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