LIVER CIRRHOSIS

DESCRIPTION
It is a chronic disease characterized by replacement of normal liver tissue with
diffuse fibrosis that disrupts the structure and function of the liver.
It is the 11th most common cause of death in the United States and is most
common among people ages 45 to 75.

TYPES OF CIRRHOSIS
1. Alcoholic cirrhosis the scar tissue characteristically surrounds the
portal areas.
2. Postnecrotic cirrhosis there are broad bands of scar tissue. This is
a late result of a previous bout of acute viral hepatitis.
3. Biliary cirrhosis scarring occurs in the liver around the bile ducts.

RISK FACTORS

Nutritional deficiency with reduced protein intake

Excessive alcohol consumption
Chronic Infection with Hepatitis B, C, or D
Nonalcoholic Fatty Liver Disease
Secondary Biliary Cirrhosis
Hepatic Congestion
Inherited Disorders (Hemochromatosis, Wilsons Disease, Galactosemia,
Glycogen storage diseases, Cystic fibrosis, Budd-Chiari syndrome)
Autoimmune Hepatitis
Severe adverse reactions to prescription drugs, such as isoniazid and
methotrexate
Chronic exposure to environmental toxins
Repeated episodes of heart failure with liver congestion
The parasitic infection schistosomiasis

ASSESSMENT

COMPENSATED

Intermittent mild fever

Vascular spiders
Palmar erythema (reddened palms)
Unexplained epistaxis
Ankle edema
Vague morning indigestion
Flatulent dyspepsia

DECOMPENSATED

Ascites
Jaundice
Weakness
Muscle wasting
Weight loss
Continuous mild fever
Clubbing of fingers
Purpura (due to decreased platelet count)
Spontaneous bruising
Epistaxis
Hypotension
Sparse body hair
White nails
Gonadal atrophy

LABORATORY AND DIAGNOSTIC TEST

LIVER BIOPSY the definitive test for cirrhosis, biopsy detects hepatic tissue
destruction and fibrosis
ABDOMINAL X-RAYS Films show liver size and reveal cysts or gas within the
biliary tract or liver, liver calcification, and massive ascites
ULTRASOUND AND DOPPLER ULTRASONOGRAPHY ultrasound is helpful
to assess liver size and detect ascites or hypotic nodules. With Doppler
ultrasonography, determining patency of the splenic portal and hepatic veins is
possible.
COMPUTED TOMOGRAPHY AND LIVER SCANS determine liver size,
identify liver masses, and visualize hepatic blood flow and obstruction
ESOPHAGOGASTRODUODENOSCOPY reveals bleeding esophageal
varices, stomach irritaton or ulceration

 SPECIAL TESTS angiogram wedge pressures of hepatic vein may establish

he presence and cause of portal hypertension
BLOOD STUDIES liver enzymes (alanine aminotransferase, aspartate
aminoransferase), total serum bilirubin, and indirect bilirubin levels are elevated.
Total serum albumin and protein levels decrease; prothrombin time is prolonged.
Hemoglobin, hematocrit, and serum electrolyte levels decrease. Vitamins A, C,
and K are deficient, gamma globulin levels increase
URINE AND STOOL STUDIES urine levels of bilirubin and urobilinogen
increases, fecal urobilinogen levels fall
ELECTROCARDIOGRAM often show prolonged QT essential sympathetic
nervous system activation

PATHOPHYSIOLOGY

Alcohol abuse
cirrhosis

Alcoholic

Malnutirition
Infection
cirrhosis
Drugs

Postnecrotic

DESTRUCTON OF
HEPATOCYTES

FIBROSIS / SCARRING

Obstruction of blood flow

Increased pressure in the venous
and sinusoidal channels
Fatty infiltration FIBROSIS/SCARRING

PORTAL HYPERTENSION
Alcoholic Cirrhosis is characterized by episodes of necrosis involving the liver cells,
which sometimes occur repeatedly throughout the course of the disease. The destroyed
liver cells are gradually replaced by scar tissue. Eventually, the amount of scar tissue
exceeds that of the functioning liver tissue. Islands of residual normal tissue and
regenerating liver tissue may project from constricted areas, giving the cirrhotic liver its
characteristic hobnail appearance.

NURSING DIAGNOSIS
1. Activity intolerance related to fatigue, lethargy, and malaise
NURSING INTERVENTIONS

RATIONALE

 Assess level of activity tolerance

and degree of fatigue, lethargy, and

malaise when performing routine
activities of daily living.
Assist with activities and hygiene
when fatigued.
Encourage rest when fatigued or
when abdominal pain or discomfort
occurs.

Provides baseline for further

assessment and criteria for
assessment of effectiveness of
interventions.
Promotes exercise and hygiene
within patients level of tolerance.
Conserves energy and protects
liver.

2. Imbalanced nutrition: less than body requirements related to abdominal

distention and discomfort and anorexia
NURSING INTERVENTIONS
Assess dietary intake and nutritional
status through diet history and
diary, daily weight measurements,
and laboratory data.
Provide diet high in carbohydrates
with protein intake consistent with
liver function.
Assist patient in identifying lowsodium foods.

RATIONALE
Identifies deficits in nutritional intake
and adequacy of nutritional state.

Provides calories for energy,

sparing protein for healing.
Reduces edema and ascites
formation.

3. Impaired skin integrity related to pruritus from jaundice and edema

NURSING INTERVENTIONS
Assess degree of discomfort related
to pruritus and edema.
Keep patients fingernails short and
smooth.
Provide frequent skin care; avoid
the use of soaps and alcohol-based
lotions.

RATIONALE
Assists in determining appropriate
interventions.
Prevents skin excoriation and
infection from scratching.
Reoves waste products from skin
while preventing dryness of skin.

4. Risk for injury related to altered clotting mechanisms and altered level of
consciousness

NURSING INTERVENTIONS
Assess level of consciousness and
cognitive level.

Provide safe environment (pad side

rails, remove obstacles in room,
prevent falls).
Provide frequent surveillance to
orient patients, and avoid the use of
restraints.

RATIONALE
Assists in determining patients
ability to protect self and comply
with required self-protective actions;
may detect deterioration of hepatic
function.
Minimizes falls and injury if falls
occur.
Protects patient from harm while
stimulating and orienting patient;
the use of restraints may disturb
patient further.

5. Chronic pain and discomfort related to enlarged tender liver and ascites
NURSING INTERVENTIONS
Maintain bed rest when patient
experiences abdominal discomfort.
Administer antispasmodic and
analgesic agents as prescribed.
Observe, record, and report
presence and character of pain and
discomfort.

RATIONALE
Reduces metabolic demands and
protects the liver.
Reduces irritability of the
gastrointestinal tract and decreases
abdominal pain and discomfort.
Provides baseline to detect further
deterioration of status and to
evaluate interventions.

DRUGS AND NURSING RESPONSIBILITIES

1. DIURETICS
SPIRONOLACTONE
To reduce edema

NURSING RESPONSIBILITIES

Instruct the patient that high-potassium diet is contraindicated.

Monitor other medications for potassium sources
Frequently monitor complete blood count (CBC)
Assess potassium levels closely if patient is receiving blood.

2. ANTIBIOTICS
To control intestinal flora that aggravate encephalopathy

NURSING RESPONSIBILITIES
Assess for the results of the C&S or ensure that the culture has been
completed before starting anew antibiotic
Instruct the patient to take all of the medication, even after symptoms
subside, to prevent recurrence of the infection.
Instruct the patient to immediately report any signs of allergic response.
Monitor blood levels

3. HEMATINICS AGENTS
FERROUS SULFATE
To control anemia and replace iron after abnormal blood loss

NURSING RESPONSIBILITIES
Instruct the patient to take PO form before or after eating.
Monitor the patients complete blood count
Inform the patient that dark, tarry stools are normal when taking iron
supplements.
Teach patient the symptoms of accidental poising: lethargy, nausea,
vomiting, abdominal pain, diarrhea, convulsions, pallor, or cyanosis.

4. LAXATIVES
To prevent straining and rupture of varices

NURSING RESPONSIBILITIES

Monitor the patient for misuse of these agents; can be habit forming.
Monitor the patients electrolytes
Assess patients bowel elimination pattern, GI discomforts
Discontinue if diarrhea persists; do not give if obstruction is suspected
Teach the patient the proper diet and exercise to aid in elimination.
Patient who should avoid straining may benefit from a lubricant
laxative.

5. ANTIDIARRHEALS
To control diarrhea

NURSING RESPONSIBILITIES
Instruct the patient that the agents relieve symptoms but do not cure;
notify physician if diarrhea persists longer than 48 hours
Assess the patients elimination, dehydration, and the results obtained