levels)
- Hypoxia (tissue oxygen deficiency)
Expected outcomes:
- Patient will demonstrate a normal breathing pattern without respiratory distress.
- Patient will report comfortable breathing while sitting or lying with minimal support.
Assessment:
1. Assess Respiratory Status. Monitor respiratory rate, depth, and effort regularly. A respiratory rate exceeding 30 breaths per minute, especially with other signs of distress, indicates significant respiratory compromise.
2. Auscultate Breath Sounds. Assess breath sounds for abnormalities like crackles or wheezes, which may indicate fluid overload, atelectasis, or infection.
3. Assess Level of Consciousness. Changes in mentation, confusion, or decreased LOC can be signs of hypoxemia secondary to ineffective breathing patterns or hepatopulmonary syndrome.
Interventions:
1. Position for Comfort. Elevate the head of the bed (semi-Fowler’s or high-Fowler’s position) to facilitate diaphragmatic excursion and ease breathing. Upright positioning reduces pressure from ascites on the diaphragm.
2. Use Pillows for Support. Provide pillows to support the arms and chest, promoting chest expansion and reducing accessory muscle use in breathing.
3. Monitor ABGs and Oxygen Saturation. Regularly assess arterial blood gases (ABGs) and pulse oximetry (SpO2) to detect hypoxemia or hypercapnia, guiding oxygen therapy and ventilator support decisions.
4. Provide Supplemental Oxygen. Administer supplemental oxygen via nasal cannula or mask as indicated to maintain adequate oxygen saturation and treat hypoxemia.
5. Prepare for Paracentesis. Abdominal paracentesis to remove ascitic fluid can relieve abdominal pressure on the diaphragm, improving respiratory function and easing dyspnea. Prepare the patient for the procedure and monitor post-paracentesis respiratory status.
Ineffective Tissue Perfusion
Liver cirrhosis impairs liver function and blood flow, leading to ineffective tissue perfusion throughout the body. This is due to liver cell damage, scar tissue formation, and altered hemodynamics associated with portal hypertension.
Nursing Diagnosis: Ineffective Tissue Perfusion
Related to:
- Disease process of liver cirrhosis
- Excessive alcohol use
- Hepatitis
- Genetic disorders causing liver disease
- Bile duct abnormalities
- Toxic medications
As evidenced by:
- Easy bruising and bleeding
- Jaundice
- Edema in extremities
- Ascites
- Abdominal pain
- Confusion/altered LOC
- Skin abnormalities (spider angiomas, palmar erythema)
Expected outcomes:
- Patient will demonstrate liver enzymes, coagulation factors, and blood cell counts within acceptable ranges.
- Patient will remain free from jaundice, ascites, and bleeding complications.
Assessment:
1. Assess for Perfusion Symptoms. Monitor for signs and symptoms of ineffective tissue perfusion, including fatigue, jaundice, easy bruising, edema, ascites, and altered mental status.
2. Abdominal Assessment. Perform abdominal assessment to detect hepatomegaly (early cirrhosis) and ascites (later stages). Measure abdominal girth regularly to monitor ascites progression.
3. Review Liver Function Tests. Monitor liver enzymes (AST, ALT), bilirubin, albumin, PT/INR, and CBC. Note that AST and ALT may normalize in advanced cirrhosis due to liver cell burnout.
4. Review Diagnostic Imaging. Assess results of CT scans, MRI, Doppler ultrasound, and liver elastography to evaluate liver structure, blood flow, and fibrosis severity.
Interventions:
1. Administer Diuretics. Diuretics (spironolactone, furosemide) are used to manage edema and ascites by promoting fluid excretion. Monitor electrolyte levels and renal function during diuretic therapy. Ursodiol may be prescribed for primary biliary cholangitis.
2. Monitor Abdominal Girth. Measure and document abdominal girth daily or as ordered to assess ascites severity and response to diuretic therapy.
3. Prepare for Surgical Interventions. Prepare patients for procedures like paracentesis for ascites relief, variceal band ligation or sclerotherapy for bleeding varices, TIPS for portal hypertension, and liver transplantation for end-stage liver disease.
4. Monitor Mental Status. Assess mental status regularly for signs of hepatic encephalopathy. Monitor ammonia levels and administer lactulose as prescribed to reduce toxin buildup.
5. Monitor for Bleeding. Closely monitor for signs and symptoms of bleeding (bruising, petechiae, melena, hematemesis). Implement bleeding precautions and manage coagulation abnormalities with vitamin K or blood product transfusions as needed.
Risk For Impaired Skin Integrity
Liver cirrhosis compromises skin integrity due to fluid overload (edema, ascites), bile salt accumulation causing pruritus and jaundice, and bleeding tendencies leading to skin manifestations like spider angiomas.
Nursing Diagnosis: Risk For Impaired Skin Integrity
Related to:
- Accumulation of bile salts causing jaundice and pruritus
- Fluid buildup causing edema and ascites
- Bleeding tendencies leading to spider angiomas
- Poor nutrition
As evidenced by:
A risk diagnosis is not evidenced by signs and symptoms as the problem has not yet occurred. Nursing interventions are directed at prevention.
Expected outcomes:
- Patient will maintain intact skin without breakdown.
- Patient will monitor for worsening edema and ascites and report changes promptly.
- Patient will implement strategies to prevent skin breakdown.
Assessment:
1. Perform Skin Assessment. Conduct thorough and regular skin assessments, noting skin color, turgor, presence of edema, ascites, jaundice, bruising, spider angiomas, and any lesions or areas of potential breakdown.
2. Assess Nutritional Status. Evaluate nutritional intake, hydration status, and signs of malnutrition. Malnutrition increases skin breakdown risk.
Interventions:
1. Prevent Skin Tearing/Shearing. Handle skin gently during repositioning, transfers, and hygiene care to avoid tearing or shearing, especially in edematous areas. Use lift sheets and gentle techniques.
2. Prevent Edema. Implement measures to reduce edema: sodium restriction, diuretic therapy, elevation of extremities. Regularly assess and manage fluid balance.
3. Monitor Post-Paracentesis Site. After paracentesis, monitor the puncture site for signs of infection (redness, drainage, pain, swelling). Apply sterile dressing and maintain site care per protocol.
4. Control Pruritus. Manage pruritus by avoiding hot water and harsh soaps during bathing. Use cool compresses, calamine lotion, or emollients to soothe itchy skin. Administer antihistamines (Benadryl, hydroxyzine) as prescribed to relieve histamine-mediated itching. Advise patient to avoid scratching to prevent skin damage.
5. Treat Malnutrition. Improve nutritional status through dietary interventions and nutritional supplements as needed. Increase protein and nutrient intake to promote skin health and healing. Consider enteral nutrition if oral intake is insufficient.
