Liver cirrhosis

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Liver cirrhosis

  1. 1. Liver Cirrhosis<br />Ma. Tosca Cybil A. Torres, RN, MAN<br />
  2. 2. LEARNING OBJECTIVES:<br />After 2 hours of active lecture discussion, the students will be able to:<br />Define liver Cirrhosis<br />Enumerate the different types of liver cirrhosis<br />Enumerate the predisposing/ contributing factors of liver cirrhosis <br />Discuss the pathophysiological changes and clinical manifestations of patients with liver cirrhosis<br />Formulate possible nursing diagnoses applicable for patients with liver cirrhosis<br />Enumerate nursing interventions applicable for each identified nursing diagnosis<br />Integrate Christian Values in rendering nursing care for clients with liver cirrhosis<br />MTCAT '10<br />
  3. 3. Liver Cirrhosis<br /><ul><li>a chronic, degenerative disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver </li></ul>MTCAT '10<br />
  4. 4. Liver Cirrhosis <br />Types: <br />Alcoholic Cirrhosis ( Laennec’s Cirrhosis)<br />Most common type of liver cirrhosis<br />Caused by chronic alcoholism <br />Postnecrotic cirrhosis<br />Late result of a previous bout of acute viral hepatitis<br />Biliary cirrhosis<br />Resulted from chronic biliary obstruction and infection <br />Least common type <br />MTCAT '10<br />
  5. 5. Liver Cirrhosis<br />Predisposing/ Precipitating factors:<br /><ul><li>malnutrition
  6. 6. effects of alcohol abuse
  7. 7. chronic impairment of bile excretion – biliary obstruction in the liver and common bile duct (gallbladder stones)
  8. 8. necrosis from hepatotoxins or viral hepatitis
  9. 9. Congestive heart failure</li></ul>MTCAT '10<br />
  10. 10. Liver Cirrhosis<br />Pathophysiology:<br /><ul><li>liver cell damage result in inflammation & hepatomegaly
  11. 11. attempts at regeneration eventually result to fibrosis and a small nodular liver
  12. 12. hepatic function is slowly impaired
  13. 13. obstruction of venous channels blocks hepatic blood flow and cause portal hypertension</li></ul>MTCAT '10<br />
  14. 14. MTCAT '10<br />
  15. 15. MTCAT '10<br />
  16. 16. MTCAT '10<br />
  17. 17. Assessment: <br />Clinical Manifestations <br />S/Sx - early: <br /><ul><li>anorexia, nausea, indigestion
  18. 18. aching or heaviness in right upper quadrant
  19. 19. weakness & fatigue</li></ul>MTCAT '10<br />
  20. 20. Clinical Manifestations <br />Late signs: <br /><ul><li>abnormal liver function tests:
  21. 21. bilirubin (N=0-0.9mg/dl),
  22. 22. AST (N=4.8-19U/L)
  23. 23. ALT (N= 2.4-17U/L)
  24. 24. Serum alkaline phosphatase (N=30-40U/L)
  25. 25. Ammonia (plasma) (N= 15-45umol/L)
  26. 26. intermittent jaundice, pruritus
  27. 27. edema, ascites, prominent abdominal wall veins
  28. 28. Ecchymosis, bleeding tendencies
  29. 29. anemia
  30. 30. Infection
  31. 31. Gynecomastia, testicular atrophy
  32. 32. Neurologic changes </li></ul>MTCAT '10<br />
  33. 33. Complications of Liver Cirrhosis<br />1. Ascites<br /><ul><li>abnormal intraperitoneal accumulation of watery fluid containing small amounts of protein
  34. 34. due to:
  35. 35. intravascular colloidal pressure
  36. 36. capillary hydrostatic pressure
  37. 37. Na and H2O retention
  38. 38. Failure of the liver to metabolize aldosterone</li></ul>MTCAT '10<br />
  39. 39. Ascites<br />S/sx:<br /><ul><li>abdominal enlargement,  wt.
  40. 40. fatigue
  41. 41. abdominal discomfort, respiratory difficulty</li></ul>Med. Mgt.(depending on severity of ascites)<br /><ul><li>Na+ & fluid restriction (500-1000 ml/day)
  42. 42. diuretic therapy (furosemide/ spironolactone)
  43. 43. Paracentesis– for diagnosis or when fluid volume compromise comfort & breathing</li></ul>MTCAT '10<br />
  44. 44. Ascites<br />Nursing Interventions to ascites & increase/promote comfort<br /><ul><li>maintain on bed rest
  45. 45. fluid & Na restriction
  46. 46. monitor I/O, daily wt.
  47. 47. measure abd. girth every shift
  48. 48. maintain on high-Fowlers for max. respiration
  49. 49. support abdomen with pillows
  50. 50. administer diuretics, salt-poor albumin IV as ordered</li></ul> - monitor for signs of CHF, pulmonary edema, dehydration,<br /> electrolyte imbalance, hypersensitivity reaction<br />Assist with Paracentesis<br /><ul><li>have the client void before the procedure
  51. 51. high –fowlers position during the procedure
  52. 52. monitor pt. for hypovolemia & electrolyte imbalance
  53. 53. observe puncture wound for leakage & signs of infection</li></ul>MTCAT '10<br />
  54. 54. Complications of Liver Cirrhosis<br />2. Hepatic Encephalopathy<br /><ul><li>cerebral dysfunction assoc. with severe liver disease
  55. 55. inability of the liver to metabolize substances that can be toxic to the brain such as ammonia, which is produced by the breakdown of protein in the intestinal tract</li></ul>MTCAT '10<br />
  56. 56. Pathogenesis of Hepatic Encephalopathy<br />BRAIN<br />LIVER<br />Toxic N2 metabolites<br />From Intestines<br />MTCAT '10<br />
  57. 57. Hepatic Encephalopathy <br />S/Sx: <br /><ul><li>Asterixis- flapping hand tremors ---early sign
  58. 58. LOC – lethargy progressing to coma
  59. 59.  mental status, confusion, disorientation
  60. 60. dullness, slurred speech
  61. 61. behavioral changes, lack of interest in grooming/ appearance
  62. 62. twitching, muscular incoordination, tremors
  63. 63. Fetor hepaticus
  64. 64. elevated serum ammonia level</li></ul>MTCAT '10<br />
  65. 65. Hepatic Encephalopathy <br />Interventions:<br />a. )  ammonia production<br /><ul><li>dietary protein to 20-40 g/day, maintain adequate calories
  66. 66.  ammonia formation in the intestine – give laxative, enema as ordered and Neomycin -  bacterial ammonia production</li></ul>b.) Protect pt. from injury<br /><ul><li>side rails up
  67. 67. turning to side
  68. 68. assess mental status, LOC
  69. 69. proper positioning (semi-Fowler’s)
  70. 70. prevent aspiration</li></ul>c.) Prevent further episodes of encephalopathy<br /><ul><li>low protein diet
  71. 71. prescribed medications
  72. 72. avoid constipation ( to  ammonia production by bacteria in the GIT)
  73. 73. early signs of encephalopathy (restlessness, slurred speech, dec. attention span)</li></ul>MTCAT '10<br />
  74. 74. Complications of Liver Cirrhosis<br />3. Esophageal Varices<br /><ul><li>distention of the smaller blood vessels of the esophagus as a result of portal hypertension – due to obstruction of venous circulation w/in the damaged liver
  75. 75. the  portal venous pressure causes blood to be forced into these vessels – become tortous and fragile
  76. 76. blood vessel become prone to injury by mechanical trauma from ingestion of coarse food and acid pepsin erosion which may result in bleeding
  77. 77. bleeding may also occur as a result of coughing, vomiting, sneezing, straining at stool or any physical exertion that  abdominal venous pressure </li></ul>MTCAT '10<br />
  78. 78. Esophageal Varices<br />S/Sx:<br /><ul><li>upper GI bleeding</li></ul> (hematemesis)<br /> - melena<br /><ul><li>massive hemorrhage
  79. 79. signs/symptoms of hypovolemic shock </li></ul>MTCAT '10<br />
  80. 80. Esophageal Varices<br />Medical Management:<br /><ul><li>find the source of bleeding – esophagoscopy, angiography
  81. 81. control bleeding </li></ul>Gastric lavage, administration of antacid via NGT<br />Surgical bypass procedures (splenorenal shunt) <br />Variceal band ligation (esophageal variceal ligation (EVL))<br />Endoscopic sclerotherapy or injection sclerotherapy<br />Balloon tamponade<br /><ul><li>insertion of Sengstaken–Blakemore tube with gastric and esophageal balloon that are inflated to stop bleeding</li></ul>MTCAT '10<br />
  82. 82. Balloon tamponade<br />MTCAT '10<br />
  83. 83. MTCAT '10<br />
  84. 84. esophageal variceal ligation (EVL)<br />MTCAT '10<br />
  85. 85. Possible Nursing Diagnoses <br />Activity intolerance R/T fatigue, lethargy, and malaise <br />Imbalanced nutrition R/T abdominal distention and discomfort, and anorexia <br /> Impaired skin integrity R/T pruritus from jaundice and edema<br />High risk for injury R/T altered clotting mechanisms and altered LOC<br />Disturbed body image R/T changes in appearance, sexual dysfunction, and role function<br />Chronic pain R/T enlarged tender liver and ascites<br />Fluid volume excess R/T ascites and edema formation <br />Ineffective breathing pattern R/T restriction of thoracic excursion secondary to ascites and abdominal distention<br />MTCAT '10<br />
  86. 86. Nsg. Interventions:<br />1. Reduce metabolic demands on the liver<br /><ul><li>provide bed rest
  87. 87. eliminate ingestion of toxic substances to the liver: sedatives opiates, alcohol, acetaminophen
  88. 88.  activities</li></ul>MTCAT '10<br />
  89. 89. Nsg. Interventions:<br />2. Provide adequate nutrition & hydration<br /><ul><li>Low – protein, high-carbohydrate, high calorie, sodium- restricted diet
  90. 90. multiple vitamin therapy
  91. 91. restrict fluids & sodium if there is edema or ascites
  92. 92. provide mouth care before meals
  93. 93. monitor I/O, daily wt.</li></ul>3. Prevent infection<br /><ul><li>encourage good personal hygiene
  94. 94. reverse isolation
  95. 95. assess for signs of infection esp. urinary
  96. 96. encourage deep breathing/position changes</li></ul>MTCAT '10<br />
  97. 97. Nsg. Interventions:<br />4. Protect pt. from bleeding<br /><ul><li>monitor urine, stool, gums, skin for signs of bleeding/ bruising
  98. 98. avoid injections, apply pressure to venipuncture sites for at least 5 mins.
  99. 99. Monitor prothrombin time, bleeding time
  100. 100. Teach pt. to use soft toothbrush, avoid constipation
  101. 101. Prevent scratching from pruritus, proper skin care
  102. 102. Administer Vit. K as ordered </li></ul>MTCAT '10<br />
  103. 103. Questions?????<br />MTCAT '10<br />
  104. 104. ASSIGNMENT:<br />Answer situation #4 in critical thinking exercises, Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 11th Edition, 2009 Page 1341 <br />WRITE your answers in a whole sheet of yellow paper<br />MTCAT '10<br />
  105. 105. Thank you... ¥Øøµ<br />MTCAT '10<br />

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