NURSING CARE FOR A PATIENT WITH Liver Cirrhosis

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Liver

– largest glandular organ in the body

– weighs about 1.5gm

– located in the right upper quadrant

– consists of 4 lobes (2 caudate and 2 quadate)

Function of Liver

– A healthy liver is essential for life

– Performs more than 400 functions in three

categories:

STORAGE, PROTECTION, METABOLISM

1. STORAGE

– Stores vitamins B12 and ADEK, glycogen, and Fe

2. PROTECTION

– Protects the body through phagocytic Kupffer cells

 

– Large cells in the body

• form part of the reticulo-endothelial system (a network of cells and tissues throughout the body)

• play a role in RBC formation, destruction, inflammation and immunity

• also assist in detoxification action of the liver

 

3. METABOLISM

– Metabolizes glucose

• Converts excess glucose to glycogen and release it as it is required thereby maintaining the blood glucose level

– Metabolizes lipids

• Breaking down fatty acids, synthesising cholesterol and phospholipids, and converting excess carbohydrates and protein into fats

– Metabolises protein

• Converting amino acids into different forms in which they will be needed by the body

– Amino Acid Synthesises

• Either from breakdown of protein or from lactate by the product of muscle exercise to form glucose (gluconeogenesis)

– Metabolises drugs, chemicals, bacteria and other foreign elements

– Forms and continuously release bile which is necessary for fat digestion

– Synthesis of factors needed for blood coagulation (prothrombin and fibrinogen)

– Converts ammoniato urea for execretion

– Excretes bilirubin

 

STRESSORS – Liver disease

PHYSIOLOGICAL

1. Autoimmune-failure of the immune system

2. Contact with infected person

3. Trauma – injury or surgery of liver, pancreas and spleen.

4. Poor nutrition

5. Toxic substances – drugs, fumes etc.

6. Blood transfusion

7. Secondary causes:

Biliary diseases

Cardiac diseases

8. Infection-viral

9. Tumor

10. Gallstones

 

DEVELOPMENTAL

– age

SOCIO-CULTURAL

  • feeding habits
  • tatoo
  • tribal mark

Problems/ Common reactions

JAUNDICE

  • Greenish-yellowish discoloration of the skin, mucous membrane, and sclera of the eyes
  • Indicates high levels of bile pigment (bilirubin)
  • Three types of jaundice:
  • Haemolytic, Hepatocellular, and Obstructive

– is a condition caused when excess amounts of bilirubin circulating in the blood stream dissolve in the subcutaneous fat (the layer of fat just beneath the skin) causing a yellowish appearance of the skin and the whites of the eyes

With the exception of normal newborn, jaundice in the first week of life and all other jaundice indicates overload or damage to the liver, or inability to move bilirubin from the liver through the biliary tract to the gut

 

ASCITIS

Collection of fluid in the abdominal cavity a decrease in the volume of fluid in the intra vascular space (blood vessels)

Nutritional deficits

Bleeding and bruising —> lack of vit. K and prothrombin —> fatigue, anemia

and malnutrition

 

Portal hypertension (complication)

• Dilation of abdominal wall veins (caput medusa)

• Distension of veins of the oesophagus and stomach (esophageal varices)

• Distension of rectal veins (hemorrhoid)

 

Health Assessment/ Common Reactions (Liver Diseases)

• Nausea & vomiting

• Anorexia, dyspepsia

• Abdominal distension

• Change in bowel habits

• Weight loss

• Weakness, fatigue, & malaise

• Abdominal pain

• Bleeding tendencies (gums, skin, urine, stool)due to reduced prothrombin

• Itching

• Oedema

• Ascites

• Jaundice

• Dark urine

• Fever

• Clay coloured (soft) stool

• Palmer eyrthema (redness of the palm that blanches with pressure)

• Haemorrhoidal and umbilical varicose veins

• Poor skin tugor (dehydration)

• Headache

• Drowsy, confused

• Coma

 

Diagnostic Tests (Liver Diseases)

Total bilirubin

  • elevated
  • Normal: 0.2 – 1.0 mg/dL

Alanine aminotransferase (ALT)

  • elevated
  • Normal: 7 – 24u/L

Aspartate aminotransferase (AST)

  • elevated
  • Normal: 6 – 20U/L

Ammonia

  • elevated
  • Normal: 14 – 45ug/dL

Prothrombin time

  • Normal: 8 – 10 secs
  • increased time with abnormal bleeding

CT scan

  • Determines the size and extent of liver damage
  • Hepatomegaly

 

Percutaneous Liver Biopsy

• needle aspiration biopsy to examine a small liver sample

• Post procedure bleeding and necrosis are possible complications

• Result may show calcification

• Not a routine procedure Performed when it is necessary:

– to determine the presence of liver disease

– to look for malignancy, cysts, parasites, or other pathology

 

Liver Biopsy

The actual procedure is only slightly uncomfortable, usually local or general anesthesia is used

Most of the discomfort arises from being required to maintain bed rest for several hours afterwards to prevent bleeding from the biopsy site

 

Cirrhosis of the liver

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• Degenerative liver disorder characterized by irreversible chronic destruction of hepatic cells, which are replaced by fibrous cells and necrotic tissue

• Therefore the function of the liver is compromised

 

 

CAUSES

Alcoholic Laennec’s or portal cirrhosis; most common, results from chronic alcoholism, malnutrition

Post necrotic Destruction of the liver cells Secondary to Hepatitis (Viral infection)

Metabolic liver disease or exposure to hepatotoxins like drugs Secondary to other diseases -cardiac, bile-duct disease

 

Complications of cirrhosis

• Portal Hypertension

• Esophageal varices

• Ascites

• Hepatic Encephalopathy

 

Portal Hypertension

• The portal vein consists of veins coming out from the intestines: the gastric and splenic veins which drain absorbed nutrients from the digestive system into the portal veins in the liver for

• After detoxification and purification of blood in the liver, the blood goes through the hepatic vein to the inferior vena cava

• In scarred cirrhotic liver, the blood flow in the intrahepatic vessels may be obstructed

• Therefore, blood backs up in the portal venous system

• Congestion and increased fluid pressure results in portal hypertension

• Obstruction results in distension of the collateral arteries in esophagus as esophageal varices, in rectum as internal hemorrhoids, and in abdominal cavity as caput medusa

 

Nursing management for Portal hypertension

Goal

to promote blood flow within the intrahepatic vessels and venous pressure

Interventions

• Reduce Na intake

• Give diuretics as prescribed

• Give antihypertensives as prescribed

• Surgical shunt- graft to divert blood into the systemic circulation

 

Esophageal Varices

• Dilated bulging of esophageal veins

• Results from portal hypertension

• Prone (at risk) to bleed because veins are superficial and can easily rupture

• Bleeding in the upper GI could be massive and life threatening

 

Esophageal Varices (management)

• Treat the underlying cause: portal hypertension

• Give soft diet and stool softener

• Endoscopy: Scleropathy

• Surgical: variceal band ligation

• Resuscitative measures if life threatening. (IV somatostatin (octreotide): to reduce portal pressure)

• Urgent endoscopy

• Balloon tamponade

 

Ascites

• Collection of fluid in the peritoneal cavity

• Caused by portal hypertension

• Leads to hepatorenal syndrome

• Increased pressure leads plasma proteins into the peritoneal cavity

By the process of osmosis fluid is drawn to the peritoneal cavity

 

Ascites ( Management)

• Low Na diet

• Diuretics

• Paracentesis abdominus – Removal of fluid by introduction of needle into the abdominal cavity

• Aseptic technique

 

Hepatic encephalopathy

• A CNS manifestation of advanced liver disease which could lead to coma and death

• High level of ammonia results from inability of the liver to detoxify ammonia by converting to urea

• Ammonia results from bacteria action on protein digestion

• Accumulation of ammonia makes it cross the blood brain barrier where it interferes with brain metabolism and neuro transmission

This leads to mental changes – disorientation, confusion, personality changes and memory loss, +Babinski reflex, and sulfurous breath odour (fetor hepaticus)

MANAGEMENT of Hepatic encephalopathy

• No protein diet

• Intestinal antibiotics to destroy intestinal microbes thereby reducing ammonia

• Laxatives and enema to reduce serum ammonia

• Neuro transmitter e.g. levodopa

• IV fluid for electrolyte

• TPN – Total parenteral nutrition

 

Health Assessment/ Common Reactions (Liver Cirrhosis)

• Early Stage

– Vague signs and symptoms

– Nausea & vomiting

– Anorexia, dyspepsia

– Abdominal pain

– Change in bowel habits (diarrhea or constipation)

– Weakness, fatigue, & malaise

– Abdominal distension

– Possible Weight loss

• Later Stage

– Clay coloured (soft) stool: Bilirubin

– Fever

– Itching: bile products deposits in the skin

– Edema & Ascites: accumulated fluids

– Jaundice: Bilirubin

– Dark urine

– Bleeding and bruising tendencies (gums, skin, urine, stool)due to reduced prothrombin

 

Health Assessment/ Common Reactions (Liver Diseases)

• Palmer eyrthema (redness of the palm that blanches with pressure)

• Haemorrhoidal and umbilical and esophageal varicose veins (portal HTN)

• Poor skin tugor (dehydration)

• Encephalopathy:

– Drowsy, confused

– Coma

 

Nursing management: (Cirrhosis)

Nursing INTERVENTIONS

• Assess vital signs every 4hrs; more often if there is evidence of haemorrhage

• Assess mental status and report changes

• Assist with ADL as necessary to conserve energy

• Provide for adequate rest

• Serve small frequent attractive food, tailored to clients’ preference and dietary restrictions

• Check tolerance, after each meal

• Cleanse skin with mild soap and apply soothing cream to control pruritus

• Administer mouth care and offer mouth wash frequently

• Observe for gastrointestinal haemorrhage as evidenced by epistaxis, hematemesis, melena, anxiety, restlessness and feeling of gastric fullness

• Observe for edema by measuring the ankles daily

• Observe for ascites by measuring abdomen daily

• Measure intake and output

• Weigh daily

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