Cirrhosis is a chronic disease of the liver characterized by alteration in structure, degenerative changes and widespread destruction of hepatic cells, impairing cellular function and impeding blood flow through the liver. Causes include malnutrition, inflammation (bacterial or viral), and poisons (e.g., alcohol, carbon tetrachloride, acetaminophen).
Cirrhosis is the fourth leading cause of death in the United States among people ages 35 to 55 and represents a serious threat to long-term health.
CARE SETTING
May be hospitalized on a medical unit during initial or recurrent acute episodes with potentially life-threatening complications. Otherwise, this condition is handled at the community level.
RELATED CONCERNS
Alcohol: acute withdrawal
Substance dependence/abuse rehabilitation
Fluid and electrolyte imbalances
Psychosocial aspects of care
Renal dialysis
Renal failure: acute
Total nutritional support: parenteral/enteral feeding
Upper gastrointestinal/esophageal bleeding
Patient Assessment Database
Data depend on underlying cause of the condition.
ACTIVITY/REST
May report: Weakness, fatigue, exhaustion
May exhibit: Lethargy
Decreased muscle mass/tone
CIRCULATION
May report: History of/recent onset of HF, pericarditis, rheumatic heart disease, or cancer (causing liver impairment leading to failure)
Easy bruising, nosebleeds, bleeding gums
May exhibit: Hypertension or hypotension (fluid shifts)
Dysrhythmias, extra heart sounds (S3, S4)
JVD; distended abdominal veins
Jaundiced skin, sclera
ELIMINATION
May report: Flatulence
Diarrhea or constipation; gradual abdominal enlargement
May exhibit: Abdominal distention (hepatomegaly, splenomegaly, ascites)
Decreased/absent bowel sounds
Clay-colored stools, melena
Dark, concentrated urine; oliguria (renal failure)
FOOD/FLUID
May report: Anorexia, food intolerance/ingestion
Nausea/vomiting
May exhibit: Weight loss or gain (fluid)
Tissue wasting
Edema generalized in tissues
Dry skin, poor turgor
Halitosis/fetor hepaticus, bleeding gums
NEUROSENSORY
May report: SO(s) may report personality changes, depressed mentation
May exhibit: Changes in mentation, confusion, hallucinations, coma
Slowed/slurred speech
Asterixis (involuntary jerking movements of hands/tongue/feet associated with hepatic encephalopathy)
PAIN/DISCOMFORT
May report: Abdominal tenderness/RUQ pain
Itching
Pins/needles sensation, burning pain in extremities
May exhibit: Guarding/distraction behaviors
Self-focus
RESPIRATION
May report: Dyspnea
May exhibit: Tachypnea, shallow respiration, adventitious breath sounds
Limited thoracic expansion (ascites)
Hypoxia
SAFETY
May report: Severe itching of the skin/dryness
May exhibit: Fever (more common in alcoholic cirrhosis)
Jaundice, ecchymosis, petechiae
Spider angiomas/telangiectasis, palmar erythema
SEXUALITY
May report: Menstrual disorders (women), impotence (men)
May exhibit: Testicular atrophy, gynecomastia, loss of hair (chest, underarm, pubic)
TEACHING/LEARNING
May report: History of long-term alcohol use/abuse, alcoholic liver disease
History of biliary disease, hepatitis, exposure to toxins; liver trauma; upper GI bleeding; episodes of bleeding esophageal varices; use of drugs affecting liver function
Discharge plan
DRG projected mean length of inpatient stay: 6.4 days
May need assistance with homemaker/management tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Liver scans/biopsy: Detects fatty infiltrates, fibrosis, destruction of hepatic tissues, tumors (primary or metastatic), associated ascites.
Percutaneous transhepatic cholangiography (PTHC): May be done to rule out/differentiate causes of jaundice or to perform liver biopsy.
Esophagogastroduodenoscopy (EGD): May demonstrate presence of esophageal varices, stomach irritation or ulceration, duodenal ulceration or bleeding.
Percutaneous transhepatic portal angiography (PTPA): Visualizes portal venous system circulation.
Serum bilirubin: Elevated because of cellular disruption, inability of liver to conjugate, or biliary obstruction.
Liver enzymes:
AST/ALT, LDH, and isoenzymes (LDH5): Increased because of cellular damage and release of enzymes.
Alkaline phosphatase (ALP) and isoenzyme (LAP1): Elevated because of reduced excretion.
Gamma glutamyl transpeptidase (GTT): Elevated.
Serum albumin: Decreased because of depressed synthesis.
Globulins (IgA and IgG): Increased synthesis.
CBC: Hb/Hct and RBCs may be decreased because of bleeding. RBC destruction and anemia is seen with hypersplenism and iron deficiency. Leukopenia may be present as a result of hypersplenism.
PT/activated partial thromboplastin time (aPTT): Prolonged (decreased synthesis of prothrombin)
Fibrinogen: Decreased.
BUN: Elevation indicates breakdown of blood/protein.
Serum ammonia: Elevated because of inability to convert ammonia to urea.
Serum glucose: Hypoglycemia suggests impaired glycogenesis.
Electrolytes: Hypokalemia may reflect increased aldosterone, although various imbalances may occur. Hypocalcemia may occur because of impaired absorption of vitamin D.
Nutrient studies: Deficiency of vitamins A, B12, C, K; folic acid, and iron may be noted.
Urine urobilinogen: May/may not be present. Serves as guide for differentiating liver disease, hemolytic disease, and biliary obstruction.
Fecal urobilinogen: Decreased.
NURSING PRIORITIES
1. Maintain adequate nutrition.
2. Prevent complications.
3. Enhance self-concept, acceptance of situation.
4. Provide information about disease process/prognosis, potential complications, and treatment needs.
DISCHARGE GOALS
1. Nutritional intake adequate for individual needs.
2. Complications prevented/minimized.
3. Dealing effectively with current reality.
4. Disease process, prognosis, potential complications, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
Cirrhosis is the fourth leading cause of death in the United States among people ages 35 to 55 and represents a serious threat to long-term health.
CARE SETTING
May be hospitalized on a medical unit during initial or recurrent acute episodes with potentially life-threatening complications. Otherwise, this condition is handled at the community level.
RELATED CONCERNS
Alcohol: acute withdrawal
Substance dependence/abuse rehabilitation
Fluid and electrolyte imbalances
Psychosocial aspects of care
Renal dialysis
Renal failure: acute
Total nutritional support: parenteral/enteral feeding
Upper gastrointestinal/esophageal bleeding
Patient Assessment Database
Data depend on underlying cause of the condition.
ACTIVITY/REST
May report: Weakness, fatigue, exhaustion
May exhibit: Lethargy
Decreased muscle mass/tone
CIRCULATION
May report: History of/recent onset of HF, pericarditis, rheumatic heart disease, or cancer (causing liver impairment leading to failure)
Easy bruising, nosebleeds, bleeding gums
May exhibit: Hypertension or hypotension (fluid shifts)
Dysrhythmias, extra heart sounds (S3, S4)
JVD; distended abdominal veins
Jaundiced skin, sclera
ELIMINATION
May report: Flatulence
Diarrhea or constipation; gradual abdominal enlargement
May exhibit: Abdominal distention (hepatomegaly, splenomegaly, ascites)
Decreased/absent bowel sounds
Clay-colored stools, melena
Dark, concentrated urine; oliguria (renal failure)
FOOD/FLUID
May report: Anorexia, food intolerance/ingestion
Nausea/vomiting
May exhibit: Weight loss or gain (fluid)
Tissue wasting
Edema generalized in tissues
Dry skin, poor turgor
Halitosis/fetor hepaticus, bleeding gums
NEUROSENSORY
May report: SO(s) may report personality changes, depressed mentation
May exhibit: Changes in mentation, confusion, hallucinations, coma
Slowed/slurred speech
Asterixis (involuntary jerking movements of hands/tongue/feet associated with hepatic encephalopathy)
PAIN/DISCOMFORT
May report: Abdominal tenderness/RUQ pain
Itching
Pins/needles sensation, burning pain in extremities
May exhibit: Guarding/distraction behaviors
Self-focus
RESPIRATION
May report: Dyspnea
May exhibit: Tachypnea, shallow respiration, adventitious breath sounds
Limited thoracic expansion (ascites)
Hypoxia
SAFETY
May report: Severe itching of the skin/dryness
May exhibit: Fever (more common in alcoholic cirrhosis)
Jaundice, ecchymosis, petechiae
Spider angiomas/telangiectasis, palmar erythema
SEXUALITY
May report: Menstrual disorders (women), impotence (men)
May exhibit: Testicular atrophy, gynecomastia, loss of hair (chest, underarm, pubic)
TEACHING/LEARNING
May report: History of long-term alcohol use/abuse, alcoholic liver disease
History of biliary disease, hepatitis, exposure to toxins; liver trauma; upper GI bleeding; episodes of bleeding esophageal varices; use of drugs affecting liver function
Discharge plan
DRG projected mean length of inpatient stay: 6.4 days
May need assistance with homemaker/management tasks
Refer to section at end of plan for postdischarge considerations.
DIAGNOSTIC STUDIES
Liver scans/biopsy: Detects fatty infiltrates, fibrosis, destruction of hepatic tissues, tumors (primary or metastatic), associated ascites.
Percutaneous transhepatic cholangiography (PTHC): May be done to rule out/differentiate causes of jaundice or to perform liver biopsy.
Esophagogastroduodenoscopy (EGD): May demonstrate presence of esophageal varices, stomach irritation or ulceration, duodenal ulceration or bleeding.
Percutaneous transhepatic portal angiography (PTPA): Visualizes portal venous system circulation.
Serum bilirubin: Elevated because of cellular disruption, inability of liver to conjugate, or biliary obstruction.
Liver enzymes:
AST/ALT, LDH, and isoenzymes (LDH5): Increased because of cellular damage and release of enzymes.
Alkaline phosphatase (ALP) and isoenzyme (LAP1): Elevated because of reduced excretion.
Gamma glutamyl transpeptidase (GTT): Elevated.
Serum albumin: Decreased because of depressed synthesis.
Globulins (IgA and IgG): Increased synthesis.
CBC: Hb/Hct and RBCs may be decreased because of bleeding. RBC destruction and anemia is seen with hypersplenism and iron deficiency. Leukopenia may be present as a result of hypersplenism.
PT/activated partial thromboplastin time (aPTT): Prolonged (decreased synthesis of prothrombin)
Fibrinogen: Decreased.
BUN: Elevation indicates breakdown of blood/protein.
Serum ammonia: Elevated because of inability to convert ammonia to urea.
Serum glucose: Hypoglycemia suggests impaired glycogenesis.
Electrolytes: Hypokalemia may reflect increased aldosterone, although various imbalances may occur. Hypocalcemia may occur because of impaired absorption of vitamin D.
Nutrient studies: Deficiency of vitamins A, B12, C, K; folic acid, and iron may be noted.
Urine urobilinogen: May/may not be present. Serves as guide for differentiating liver disease, hemolytic disease, and biliary obstruction.
Fecal urobilinogen: Decreased.
NURSING PRIORITIES
1. Maintain adequate nutrition.
2. Prevent complications.
3. Enhance self-concept, acceptance of situation.
4. Provide information about disease process/prognosis, potential complications, and treatment needs.
DISCHARGE GOALS
1. Nutritional intake adequate for individual needs.
2. Complications prevented/minimized.
3. Dealing effectively with current reality.
4. Disease process, prognosis, potential complications, and therapeutic regimen understood.
5. Plan in place to meet needs after discharge.
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