Cirrhosis of the LiverCh. 44 Case Study

Group F: Sai-Han Ackerman, Scott Demar, Natalie Drorbaugh, Elizabeth Farr, David Fuentes, Emily Groves, Meredith Pelty, Tricia Salls, Whitney Ligon, & Athena Watkins

Learning Objectives 1. Identify 3 possible causes of cirrhosis

2. List the clinical manifestations of cirrhosis

3. Name 2 laboratory tests used to assess liver function

4. List 3 nurisng interventions for a patient with cirrhosis

Our Patient M.B. - 55-y.o. Native American man• Admitted with liver cirrhosis Dx• Bloody vomiting for 2 days• Has had cirrhosis for 12 years• Sober for past 2 years, drank for 20 years• Complaints: anorexia, nausea, abdominal discomfort• Thin, malnourished, moderate ascites, jaundice of skin and

sclera, 4+ pitting edema of LE, palpable liver and spleen

Question 1

What are the possible causes of cirrhosis?

Possible Causes• Alcohol abuse

• Complication of hepatitis

• Chronic biliary obstruction

• Infection

• Long-standing, severe, right-sided heart failure

iClicker QuestionWhat type of cirrhosis does M.B. probably have?

A) Alcoholic cirrhosis

B) Biliary cirrhosis

C) Cardiac cirrhosis

D) A and C

Question 2

Describe the pathophysiologic changes that occur in the liver as cirrhosis develops.

Pathophysiology & Etiology

• Progressive disease characterized by:• Extensive degeneration• Destruction of parenchymal cells• Any long-term liver disease, including excessive alcohol intake

causes cirrhosis• 20% of patients with chronic Hepatitis C develop cirrhosis• Primary biliary cirrhosis• Primary sclerosing cholangitis• Cardiac cirrhosis—right-sided HF

• Still alcohol is the single most common cause of cirrhosis

i-Clicker QuestionThe scaring of the liver specifically originates with collagen and fibrin deposits within?

A) The sinusoid

B) The hepatocyte

C) The peritoneal Space

D) The perisinusoidal Space

Question 3

List M.B.’s clinical manifestations of liver failure.

Clinical Manifestations• Anorexia/Nausea/Abdominal discomfort

• Ascites

• Jaundice of sclera and skin

• Palpable liver & spleen

i-Clicker QuestionJaundice of the sclera and skin in liver cirrhosis is due to:

A) An accumulation of ammonia in the blood stream

B) The inability of the damaged liver to conjugate and excrete bilirubin

C) Splenomegaly due to portal hypertension

D) Elevated AST and ALT levels

Question 4

Explain the significance of the results of his laboratory values.

Laboratory Results• Total bilirubin: Conjugated + Unconjugated

• Indicator for biliary obstruction, impaired liver function, hemolytic anemia, and pernicious anemia

• Serum Ammonia• Indicator for severe liver disease

• AST: Aspartate aminotransferase• Indicator for liver disease, MI, pulmonary infarction, and acute hepatitis

• ALT: Alanine aminotransferase• Indicator for liver disease and shock

Laboratory ValuesResults• Total bilirubin

• 15 mg/dl• (257 mmol/L)

• Serum ammonia• 220 mcg/dL• (122 mmol/L)

• AST• 190 U/L (3.2 µkat/L)

• ALT• 210 U/L (3.5 µkat/L)

Normal Levels• Total bilirubin

• 0.2-1.2 mg/dL• (3-21 mmol/L)

• Serum ammonia• 15-45 mcg N/dL• (11-32 mmol N/L)

• AST• 10-30 U/L (0.17-0.51 µkat/L)

• ALT• 10-40 U/L (0.17-0.68 µkat/L)

i-Clicker QuestionIn liver disease, ALT and AST are increased due to the:

A) Result of the liver's inability to convert ammonia into urea and stay in the system.

B) Release of enzymes from damaged liver cells.

C) Result of liver's inability to excrete or take up bilirubin.

D) Two of these answers.

Question 5

If M.B. begins to manifest signs and symptoms of hepatic encephalopathy, what would you monitor? What measures should be instituted to control or decrease the encephalopathy?

Clinical Manifestations• Early Stage

• Euphoria• Depression• Irritability• Memory loss• Confusion• Drowsiness• Insomnia• Slurred speech• Slow and deep respirations• Positive Babinski reflex

• Impending Coma• Disorientation to time, place,

person• Hyperventilation• Hypothermia• Graspin relfexes

**Asterixis or glapping tremor or liver flap

Managing Hepatic Encephalopathy

• Neurologic and mental responsiveness• From lethargy to coma• ↑ ammonia blood levels

• Goal in management• ↓ ammonia formation in the intestines (Lactulose)• Sterilization of the intestines with antibiotics• Cathartics and enemas to ↓ bacterial action• Constipation should be prevented

• Controlling preciptating causes• GI hemorrhage to ↓ protein in intestines• Electrolyte & acid-base imbalances

i-Clicker QuestionWhen assessing the neurologic status of a patient with a diagnosis of hepatic encephalopathy, the nurse asks the patient to

A) Stand on one foot.

B) Ambulate with the eyes closed.

C) Extend both arms.

D) Perform the Valsalva maneuver.

Question 6

What are possible causes of his gastrointestinal bleeding?

• Esophageal varices• Alterations in normal blood clotting mechanisms

Esophageal Varices• Veins at the lower end of the

esophagus that have become distended as a result of portal hypertension

• Vessels rupture in response to irritation

• Causes of irritation include• Alcohol• Swallowing poorly chewed food• Acid regurgitation from the stomach• Increase intraabdominal pressure

caused by nausea, vomiting, straing at stool, coughing, sneezing, or lifting heavy objects

(Merkel & Montagnese, 2012)

Alterations in Normal Blood Clotting• Result from liver’s inability to produce prothrombin and other

clotting factors• Manifestations include

• Epistaxis• Purpura• Petechiae• Easy bruising• Ginival bleeding• Heavy menstraul bleeding

iClicker QuestionAll of the following are triggers that can cause esophageal varices to rupture except what?

A) alcohol consumption

B) pressure caused by nausea and vomiting

C) sitting in high-fowler's position

D) swallowing poorly chewed food

Question 7

Priority Decision: Based on the assessment data, what are the priority nursing diagnoses? Are there any collaborative problems?

Nursing Diagnoses Priority Nursing Diagnoses for M.B.:• Imbalanced Nutrition: less than body requirement related to vomiting as evidenced

by thin and malnourished appearance• Excess fluid volume related to portal hypertension as evidenced edema and ascites• Impaired skin integrity related to peripheral edema and ascites as evidenced by

shiny skin over edematous areas

Other Common Diagnoses for People with Cirrhosis: • Dysfunctional family process: alcoholism• Ineffective breathing pattern• Compromised family coping • Potential complication: hemorrhage• Potential complication: hepatic encephalopathy

Collaborative Problems• Ascites

• Esophageal and Gastric Varices

• Hepatic Encephalopathy

• Nutritional Therapy

iClicker QuestionA nurse understands that M.B. needs additional patient education

regarding his ascites management when he says:

A) I will consume a low sodium diet of 250-500 mg of sodium per day

B) I will need to take prescription Diuretics

C) I should reduce my daily fluid intake

D) A paracentesis may need to be performed if I have difficulty breathing or abdominal pain

Question 8

Priority decision: What are the priority nursing interventions for the patient at this stage of illness?

Priority Nursing InterventionsHealth Promotion

• Remain sober & alcohol free• Maintain adequate nutrition• Although not pertinent for M.B., individuals should identify

and treat early cirrhosis and early hepatitis• Avoid liver-toxic drugs• Treat biliary disease to prevent stone obstruction and

infection• Treat the underlying cause of right-sided heart failure to

prevent it from leading to cirrhosis• If obese, have bariatric surgery

Priority Nursing InterventionsAcute Intervention• Allow the patient to rest• Oral hygiene before meals for taste• Between-meal nourishments• Nurisng assessment

• Jaundice?, urine and stool color, edema and ascites present?, I & O, dyspnea

• Skin Care• Turning schedule/ROM exercise• Coughing & deep breathing• Monitor bleeding, anemia, infection• Bleeding varices

• Treat hepatic encephalopathy

Patient Education

What should the RN teach the patient?

Patient Education• Prevent further damage to liver

• Avoid alcohol• No acetaminophen, NSAIDs, aspirin• Talk to heatlh care provider before taking any

medication (presciption or OTC)

• Nutrition• Low sodium diet (to prevent further fluid retention• Balanced diet

Patient Education• Avoid Infection

• Immunizations: influenza, hepatitis A, hepatitis B, pneumococcal

• Aboid raw shellfish• Practice safe sex• Use clean needles for tattoos or piercings • Do not share needles, razors, toothbrushes, or other

personal items with others

iClicker QuestionWhich of the following statements, if made by the patient, indicates that further teaching is necessary?

A) I will avoid taking Ibuprofen.

B) I will not share personal items like razors with others in my household.

C) I should make sure to schedule time for rest and adequate sleep.

D) I will order potato chips with my sandwich.

Clinical Nurse Leader

What CNL role could be useful in regards to cirrhosis of the liver?

Clinical Nurse LeaderEducator• Health promotion for M.B. after the dx of liver cirrhosis is the

primary concern for the CNL• The CNL can

• Educate the pt on the importance of avoiding alcohol use• Promote a diet that supports liver health• S/S of hepatitis• Teach M.B. to avoid drugs that are particularly hepatotoxic

• Such as acetaminophen

AACN. White paper on the education and role of the clinical nurse leader. (February 2007).

SummaryPossible causes of cirrhosis are• Alcohol abuse• Complication of hepatits• Chronic biliary obstruction• Infection• Long-standing, severe, right-sided HF

The clinical manifestations of cirrhosis are• Anorexia/nausea/abdominal discomfort• Ascites • Jaundice of sclera and skin• Palpable liver/spleen

SummaryLaboratory tests used to check liver function are• Total bilirubin• Serum ammonia• AST• ALT

Nursing interventions for a patient with cirrhosis include• Maintain adequate nutrition• Avoid liver-toxic drugs• Allow rest• Skin care• Coughing and deep breathing• Monitor bleeding, anemia, infection, bleeding varices

ReferencesAACN. (2007). White paper on the education and role of the clinical nurse leader.

Retrieved from http://www.aacn.nche.edu/publications/white-papers/cnl

American Liver Foundation. (2011). Cirrhosis. Retrieved from http://www.liverfoundation.org/abouttheliver/info/cirrhosis/

Bonis, B. A. L., & Chopra, S. (2011). Patient information: Cirrhosis (beyond the basics) Retrieved from http://www.uptodate.com/contents/cirrhosis-beyond-the-basics

Croghan, A. & Heitkemper, M.M. (2011). Liver, pancreas, and biliary tract problems. In Lewis, Dirksen, Heitkemper, Bucher, Camera (Eds.), Medical-surgical nursing (pp. 1058-1102). St. Louis, MI: Elsevier Mosby.

Dirksen, S. R., Lewis, S. L., Heitkemper, M. M, & Bucher, L. (2011). Clinical companion, Medical surgical nursing: Assessment and management of clinical problems. (8th ed.) St. Louis, MO: Elsevier Mosby.

Merkel, C. & Montagnese, S. (2012). Secondary prophylaxis in patients who have experienced portal hypertensive bleeding. Clinical Liver Disease, 1, 155–157. doi: 10.1002/cld.86

THE END

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