Liver Cirrhosis case pres

Liver Cirrhosis

Objectives

This case study aims to come up with a more in-depth understanding of the disease, Liver Cirrhosis for us (and other nursing students) to be able to come up with the best nursing care plan in the care of patients with the said disease.

Cirrhosis of the Liver

The liver, the largest organ in the body, is essential in keeping the body functioning properly. It removes or neutralizes poisons from the blood, produces immune agents to control infection, and removes germs and bacteria from the blood. It makes proteins that regulate blood clotting and produces bile to help absorb fats and fat-soluble vitamins. You cannot live without a functioning liver.

Cirrhosis of the Liver

Cirrhosis is a potentially life-threatening condition that occurs when scarring damages the liver. This scarring replaces healthy tissue and prevents the liver from working normally. Cirrhosis usually develops after years of liver inflammation. When chronic diseases cause the liver to become permanently injured and scarred, the condition is called Cirrhosis.

Three major forms

Laennec’s (alcohol induced) Cirrhosis

Three major forms

Postnecrotic (micronodular) Cirrhosis

Three major forms

Biliary Cirrhosis

Patient’s Profile

Name Manuel Tambago

Address 181, Salaca, Bugallon, Pangasinan

Sex Male

Age 63 year old

Nationality Filipino

Religion Roman Catholic

Admitted Date

February 14, 2009 @ 7:35 am

Chief Complaints

Epigastric Pain

Admitting Physician

Dr. Cabuang

Diagnosis Liver Parenchymal Disease

ETIOLOGY

Chronic alcoholism

Chronic Hepatitis C, B and D

Autoimmune Hepatitis

Inherited Diseases

Nonalcoholic Steatohepatitis

Blocked Bile Ducts

Drugs, toxins and infections

Clinical Manifestations

Weakness, fatigue

Anorexia

Stomatitis

Tea colored Urine

Clay colored Stool

Amenorrhea

Decrease sexual urge

Loss of pubic/axilla hair

Hepatomegaly

Jaundice

Pruritus or Urticaria

Hematological Changes

Endocrine Changes

GIT Changes

Neurological Changes

Complications

Edema and Ascites

Bruising and Bleeding

Jaundice

Itching

Gallstones

Toxins in the blood or brain

Sensitivity to medication

Portal Hypertension

Varices

Insulin resistance and type 2 DM

Liver Cancer

Problems in other organs

Pathophysiology

Persistent Injury to the liver

alcoholismDrugstoxinsvirussystemicinfections

Fibrotic changes or Fibrosis will occur

Nutritional metabolism

Alteration in physiologic function

Fibrosis

Increase Portal Pressure

Process can be arrested with adequate liver regeneration

Without adequate and proper regeneration

Death

Diagnostic Evaluation

Ultrasound of Whole Abdomen

The liver is unenlarge exhibiting smooth contour and heterogenous parenchymal echopatter. There is no focal mass. Undilated bile canaliculi, portal and systemic vessels. There is no free peritoneal fluid.

The Gallbladder is undilated with even, unthickened wall. No luminal shadowing calculus or focal mass is seen.

IMPRESSION: Mild liver parenchymal changes

Vitros Clinical Chem. Report

TEST NAME RESULT NORMAL VALUE

SODIUM LO 131. mmol/L 148.

POTASSIUM LO 3.4 mmol/L 5.3

CHLORIDE LO 96. mmol/L 107.

HEMATOLOGY

Hemoglobin: 147 g/1; normal: M = 140-170g/1WBC: 12.8 x 109/1; nomarl: 5-10 x 109/1Hematocrit: 45vo1%; normal: M = 40-50 vo1/%

Differential Count Result Normal Values

Segmenters .90 .50 - .70

Lynphocytes .08 .20 - .40

monocytes .02 .02 - .08

Other Diagnostic Procedures for Liver Cirrhosis

Liver biopsy - detects destruction and fibrosis of hepatic tissue.

Other Diagnostic Procedures for Liver Cirrhosis

Liver scan- shows abdominal thickening and liver mass

Other Diagnostic Procedures for Liver Cirrhosis

CT scan- determines the size of the liver and its irregular nodular surface.

Other Diagnostic Procedures for Liver Cirrhosis

Esophagoscopy – to determine esophageal varices.

Other Diagnostic Procedures for Liver Cirrhosis

Paracentesis – to examine ascetic fluid for cell, protein and bacterial count.

Other Diagnostic Procedures for Liver Cirrhosis

Laparoscopy – permits direct visualization of the liver.

Other Diagnostic Procedures for Liver Cirrhosis

Serum liver function test – results are elevated.

Medical ManagementPharmacologic Interventions:1. Provide asymptomatic relief measures such as

pain medications and antiemetics.2. Diuretic therapy, frequently with spironolactone, a

potassium-sparing diuretic that inhibits the action of aldosteroe on the kidneys.

3. I.V albumin to maintain osmotic pressure and reduce ascites.

4. Administration of lactulose or neomycin through a nasogastric tube or retention enema to reduce ammonia levels during periods of hepatic encephalopathy.

Medical ManagementSurgical Interventions:1. Transjugular intrahepatic portosystemic

shunt may be performed in patients whose ascites prove resistant. This percutaneous procedure creates a shunt from the portal to systemic circulation to reduce portal pressure and relieve ascites.

2. Orthotopic liver transplantation may be necessary.

Nursing InterventionPromoting Activity Tolerance

1. Encourage alternating periods of rest and ambulation.

2. Maintain some periods of bed rest with legs elevated to mobilize edema and ascites.

3. Encourage and assist with gradually increasing periods of exercise.

Nursing InterventionImproving Nutritional Status

1. Encourage patient to eat high calorie, moderate protein meal and to have supplementary feedings.

2. Suggest small, frequent feedings and attractive meals in an aesthetically pleasing setting at meal time.

3. Encourage and assist with gradually increasing periods of exercise.

Nursing InterventionProtecting Skin Integrity

1. Note and record degree of jaundice of skin and sclera and scratches on the body.

2. Encourage frequent skin care, bathing without soap, and massage with emollient lotions.

3. Advise patient to keep fingernails short.

Nursing InterventionPatient Education and Health Maintenance Stress the necessity of giving up alcohol

completely. Urge acceptance of assistance from a

substance abuse program. Provide written dietary instructions. Encourage daily weighing for self-

monitoring of fluid retention depletion. Discuss adverse effects of diuretic therapy.

Nursing InterventionPatient Education and Health Maintenance Emphasize the importance of rest, a

sensible lifestyle, and an adequate, well-balanced diet.

Involve the person closest to the patient because recovery usually is not easy and relapses are common.

Stress the importance of continued follow –up for laboratory test and evaluation by a health care provider

Nursing Care Plan

EvaluationAchievement of outcomes is successful if the patient with cirrhosis:

• Has clear breath sounds throughout lung fields and normal percussion results from thoracic cavity.

• Increases involvement in daily self-care activities and ambulation in hospital hallways.

• Loses 1 to 2 lb/day until dry weight is reached; has decreasing edema, decreasing abdominal girth, and urine output of 500 to 1000 ml greater than intake until dry weight is reached.

• Has normal body temperature and no indications of infections.

EvaluationAchievement of outcomes is successful if the patient with cirrhosis:

• Shows normal prothrombin time and hematocrit; hemoglobin levels that are increasing; no orthostatic vital sign changes; and no falls, cuts, or other injuries.

• Maintains adequate food intake to regain or keep weight as appropriate with incorporation of foods from all food groups and restriction of sodium and protein as necessary.

• Shows no evidence of scratching and states that itching is decreased and controlled.

• Makes positive statements about self and realistic statements about future goals.

• Maintains intact skin and appropriate healing of any lesions.

Recommendation• Avoid further hepatic damage: abstain from alcohol;

abstain from any drugs not prescribe by physician, including over-the-counter drugs, such as analgesics or cold remedies; avoid exposure to hepatotoxins in the work and home environments.

• Dietary regimen (may include sodium and/or protein restrictions) should be well balanced and include sources high in protein such as milk, eggs, fish, and poultry.

• Fluid restriction if required; how to incorporate restrictions throughout the day.

Recommendation• Signs and symptoms requiring immediate follow-up:

weight gain; increased abdominal girth; recurrence of edema, fever, or bleeding (blood in urine, stool, or vomitus; epistaxis; cuts that continue to bleed); change in metal function or behavior.

• Measures that lessen chance of bleeding.• Activity plan than promotes adequate rest.• Care measures that help to control prurirus.