NURSING
PROCESS: THE PATIENT WITH HEPATIC CIRRHOSIS
Nursing
assessment focuses on the onset of symptoms and the his-tory of precipitating
factors, particularly long-term alcohol abuse, as well as dietary intake and
changes in the patient’s physical and mental status. The patient’s past and
current patterns of alcohol use (duration and amount) are assessed and
documented. It is also important to document any exposure to toxic agents
encountered in the workplace or during recreational activities. The nurse
doc-uments and reports exposure to potentially hepatotoxic substances
(medications, illicit IV/injection drugs, inhalants) or general anes-thetic
agents.
The
nurse assesses the patient’s mental status through the in-terview and other
interactions with the patient; orientation to person, place, and time is noted.
The patient’s ability to carry out a job or household activities provides some
information about physical and mental status. The patient’s relationships with
family, friends, and coworkers may give some indication about incapaci-tation
secondary to alcohol abuse and cirrhosis. Abdominal dis-tention and bloating,
GI bleeding, bruising, and weight changes are noted.
The
nurse assesses nutritional status, which is of major im-portance in cirrhosis,
by daily weights and monitoring of plasma proteins, transferrin, and creatinine
levels.
Based
on all the assessment data, the patient’s major nursing di-agnoses may include
the following:
•
Activity intolerance related to fatigue, general
debility, mus-cle wasting, and discomfort
•
Imbalanced nutrition, less than body requirements,
related to chronic gastritis, decreased GI motility, and anorexia
•
Impaired skin integrity related to compromised
immuno-logic status, edema, and poor nutrition
•
Risk for injury and bleeding related to altered clotting
mechanisms
Based
on assessment data, potential complications may include:
•
Bleeding and hemorrhage
•
Hepatic encephalopathy
•
Fluid volume excess
The
goals for the patient may include increased participation in activities,
improvement of nutritional status, improvement of skin integrity, decreased
potential for injury, improvement of mental status, and absence of
complications.
The
patient with active liver disease requires rest and other sup-portive measures
to permit the liver to reestablish its functional ability. If the patient is
hospitalized, weight and fluid intake and output are measured and recorded
daily. The nurse adjusts the patient’s position in bed for maximal respiratory
efficiency, which is especially important if ascites is marked because it
interferes with adequate thoracic excursion. Oxygen therapy may be re-quired in
liver failure to oxygenate the damaged cells and prevent further cell
destruction.
Rest
reduces the demands on the liver and increases the liver’s blood supply.
Because the patient is susceptible to the hazards of immobility, efforts to
prevent respiratory, circulatory, and vascu-lar disturbances are initiated. These
measures may help prevent such problems as pneumonia, thrombophlebitis, and
pressure ul-cers. When nutritional status improves and strength increases, the
nurse encourages the patient to increase activity gradually. Activ-ity and mild
exercise, as well as rest, are planned.
The
patient with cirrhosis who has no ascites or edema and ex-hibits no signs of
impending hepatic coma should receive a nu-tritious, high-protein diet if
tolerated, supplemented by vitamins of the B complex and others as indicated
(including vitamins A, C, K and folic acid). Because proper nutrition is so
important, the nurse makes every effort to encourage the patient to eat. This
is as important as any medication. Often small, frequent meals are tol-erated
better than three large meals because of the abdominal pres-sure exerted by
ascites. Protein supplements may also be indicated.
Patient
preferences are considered. Patients with prolonged or severe anorexia, or
those who are vomiting or eating poorly for any reason, may receive nutrients
enterally or parenteral nutrition.
Patients
with fatty stools (steatorrhea) should receive water-soluble forms of
fat-soluble vitamins—A, D, and E (Aquasol A, D, and E). Folic acid and iron are
prescribed to prevent anemia. If the patient shows signs of impending or
advancing coma, the amount of protein in the diet is decreased temporarily. In
the absence of hepatic encephalopathy, a moderate-protein, high-calorie intake
is provided, with protein foods of high biologic value. A diet con-taining 1 to
1.5 g of protein per kilogram of body weight per day is required unless the
patient is malnourished. Protein is restrictedif encephalopathy develops.
Incorporating vegetable protein to meet protein needs may decrease the risk of
encephalopathy. Sodium restriction is also indicated to prevent ascites.
A
high-calorie intake should be maintained, and supplemen-tal vitamins and
minerals should be provided (eg, oral potassium if the serum potassium level is
normal or low and if renal func-tion is normal).
Providing
careful skin care is important because of subcutaneous edema, the patient’s
immobility, jaundice, and increased suscep-tibility to skin breakdown and
infection. Frequent position changes are necessary to prevent pressure ulcers.
It is important to avoid irritating soaps and the use of adhesive tape to
prevent trauma to the skin. Lotion may be soothing to irritated skin; the nurse
takes measures to minimize scratching by the patient.
The
nurse protects the patient with cirrhosis from falls and other injuries. The
side rails should be in place and padded with blan-kets in case the patient
becomes agitated or restless. To minimize agitation, the nurse orients the
patient to time and place and ex-plains all procedures. The nurse instructs the
patient to ask for as-sistance to get out of bed. The nurse carefully evaluates
any injury because of the possibility of internal bleeding.
Because
of the risk for bleeding from abnormal clotting, the pa-tient should use an
electric rather than a safety razor. A soft-bristled toothbrush will help to
minimize bleeding gums, and pressure applied to all venipuncture sites will
help to minimize bleeding.
The
patient is at increased risk for bleeding and hemorrhage be-cause of decreased
production of prothrombin and decreased ability of the diseased liver to
synthesize the substances necessary for blood coagulation. Precautionary
measures include protect-ing the patient with padded side rails, applying
pressure to injec-tion sites, and avoiding injury from sharp objects. The nurse
observes for melena and assesses stools for blood (signs of possi-ble internal
bleeding). Vital signs are monitored regularly. Pre-cautions are taken to
minimize rupture of esophageal varices by avoiding further increases in portal
pressure (discussed previ-ously). Dietary modification and appropriate use of
stool soften-ers may help prevent straining during defecation. The nurse
closely monitors the patient for GI bleeding and keeps readily available
equipment (Sengstaken–Blakemore tube), IV fluids, and medications needed to
treat hemorrhage from esophageal and gastric varices.
If
hemorrhage occurs, the nurse assists the physician in initiat-ing measures to
halt the bleeding, administering fluid and blood component therapy and
medications. The patient with massive hemorrhage from bleeding esophageal or
gastric varices may be transferred to the intensive care unit and may require
emergency surgery or other treatment modalities. The patient and family
re-quire explanations about the event and the necessary treatment.
Hepatic
encephalopathy and coma, possible complications of cir-rhosis, may present as
deteriorating mental status and dementia as well as physical signs such as
abnormal voluntary and involuntary movements. Hepatic encephalopathy is mainly
caused by the accumulation of ammonia in the blood and its effect on cerebral
me-tabolism. Many factors predispose the patient with cirrhosis to he-patic
encephalopathy; therefore, the patient may require extensive diagnostic testing
to identify hidden sources of bleeding and am-monia.
Treatment
may include the use of lactulose and nonabsorbable intestinal tract antibiotics
to decrease ammonia levels, modification in medications to eliminate those that
may precipitate or worsen he-patic encephalopathy, and bed rest to minimize
energy expenditure.
Monitoring
is an essential nursing function to identify early de-terioration in mental
status. The nurse monitors the patient’s mental status closely and reports
changes so that treatment of en-cephalopathy can be initiated promptly. Because
electrolyte dis-turbances can contribute to encephalopathy, serum electrolyte
levels are carefully monitored and corrected if abnormal. Oxygen is
administered if oxygen desaturation occurs. The nurse monitors for fever or
abdominal pain, which may signal the onset of bac-terial peritonitis or other
infection.
Patients
with advanced chronic liver disease develop cardiovascu-lar abnormalities.
These occur due to an increased cardiac output and decreased peripheral
vascular resistance, possibly resulting from the release of vasodilators. A
hyperdynamic circulatory state develops in patients with cirrhosis, and plasma
volume increases. This increase in circulating plasma volume may be due in part
to splanchnic venous congestion (Bircher et al., 1999). The greater the degree
of hepatic decompensation, the more severe the hyper-dynamic state. Close
assessment of the cardiovascular and respira-tory status is key for the nurse
caring for patients with this disorder. Pulmonary compromise is always a
potential complication of end-stage liver disease due to plasma volume excess,
making prevention of pulmonary complications an important role for the nurse.
Ad-ministering diuretics, implementing fluid restrictions, and enhanc-ing
patient positioning can optimize pulmonary function. Fluid retention may be
noted in the development of ascites and lower extremity swelling and dyspnea.
Monitoring intake and output, daily weight changes, changes in abdominal girth,
and edema for-mation is part of nursing assessment in the hospital or in the
home setting. Patients are also monitored for nocturia and, later, oliguria as
these states indicate increasing severity of liver function (Bacon & Di
Bisceglie, 2000).
During
the patient’s hospital stay, the nurse and other health care providers prepare
the patient with cirrhosis for discharge, focus-ing on dietary instruction. Of
greatest importance is the exclusion of alcohol from the diet. The patient may
need referral to Alco-holics Anonymous, psychiatric care, or counseling or may
benefit from support from a spiritual advisor.
Sodium
restriction will continue for a considerable time, if not permanently. The
patient will require written instructions, teach-ing, reinforcement, and
support from the staff as well as the family members.
The
success of treatment depends on convincing the patient of the need to adhere
completely to the therapeutic plan. This in-cludes rest, lifestyle changes,
adequate dietary intake, and the elimination of alcohol. The nurse also
instructs the patient and family about the symptoms of impending
encephalopathy, pos-sible bleeding tendencies, and susceptibility to infection.
Recovery
is neither rapid nor easy; there are frequent setbacks and apparent lack of
improvement. Many patients find it diffi-cult to refrain from using alcohol for
comfort or escape. The nurse has a significant role in offering support and
encourage-ment to this patient.
Referral of the patient for home care may
assist the patient in deal-ing with the transition from hospital to home, where
the use of al-cohol may have been an important part of normal home and social
life. The home care nurse assesses the patient’s progress at home and the
manner in which the patient and family cope with the elimina-tion of alcohol
and the dietary restrictions. The nurse also reinforces previous teaching and
answers questions that may not have occurred to the patient or family until the
patient is back home and trying to establish new patterns of eating, drinking,
and lifestyle. For an over-all view of the nursing management of the patient
with impaired liver function, refer to the Plan of Nursing Care.
Expected
patient outcomes may include:
•
Participates in activities
a)
Plans activities and exercises to allow alternating
periods of rest and activity
b)
Reports increased strength and well-being
c)
Participates in hygiene care
•
Increases nutritional intake
a)
Demonstrates intake of appropriate nutrients and
avoid-ance of alcohol as reflected by diet log
b) Gains weight without
increased edema and ascites formation
c)
Reports decrease in GI disturbances and anorexia
d)
Identifies foods and fluids that are nutritious and
allowed on diet or restricted from diet
e)
Adheres to vitamin therapy regimen
f)
Describes the rationale for small, frequent meals
•
Exhibits improved skin integrity
a)
Has intact skin without evidence of breakdown,
infec-tion, or trauma
b)
Demonstrates normal turgor of skin of extremities
and trunk, without edema
c)
Changes position frequently and inspects bony
promi-nences daily
d)
Uses lotions to decrease pruritus
•
Avoids injury
a)
Is free of ecchymotic areas or hematoma formation
b) States rationale for
side rails and asks for assistance to get out of bed
c)
Uses measures to prevent trauma (eg, uses electric
razor and soft toothbrush, blows nose gently, arranges furni-ture to prevent
bumps and falls, avoids straining during defecation)
•
Is free of complications
a)
Reports absence of frank bleeding from GI tract
(ie, ab-sence of melena and hematemesis)
b)
Is oriented to time, place, and person and
demonstrates normal attention span
c)
Has serum ammonia level within normal limits
d)
Identifies early, reportable signs of impaired
thought processes
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