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Cirrhosis

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  • 1. cirrhosis nscobie 13/12/09
  • 2. Description
    • Regenerative process is disorganized, resulting in abnormal blood vessel and bile duct relationships from fibrosis
    13/12/09
  • 3. Description
    • Normal lobular structure distorted by fibrotic connective tissue
    • Lobules are irregular in size and shape with impaired vascular flow
    • Insidious, prolonged course
    13/12/09
  • 4. Statistics
    • > 50% of liver disease is directly related to alcohol consumption
    • Of the estimated 15 million alcoholics in the USA 10-20% have or will develop cirrhosis
    13/12/09
  • 5. Statistics
    • Direct correlation between alcohol consumption in any geographic area and the death rate from cirrhosis in that area
    13/12/09
  • 6. Etiology and Pathophysiology
    • Cell necrosis occurs
    • Destroyed liver cells are replaced by scar tissue
    • Normal architecture becomes nodular
    13/12/09
  • 7. Etiology and Pathophysiology
    • Four types of cirrhosis:
      • Alcoholic (Laennec’s) cirrhosis
      • Postnecrotic cirrhosis
      • Biliary cirrhosis
      • Cardiac cirrhosis
    13/12/09
  • 8. Etiology and Pathophysiology
    • Alcoholic (Laennec’s) Cirrhosis
      • Associated with alcohol abuse
      • Preceded by a theoretically reversible fatty infiltration of the liver cells
      • Widespread scar formation
    13/12/09
  • 9. Etiology and Pathophysiology
    • Postnecrotic Cirrhosis
      • Complication of toxic or viral hepatitis
      • Accounts for 20% of the cases of cirrhosis
      • Broad bands of scar tissue form within the liver
    13/12/09
  • 10. Etiology and Pathophysiology
    • Biliary Cirrhosis
      • Associated with chronic biliary obstruction and infection
      • Accounts for 15% of all cases of cirrhosis
    13/12/09
  • 11. Etiology and Pathophysiology
    • Cardiac Cirrhosis
      • Results from longstanding severe right-sided heart failure
    13/12/09
  • 12. Manifestations of Liver Cirrhosis 13/12/09 Fig. 42-5
  • 13. Clinical Manifestations Early Manifestations
    • Onset usually insidious
    • GI disturbances:
      • Anorexia
      • Dyspepsia
      • Flatulence
      • N-V, change in bowel habits
    13/12/09
  • 14. Clinical Manifestations Early Manifestations
    • Abdominal pain
    • Fever
    • Lassitude
    • Weight loss
    • Enlarged liver or spleen
    13/12/09
  • 15. Clinical Manifestations Late Manifestations
    • Two causative mechanisms
      • Hepatocellular failure
      • Portal hypertension
    13/12/09
  • 16. Clinical Manifestations Jaundice
    • Occurs because of insufficient conjugation of bilirubin by the liver cells, and local obstruction of biliary ducts by scarring and regenerating tissue
    13/12/09
  • 17. Clinical Manifestations Jaundice
    • Intermittent jaundice is characteristic of biliary cirrhosis
    • Late stages of cirrhosis the patient will usually be jaundiced
    13/12/09
  • 18. Clinical Manifestations Skin
    • Spider angiomas ( spider nevi)
    • Palmar erythema
    13/12/09
  • 19. Clinical Manifestations Endocrine Disturbances
    • Steroid hormones of the adrenal cortex (aldosterone), testes, and ovaries are metabolized and inactivated by the normal liver
    13/12/09
  • 20. Clinical Manifestations Endocrine Disturbances
    • Alteration in hair distribution
      • Decreased amount of pubic hair
      • Axillary and pectoral alopecia
    13/12/09
  • 21. Clinical Manifestations Hematologic Disorders
    • Bleeding tendencies as a result of decreased production of hepatic clotting factors (II, VII, IX, and X)
    13/12/09
  • 22. Clinical Manifestations Hematologic Disorders
    • Anemia, leukopenia, and thrombocytopenia are believed to be result of hypersplenism
    13/12/09
  • 23. Clinical Manifestations Peripheral Neuropathy
    • Dietary deficiencies of thiamine, folic acid, and vitamin B 12
    13/12/09
  • 24. Complications
    • Portal hypertension and oesophageal varices
    • Peripheral oedema and ascites
    • Hepatic encephalopathy
    • Fetor hepaticus
    13/12/09
  • 25. Complications Portal Hypertension
    • Characterized by:
      • Increased venous pressure in portal circulation
      • Splenomegaly
      • Oesophageal varices
      • Systemic hypertension
    13/12/09
  • 26. Complications Portal Hypertension
    • Primary mechanism is the increased resistance to blood flow through the liver
    13/12/09
  • 27. Complications Portal Hypertension Splenomegaly
    • Back pressure caused by portal hypertension  chronic passive congestion as a result of increased pressure in the splenic vein
    13/12/09
  • 28. Complications Portal Hypertension Oesophageal Varices
      • Increased blood flow through the portal system results in dilation and enlargement of the plexus veins of the esophagus and produces varices
    13/12/09
  • 29. Complications Portal Hypertension Oesophageal Varices
      • Varices have fragile vessel walls which bleed easily
    13/12/09
  • 30. Complications Portal Hypertension Internal Hemorrhoids
      • Occurs because of the dilation of the mesenteric veins and rectal veins
    13/12/09
  • 31. Complications Peripheral Oedema and Ascites
      • Ascites:
        • - Intraperitoneal accumulation of watery fluid containing small amounts of protein
    13/12/09
  • 32. Complications Peripheral Oedema and Ascites
      • Factors involved in the pathogenesis of ascites:
        • Hypoalbuminemia
        •  Levels of aldosterone
        •  Portal hypertension
    13/12/09
  • 33. Complications Hepatic Encephalopathy
    • Liver damage causes blood to enter systemic circulation without liver detoxification
    13/12/09
  • 34. Complications Hepatic Encephalopathy
    • Main pathogenic toxin is NH 3 although other etiological factors have been identified
    • Frequently a terminal complication
    13/12/09
  • 35. Complications Fetor Hepaticus
    • Musty, sweetish odor detected on the patient’s breath
    • From accumulation of digested by-products
    13/12/09
  • 36. Development of Ascites 13/12/09 Fig. 42-6
  • 37. Diagnostic Studies
    • Liver function tests
    • Liver biopsy
    • Liver scan
    • Liver ultrasound
    13/12/09
  • 38. Diagnostic Studies
    • Esophagogastroduodenoscopy
    • Prothrombin time
    • Testing of stool for occult blood
    13/12/09
  • 39. Collaborative Care
    • Rest
    • Avoidance of alcohol and anticoagulants
    • Management of ascites
    13/12/09
  • 40. Collaborative Care
    • Prevention and management of oesophageal variceal bleeding
    • Management of encephalopathy
    13/12/09
  • 41. Collaborative Care Ascites
    • High carbohydrate, low protein, low Na+ diet
    • Diuretics
    • Paracentesis
    13/12/09
  • 42. Collaborative Care Ascites
    • Peritoneovenous shunt
      • Provides for continuous reinfusion of ascitic fluid from the abdomen to the vena cava
    13/12/09
  • 43. Peritoneovenous Shunt 13/12/09 Fig. 42-8
  • 44. Collaborative Care Oesophageal Varices
    • Avoid alcohol, aspirin, and irritating foods
    • If bleeding occurs, stabilize patient and manage the airway, administer vasopressin (Pitressin)
    13/12/09
  • 45. Collaborative Care
    • Endoscopic sclerotherapy or ligation
    • Balloon tamponade
    • Surgical shunting procedures (e.g., portacaval shunt, TIPS)
    13/12/09
  • 46. Sengstaken-Blakemore Tube 13/12/09 Fig. 42-9
  • 47. Portosystemic Shunts 13/12/09 Fig. 42-11
  • 48. Drug Therapy
    • There is no specific drug therapy for cirrhosis
    • Drugs are used to treat symptoms and complications of advanced liver disease
    13/12/09
  • 49. Nutritional Therapy
    • Diet for patient without complications:
      • High in calories
      •  CHO
      • Moderate to low fat
      • Amount of protein varies with degree of liver damage
    13/12/09
  • 50. Nutritional Therapy
    • Patient with hepatic encephalopathy
      • Very low to no-protein diet
    • Low sodium diet for patient with ascites and oedema
    13/12/09
  • 51. Nursing Management Nursing Assessment
    • Past health history
    • Medications
    • Chronic alcoholism
    • Weight loss
    13/12/09
  • 52. Nursing Management Nursing Diagnoses
    • Imbalanced nutrition: less than body requirements
    • Impaired skin integrity
    • Ineffective breathing pattern
    • Risk for injury
    13/12/09
  • 53. Nursing Management Planning
    • Overall goals:
      • Relief of discomfort
      • Minimal to no complications
      • Return to as normal a lifestyle as possible
    13/12/09
  • 54. Nursing Management Nursing Implementation
    • Health Promotion
      • Treat alcoholism
      • Identify hepatitis early and treat
      • Identify biliary disease early and treat
    13/12/09
  • 55. Nursing Management Nursing Implementation
    • Acute Intervention
      • Rest
      • Oedema and ascites
      • Paracentesis
      • Skin care
      • Dyspnea
      • Nutrition
    13/12/09
  • 56. Nursing Management Nursing Implementation
    • Ambulatory and Home Care
      • Symptoms of complications
      • When to seek medical attention
      • Remission maintenance
      • Abstinence from alcohol
    13/12/09
  • 57. Nursing Management Evaluation
    • Maintenance of normal body weight
    • Maintenance of skin integrity
    • Effective breathing pattern
    • No injury
    • No signs of infection
    13/12/09