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