1.Lower GI: Cirrhosis Marques Schwartz Complex Health Alterations, 543-113-3KMA, Spring 2014

2. Etiology Cirrhosis is a chronic progressive disease of the liver characterized by extensive degeneration and destruction of the liver parenchymal cells (Lewis, 1072). 3. Etiology 4. Pathophysiology The necrotic tissue attempts to regenerate, leading to fibrosis. As a result, this alters the liver structure. This hinders blood & lymph flow. In time, this reduces the efficiency of the liver. Unfortunately, this disease is not reversible. 5. Pathophysiology 6. Pathophysiology 7. Pathophysiology 8. Pathophysiology 9. Variceal hemorrhageAmerican Journal of Nursing According to Smith, an assistant professor at the Division of Nursing at Aultman College of Nursing and Health Sciences, Canton, OH: Esophageal varices (extremely dilated veins around the lower esophagus that bleed) occurs in nearly fifty-percent of all people with alcoholic cirrhosis. Out of this, about 30% will experience a variceal hemorrhage, which is a potentially fatal emergency. Treatments include balloon tamponade, endoscopic variceal ligation, endoscopic injection, and also and transjugular intrahepatic portosystemic shunt . 10. Causes 11. Causes Alcoholism Alcoholism is a primary cause 12. Causes Alcoholism 13. Causes Alcoholism 14. CausesHepatitis, toxins, chronic inflammatory bowel disease and more. 15. CausesMore On Hepatitis 16. Causes Even More On Hepatitis 17. What does Cirrhosis Look Like? Clinical Manifestations Abdominal pain Anorexia, Diarrhea and Constipation Fatigue Jaundice Ascites 18. What it really looks like 19. Variceal hemorrhage 20. Diagnosis 21. Diagnosis The Liver biopsy, the definitive test for cirrhosis * This detects hepatic tissue destruction and fibrosis. 22. Diagnosis Blood work a decrease in albumin, H&H, platelets, K, Mg, Na+, folate Increase ammonia; also, in AST, ALT and bilirubin. A CT scan (including an I.V. contrast) may help to identify any liver masses, obstructions, or an enlarged liver MRI to view hepatic nodules. 23. Diagnosis Esophagogastroduodenoscopy to see bleeding esophageal varices, as well as irritation or ulceration of the stomach or duodenal bleeding. 24. YouTube Video: Portal Hypertension Best HD video explanation ever!!! Watch the Video right here in the PowerPoint 25. YouTube Video: Ascites Paracentesis: Watch the Video right here in the PowerPoint 26. Ascites 27. Nursing Diagnoses Definitely Imbalanced nutrition: less than body requirements Also, watch for an Ineffective Breathing Pattern 28. Interventions Watch for signs and symptoms of bleeding: gums, stools, skin, emesis. Use a soft toothbrush. Watch for personality changes related to increase ammonia levels. Daily I&O's, Weight and measuring of the waist, to keep track of retention. Monitor for asterixis (hand tremors), which is a sign of developing hepatic encephalopathy. Good nutrition and healthy eating to decrease the demand of the liver 29. Pharmacological Treatment Antiemetics like Zofran For esophageal varices, vasopressin For edema, diuretics Aldactone is a potassium-sparring diuretic. Beta blockers can help prevent bleeding Laxatives like lactulose can help to reduce the serum ammonia levels. 30. Nutritional Therapy What to eat Fruits and vegetables Whole Grains Proteins Perhaps a multivitamin Perhaps vitamins A, D, E and K. High Fiber foods helps to prevent constipation Which helps to remove ammonia 31. Nutritional Therapy What to eat Those with cirrhosis related to alcoholism are at risk for insufficient nutrition, while those with a viral-related cirrhosis are generally not at risk. 32. Nutritional Therapy What Not to eat Alcohol High Fat foods 33. Teaching Topics Avoid alcohol and provide information regarding Alcoholics Anonymous. Explain the disease and the treatment options. Teach proper hand-washing to help reduce the likelihood of infections. To reduce intra-abdominal pressure, teach to avoid lifting heavy objects. Also avoid straining, or coughing during a BM. 34. Support Groups Alcoholics Anonymous Eastern Kenosha county - 262-554-6611 Cirrhosis Support Group A community of patients, family members and friends dedicated to dealing with Cirrhosis, together http://www.mdjunction.com/forums/cirrhosisdiscussions/general-support 35. End of Life Issues Pain Gabapentin is a good choice as it is not metabolized by the liver but renally, unlike most pain meds. Avoid Opiates (increases risk of encephalopathy) if possible; if not, monitor GFR. Carefully monitor the side effects. 36. End of Life: Hospice This is the requirement to qualify for Hospice through Aurora: This is the requirement to qualify for Hospice through Aurora: Cirrhosis/hepatic failure - not a candidate for liver transplant Ascites refractory to medical management (Dietary sodium restriction and diuretics) Hepatorenal syndrome Oliguria Urine Na < 10 mEq/L Elevated BUN/creatinine Hepatic encephalopathy refractory to medical management Hepatocellular carcinoma Recurrent variceal bleeding/spontaneous bacterial peritonitis Please feel free to direct any other questions regarding palliative or hospice care to 414-615-5900 or toll-free at 888-206-6955.http://www.aurorahealthcare.org/services/end-of-life/diagnostic-guide.asp 37. Lewis, S. L. , S. R. Dirksen, M. M. Heitkemper, L. Bucher, et al, and I. M. Camera Camera. Medical-Surgical Nursing, assessment and management Lewis, S. L. , S. R. Dirksen, M. M. Heitkemper, L. Bucher, et al, and I. M. Camera Camera. Medical-Surgical Nursing, assessment and managemeWorks Cited Ackley, Betty J., and Gail B. Ladwig. Nursing Diagnosis Handbook: An Evidence-based Guide to Planning Care. Maryland Heights, Mo: Mosby, 2011. Print. Lewis, S. L. , S. R. Dirksen, M. M. Heitkemper, L. Bucher, et al, and I. M. Camera Camera. Medical-Surgical Nursing, assessment and management of clinical problems. Mosby, print. NCLEX-RN Review Made Incredibly Easy! Philadelphia: Wolters Kluwer/Lippincott Williams & Wilkins Health, 2011. Print. Silvestri, Linda Anne. Saunders Comprehensive Review for the NCLEX-RN Examination. N.p.: n.p., n.d. 694-99. Print. Smith, M. (2010). Emergency. Variceal hemorrhage from esophageal varices associated with alcoholic liver disease. American Journal Of Nursing, 110(2), 32-41. doi:10.1097/01.NAJ.0000368049.57482.00 38. THANK YOU!