LIVER CIRRHOSIS

C-2-5

Liver is a largest gland in body. It has 4 lobes; right,left, caudate,and

quadrant. It is located at right side of the abdomen,

inferior to the diaphragm and anterior to the stomach.

Functions: Carbohydrate, protein and fat metabolism. Breakdown of red blood cell. Defence against microbes. Detoxification of drugs and toxics. Inactivation of hormones. Secretion of bile. Storage.

Liver cirrhosis results of long-term injury caused by variety agents.

Definition: A chronic disease that causes cell

destruction and fibrosis(scarring)of hepatic tissue

o Fibrosis alters normal liver structure and vasculature, impairing blood and lymph flow, resulting in hepatic insufficiency and hypertension in the portal vein.

o Progressive and irreversible.

ETIOLOGY Alcohol intake Obstruction and inflammation of biliary tract

viral hepatitis Heart failure (right side) Metabolic disease

PATHOPHYSIOLOGY

Inflamation and destroyed a liver tissue

Replaced fibrous tissue

There is hyperplasia of Hepatocyte adjacent to

damage area to compensate for destroyed cell

Formation of nodule consisting of hepayocyte confined within sheets of fibrous tissue

Can cause :

Early- liver enlargement, tendernest pain in RUQ ,weight loss,fatigue

anorexia,diarrea,constipation

Progress –to ompaire metabolism cause bleeding, ascites,jaundise

Condition progress portal hypertension develop, leading to congestion in the organ

drained by the tributanes of the portal vein to ascites and develop of oesophageal varices

Liver failure may occur when hyperplasia unable to keep pace with the cell destruction and increase risk

liver cancer

Hypertention may acoccur when abnormal nodule encircled conective

tissue

Fibrous connective tissue constrictve

Disturb blood and bile flow within liver lobule

Blood no longer flows freely throw the liver to inferior vena cava

Restrict blood flow lad to portal hypertension ,increase presssure in the portal

venous system

TYPES OF CIRRHOSIS

Alcoholic cirrhosis Usually occur after years of drinking too

much.Alcohol may cause swelling and inflammation in the liver.Also may cause malnutrition.

Biliary cirrhosis Occur due to obtruction to the flow of

bile duct either within the liver or outside the liver.Primary biliary cirrhosis is a condition where small and medium sized bile duct within the liver are inflamed undergo destruction and scarring.Thus bile produced by the liver cannnot reach the intestine lead to accumulation of bile in the liver,resulting in liver damaged.

Cardiac cirrhosis Liver dysfunction due to venous

congestion usually cardiac dysfunction for example right heart failure.When severe and longstanding hepatic congestive can lead to fibrosis.Increase pressure in the sublobular branches of the hepatic vein cause an engorgement of venous blood being dammed back in the inferior vena cava and hepatic veins.

Posthepatic cirrhoss Is characterized by scarring following

chronic destructive inflammationof the liver parenchyma that slowly spreads from the portal regions throughout the lobe of the portal region.

Metabolic cirrhosis Associated with metabolic disease such

as hemochromatasis and wilson’s disease.

CLINICAL MANIFESTATIONS In early stage, the patient may

experience only vague sign and symptoms , but typically he complains of abdominal pain, diarrhea, fatigue, nausea and vomiting.

Later, as the disease progresses, he may complains of chronic dyspepsia, constipation, pruritus,(high serum bilirubin produce) and weight loss. He also may report may report tendency for easy bleeding, such as easy bruising and bleeding gum

INVESTIGATIONLiver function studies- ALT,AST, alkaline phosphatase,GGT. All may elevated in cirrhosisLiver biopsy- not necessary for cirrhosis but can be determine the extent and nature of the liver damage.Esophagascopy – to identify presence of esophageal varices.

Is characterized by scarring following chronic destructive inflammationof the liver parenchyma that slowly spreads from the portal regions throughout the lobe of the portal region.

Abdomen ultarsound to evaluate liver size,detect ascites and liver nodules.

CBC with platelet count- low RBC,HCT and Hb demonstrate anemia related to bone marrow suppression.-increase RBC destruction causes platelet low due to spleenomegaly.

TREATMENTDietary and fluid management

1. Restrict fluid and sodium based on diuretic therapy, urine output, electrolytes values to decrease fluid retention in abdomen and prevent hypernatremia.

2. Consume protein at least 75-100 grams per day because accumulation of abdomen fluid rich in protein will lead to hypoalbunemia.

3. Increase carbohydrates intake and consume moderate amount of fats or administer total parenteral nutrition due to loss in body weight resulted from impaired metabolism.

4. Increase intake of vitamin and mineral supplements. For examples, vitamin A, B, D, E, K and Mg due to the failure of liver to store vitamins and lost of these vitamins and minerals resulted from diarrhea.

Complication management

1. Perform paracentesis to remove fluid form the abdomen thus prevent ascites and associated respiratory distress. It is able to remove 5 or more liters of fluid.

2. For bleeding esophageal varices: Perform blood transfusion, fresh frozen plasma

transfusion, infuse fluids to restore hemodynamic stability after a severe bleeding.

Administer vasoconstrictive medications such as somatotastin, octreotide and vasopressin to control bleeding.

Perform upper endoscopy such as variceal ligation or endoscopic sclerosis to treat varices with banding.

Perform ballon tamponade if bleeding not controlled or endoscopy unavailable as short term measure to control bleeding.

3. Perform insertion of transjugular intrahepatic portosystmic shunt ( TIPS ):

Using a stent to channel blood between portal and hepatic vein and bypassing liver due to obstruction of blood through liver.

It is a short term measure to control portal hypertension

Surgery

Liver transplant indicated when: Bilirubin increases Albumin level decreases Problems with complication

increases and patient responds poorly to treatment

Contraindicated in maglinant case, alcohol or drugs abused case.

MEDICATIONS Diuretics -Can be given to cirrhosis patients who are

also affected by ascites and edema. The diuretics work to remove extra fluids from the body.

-example:-furosemide(lasix) Beta-Blockers -Doctors may recommend beta-blockers to

reduce or eliminate bleeding in the gastrointestinal tract

-Prevent esophageal from rebleeding -example:-beta blocker nadolol(corgard)

with isosorbide mononitrate

NURSING INTERVENTION

Liver Cirrhosis

Activity intolerance related to fatigue, general debility and discomfort.

1) Assess the condition and ability of patient to perform work to plan next nursing intervention.

2) Encourage alternating periods of rest and ambulation to promote rest and avoids patient fatigue.

3) Elevate the leg with pillow to mobilize edema and ascites

4) Encourage and assist patient with gradually increasing periods of exercise to avoid patient fall and fatigue.

5) Put the call bell and cardiac table near to patient’s bed so that patient able can get the things easily.

Altered nutrition: Less than body requirements related to anorexia and GI disturbances

1) Assess nutrition level of the patient from intake and output chart to perform next intervention.

2) Encourage patient to eat high calorie, moderate protein meal due to impaired protein metabolism.

3) Suggest small, frequent feeding and attractive meal to increase patient’s appetite.

4) Encourage oral hygiene before meal to increase patient’s appetite.

5) Administration of medication antiemetic such as maxalon as doctor order to prevent nausea and vomiting.

6) Daily weight the patient with same weighing scale, same cloth, same time to identify the effectiveness of the treatment.

7) Provide IV therapy such as total parental nutrition (TPN) as doctor prescribed to maintain the nutrition need the by patient.

Impaired skin integrity related edema, jaundice and compromised immunologic status.

1)Note and record degree of jaundice of skin and sclerae and scratches on the body so that next intervention can be planned.

2)Encourage frequent skin care, bathing without soap and massage with lotion to moisture the skin

3)Advise patient to keep fingernails short to prevent injury to the skin.

4)Perform any procedure gently to prevent the skin from injury.

5)Elevate the leg to reduce the edema and promote venous return.

Risk for injury related to altered clotting mechanisms

1)Observe stool and emesis about colour, consistency, amount and test each one for occult blood.

2)Be alert for symptoms of anxiety, epigastric fullness, weakness, restless which may indicate GI bleeding.

3)Observe for internal bleeding such as eechymosis,epistaxis,petechiae and bleeding gums.

4)Stay with patient and give pressure at the bleeding sites during episodes of bleeding to stop the bleeding.

5)Institute and teach measures to prevent trauma such as maintain safe environment,gentle blowing of nose and use soft tooth brush to prevent bleeding from occur.

6)Administer vit K(Aqua Mephyton) as doctor prescribed to increase clotting factor.

s1)Observe

Altered thought process related to deterioration of liver function and increased serum ammonia

1)Restrict high protein load while serum ammonia is high to prevent hepatic encephalopathy

2)Monitor ammonia level by the urine test to know the effectiveness of treatment

3)Protect from sepsis through good hand ashing and management from infection because the liver cannot function well.

4)Monitor fluid intake and output and serum electrolyte level to prevent dehydration and hypokalemia may occur with the use of diuretics which may precipitate hepatic coma