Nursing care plan for Hepatic Cirrhosis




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Assessment
Nursing assessment focuses on the onset of symptoms and the history
of precipitating factors, particularly long-term alcohol abuse,
as well as dietary intake and changes in the patient’s physical and
mental status. The patient’s past and current patterns of alcohol
use (duration and amount) are assessed and documented. It is also
important to document any exposure to toxic agents encountered
in the workplace or during recreational activities. The nurse documents
and reports exposure to potentially hepatotoxic substances
(medications, illicit IV/injection drugs, inhalants) or general anesthetic
agents.
The nurse assesses the patient’s mental status through the interview
and other interactions with the patient; orientation to
person, place, and time is noted. The patient’s ability to carry out
a job or household activities provides some information about
physical and mental status. The patient’s relationships with family,
friends, and coworkers may give some indication about incapacitation
secondary to alcohol abuse and cirrhosis. Abdominal distention

  • and bloating, GI bleeding, bruising, and weight changes

are noted.
The nurse assesses nutritional status, which is of major importance
in cirrhosis, by daily weights and monitoring of plasma
proteins, transferrin, and creatinine levels.
NURSING DIAGNOSES
Based on all the assessment data, the patient’s major nursing diagnoses
may include the following:
• Activity intolerance related to fatigue, general debility, muscle
wasting, and discomfort

• Imbalanced nutrition, less than body requirements, related
to chronic gastritis, decreased GI motility, and anorexia
• Impaired skin integrity related to compromised immunologic status, edema, and poor nutrition
- Risk for injury and bleeding related to altered clotting Mechanisms
COLLABORATIVE PROBLEMS/
POTENTIAL COMPLICATIONS
Based on assessment data, potential complications may include:
• Bleeding and hemorrhage
• Hepatic encephalopathy
• Fluid volume excess
Planning and Goals
The goals for the patient may include increased participation in
activities, improvement of nutritional status, improvement of
skin integrity, decreased potential for injury, improvement of
mental status, and absence of complications.





Nursing Interventions

PROMOTING REST
The patient with active liver disease requires rest and other supportive
measures to permit the liver to reestablish its functional
ability. If the patient is hospitalized, weight and fluid intake and
output are measured and recorded daily. The nurse adjusts the
patient’s position in bed for maximal respiratory efficiency, which
is especially important if ascites is marked because it interferes
with adequate thoracic excursion. Oxygen therapy may be required
in liver failure to oxygenate the damaged cells and prevent further cell destruction.
Rest reduces the demands on the liver and increases the liver’s
blood supply. Because the patient is susceptible to the hazards of
immobility, efforts to prevent respiratory, circulatory, and vascular
disturbances are initiated. These measures may help prevent
such problems as pneumonia, thrombophlebitis, and pressure ulcers.
When nutritional status improves and strength increases, the
nurse encourages the patient to increase activity gradually. Activity
and mild exercise, as well as rest, are planned.

IMPROVING NUTRITIONAL STATUS
The patient with cirrhosis who has no ascites or edema and exhibits
no signs of impending hepatic coma should receive a nutritious,
high-protein diet if tolerated, supplemented by vitamins of
the B complex and others as indicated (including vitamins A, C, K
and folic acid). Because proper nutrition is so important, the
nurse makes every effort to encourage the patient to eat. This is as
important as any medication. Often small, frequent meals are tolerated
better than three large meals because of the abdominal pressure
exerted by ascites. Protein supplements may also be indicated.
Patient preferences are considered. Patients with prolonged or
severe anorexia, or those who are vomiting or eating poorly for any
reason, may receive nutrients enterally or parenteral nutrition.
Patients with fatty stools (steatorrhea) should receive watersoluble
forms of fat-soluble vitamins—A, D, and E (Aquasol A, D,
and E). Folic acid and iron are prescribed to prevent anemia. If the
patient shows signs of impending or advancing coma, the amount
of protein in the diet is decreased temporarily. In the absence of
hepatic encephalopathy, a moderate-protein, high-calorie intake is
provided, with protein foods of high biologic value. A diet containing
1 to 1.5 g of protein per kilogram of body weight per day
is required unless the patient is malnourished. Protein is restricted
if encephalopathy develops. Incorporating vegetable protein to
meet protein needs may decrease the risk of encephalopathy.
Sodium restriction is also indicated to prevent ascites.
A high-calorie intake should be maintained, and supplemental
vitamins and minerals should be provided (eg, oral potassium
if the serum potassium level is normal or low and if renal function
is normal).
PROVIDING SKIN CARE
Providing careful skin care is important because of subcutaneous
edema, the patient’s immobility, jaundice, and increased susceptibility
to skin breakdown and infection. Frequent position
changes are necessary to prevent pressure ulcers. It is important
to avoid irritating soaps and the use of adhesive tape to prevent
trauma to the skin. Lotion may be soothing to irritated skin; the
nurse takes measures to minimize scratching by the patient.
REDUCING RISK OF INJURY
The nurse protects the patient with cirrhosis from falls and other
injuries. The side rails should be in place and padded with blankets
in case the patient becomes agitated or restless. To minimize
agitation, the nurse orients the patient to time and place and explains
all procedures. The nurse instructs the patient to ask for assistance
to get out of bed. The nurse carefully evaluates any injury
because of the possibility of internal bleeding.
Because of the risk for bleeding from abnormal clotting, the patient
should use an electric rather than a safety razor. A soft-bristled
toothbrush will help to minimize bleeding gums, and pressure
applied to all venipuncture sites will help to minimize bleeding.


Evaluation
EXPECTED PATIENT OUTCOMES
Expected patient outcomes may include:
1. Participates in activities
a. Plans activities and exercises to allow alternating periods
of rest and activity
b. Reports increased strength and well-being
c. Participates in hygiene care
2. Increases nutritional intake
a. Demonstrates intake of appropriate nutrients and avoidance
of alcohol as reflected by diet log
b. Gains weight without increased edema and ascites
formation
c. Reports decrease in GI disturbances and anorexia
d. Identifies foods and fluids that are nutritious and allowed
on diet or restricted from diet
e. Adheres to vitamin therapy regimen
f. Describes the rationale for small, frequent meals
3. Exhibits improved skin integrity
a. Has intact skin without evidence of breakdown, infection, or trauma
b. Demonstrates normal turgor of skin of extremities and trunk, without edema
c. Changes position frequently and inspects bony prominences daily
d. Uses lotions to decrease pruritus
4. Avoids injury
a. Is free of ecchymotic areas or hematoma formation
b. States rationale for side rails and asks for assistance to get out of bed
c. Uses measures to prevent trauma (eg, uses electric razor and soft toothbrush, blows nose gently, arranges furniture to prevent bumps and falls, avoids straining during defecation)
5. Is free of complications
a. Reports absence of frank bleeding from GI tract (ie, absence of melena and hematemesis)
b. Is oriented to time, place, and person and demonstrates normal attention span
c. Has serum ammonia level within normal limits
d. Identifies early, reportable signs of impaired thought processes

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