CIRRHOSIS

Is a chronic hepatic disease that is characterized by destruction of the functional liver cells, which leads to
cellular death. In cirrhosis, the damaged liver cells regenerate as fibrosis areas instead of functional cells, causing
alterations in liver structure, function, blood circulation, and lymph damage. The major cellular changes include
irreversible chronic injury of the functional liver tissue and the formation of regenerative nodules. These changes
result in liver cell necrosis, collapse of liver support networks, distortion of the vascular bed, and nodular regeneration
of the remaining liver cells. This disease alters liver structure and normal vasculature, impairs blood and lymph flow,
and ultimately causes hepatic insufficiency.

Nursing Key outcomes nursing care Plans for Cirrhosis

The patient will:

• Perform ADL activities of daily living without excessive fatigue or exhaustion.

• Remain oriented to his environment.

• Show no signs of circulatory overload.

• Participate in decisions about care.

• Maintain adequate caloric intake.

• Patient's fluid volume will remain within normal parameters.

• Patient's skin integrity will remain intact.

• Avoid or minimize complications.

Nursing interventions nursing care Plans for Cirrhosis

• Monitor vital signs, intake and output, and electrolyte levels to determine fluid volume status.

• Assess fluid retention

• Weigh the patient daily and document his weight.

• Administer diuretics, potassium, and protein or vitamin supplements as ordered.

• Restrict sodium and fluid intake as ordered.

• Assist and provide oral hygiene before and after meals.

• Determine food preferences and provide them within the patient's prescribed diet limitations.

• Provide frequent, small meals.

• Observe and document the degree of sclera and skin jaundice.

 • Give the patient frequent skin care.

• Observe for bleeding gums, ecchymosed, epitasis, and petechiae.

• Inspect stools for amount, color, and consistency.

• Increase the patient's exercise tolerance by decreasing fluid volumes and providing rest periods before
exercise.

• Use appropriate safety measures to protect the patient from injury.

• Watch for signs of anxiety , epigastric fullness, restlessness, and weakness.

• Observe closely for signs of behavioral or personality changes.

• Observe Report increasing stupor, lethargy, hallucinations, or neuromuscular dysfunction. Arouse the
patient periodically to determine level of consciousness. Watch for asterixis, a sign of developing
encephalopathy.

• Allow the patient to express his feelings about having cirrhosis.

• Provide psychological support and encouragement, when appropriate.

Patient teaching nursing care Plans for Cirrhosis

• Warn the patient against taking nonsteroidal anti-inflammatory drugs, straining to defecate, and blowing his
nose or sneezing too vigorously. To minimize the risk of bleeding.

• Suggest using a soft toothbrush and a electric razor

• Advise the patient that rest and good nutrition conserve energy and decrease metabolic demands on the
liver.

• Suggest the patient to eat frequent, small meals. Teach him to alternate periods of rest and activity to
reduce oxygen demand and prevent fatigue.

• Tell the patient how he can conserve energy while performing activities of daily living. For example, suggest
that he sit on a bench while bathing or dressing.

• Stress the need to avoid infections and abstain from alcohol. Refer the patient to alcohol abuse treatment
Anonymous, if appropriate

• Alcohol abuse treatment. Emphasize to the patient with alcoholic liver cirrhosis that continued alcohol use
exacerbates the disease. Stress that alcoholic liver disease in its early stages is reversible when the patient
abstains from alcohol. Encourage family involvement in. Assist the patient in obtaining counseling or support
for her or his alcoholism.

• Encourage the patient to seek frequent medical follow-up and Refer the patient to an alcohol support group
or liver transplant support group.

CARDIAC TAMPONADE
Cardiac tamponade, also known as pericardial tamponade, is an emergency condition in
which fluid accumulates in the pericardium (the sac in which the heart is enclosed). If the fluid
significantly elevates the pressure on the heart it will prevent the heart's ventricles from filling
properly. This in turn leads to a low stroke volume. The end result is ineffective pumping of
blood, shock, and often death.

Contents
[hide]
• 1 Causes
• 2 Pathophysiology
• 3 Diagnosis
• 4 Treatment
○ 4.1 Pre-hospital care
○ 4.2 Hospital management
• 5 See also
• 6 References

[edit] Causes
Cardiac tamponade occurs when the pericardial space fills up with fluid faster than the
pericardial sac can stretch. If the amount of fluid increases slowly (such as in hypothyroidism)
the pericardial sac can expand to contain a liter or more of fluid prior to tamponade occurring. If
the fluid occurs rapidly (as may occur after trauma or myocardial rupture) as little as 100 ml can
cause tamponade.[1]
Causes of increased pericardial effusion include hypothyroidism, physical trauma (either
penetrating trauma involving the pericardium or blunt chest trauma), pericarditis (inflammation
of the pericardium), iatrogenic trauma (during an invasive procedure), and myocardial rupture.
Cardiac tamponade is caused by a large or uncontrolled pericardial effusion, i.e. the buildup of
fluid inside the pericardium.[2] This commonly occurs as a result of chest trauma (both blunt and
penetrating),[3] but can also be caused by myocardial rupture, cancer, uraemia, pericarditis, or
cardiac surgery,[2] and rarely occurs during retrograde aortic dissection,[4] or whilst the patient is
taking anticoagulant therapy.[5] The effusion can occur rapidly (as in the case of trauma or
myocardial rupture), or over a more gradual period of time (as in cancer). The fluid involved is
often blood, but pus is also found in some circumstances.[2]
Myocardial rupture is a somewhat uncommon cause of pericardial tamponade. It typically
happens in the subacute setting after a myocardial infarction (heart attack), in which the infarcted
muscle of the heart thins out and tears. Myocardial rupture is more likely to happen in elderly
individuals without any previous cardiac history who suffer from their first heart attack and are
not revascularized either with thrombolytic therapy or with percutaneous coronary intervention
or with coronary artery bypass graft surgery.[6]
One of the most common settings for cardiac tamponade is in the first 24 to 48 hours after heart
surgery. After heart surgery, chest tubes are placed to drain blood. These chest tubes, however,
are prone to clot formation. When a chest tube becomes occluded or clogged, the blood that
should be drained can accumulate around the heart, leading to tamponade. Nurses will frequently
milk clots from the tubes, or strip the tubes, but even with these efforts chest tubes can become
clogged. Thus, after heart surgery it is critical to be on the watch for chest tube clogging.
[edit] Pathophysiology
The outer pericardium is made of fibrous tissue[7] which does not easily stretch, and so once fluid
begins to enter the pericardial space, pressure starts to increase.[2]
If fluid continues to accumulate, then with each successive diastolic period, less and less blood
enters the ventricles, as the increasing pressure presses on the heart and forces the septum to
bend into the left ventricle, leading to decreased stroke volume.[2] This causes obstructive shock
to develop, and if left untreated then cardiac arrest may occur (in which case the presenting
rhythm is likely to be pulseless electrical activity)
[edit] Diagnosis
Initial diagnosis can be challenging, as there are a number of differential diagnoses, including
tension pneumothorax,[3] and acute heart failure.[citation needed] In a trauma patient presenting with
PEA (pulseless electrical activity) in the absence of hypovolemia and tension pneumothorax, the
most likely diagnosis is cardiac tamponade.[8]
Classical cardiac tamponade presents three signs, known as Beck's triad. Hypotension occurs
because of decreased stroke volume, jugular-venous distension due to impaired venous return to
the heart, and muffled heart sounds due to fluid inside the pericardium.[9]
Other signs of tamponade include pulsus paradoxus (a drop of at least 10mmHg in arterial blood
pressure on inspiration),[2] and ST segment changes on the electrocardiogram,[9] which may also
show low voltage QRS complexes,[5] as well as general signs & symptoms of shock (such as
tachycardia, breathlessness and decreasing level of consciousness).
Tamponade can often be diagnosed radiographically, if time allows. Echocardiography, which is
the diagnostic test of choice**, often demonstrates an enlarged pericardium or collapsed
ventricles, and a chest x-ray of a large cardiac tamponade will show a large, globular heart.[5]
[edit] Treatment
[edit] Pre-hospital care
Initial treatment given will usually be supportive in nature, for example administration of
oxygen, and monitoring. There is little care that can be provided pre-hospital other than general
treatment for shock. A number of the Helicopter Emergency Medical Services (HEMS) in the
UK, which have doctor/paramedic teams, have performed an emergency thoracotomy to release
clotting in the pericardium caused by a penetrating chest injury.
Prompt diagnosis and treatment is the key to survival with tamponade. Some pre-hospital
providers will have facilities to provide pericardiocentesis, which can be life-saving. If the
patient has already suffered a cardiac arrest, pericardiocentesis alone cannot ensure survival, and
so rapid evacuation to a hospital is usually the more appropriate course of action.
[edit] Hospital management
Initial management in hospital is by pericardiocentesis.[3] This involves the insertion of a needle
through the skin and into the pericardium and through the fifth intercostal space, and aspirating
fluid. Often, a cannula is left in place during resuscitation following initial drainage so that the
procedure can be performed again if the need arises. If facilities are available, an emergency
pericardial window may be performed instead,[3] during which the pericardium is cut open to
allow fluid to drain. Following stabilization of the patient, surgery is provided to seal the source
of the bleed and mend the pericardium.