1. Liver Cirrhosis Ma. Tosca Cybil A. Torres, RN, MAN

2. LEARNING OBJECTIVES: After 2 hours of active lecture discussion, the students will be able to: Define liver Cirrhosis Enumerate the different types of liver cirrhosis Enumerate the predisposing/ contributing factors of liver cirrhosis Discuss the pathophysiological changes and clinical manifestations of patients with liver cirrhosis Formulate possible nursing diagnoses applicable for patients with liver cirrhosis Enumerate nursing interventions applicable for each identified nursing diagnosis Integrate Christian Values in rendering nursing care for clients with liver cirrhosis MTCAT '10

4. Liver Cirrhosis Types: Alcoholic Cirrhosis ( Laennec’s Cirrhosis) Most common type of liver cirrhosis Caused by chronic alcoholism Postnecrotic cirrhosis Late result of a previous bout of acute viral hepatitis Biliary cirrhosis Resulted from chronic biliary obstruction and infection Least common type MTCAT '10

6. effects of alcohol abuse

7. chronic impairment of bile excretion – biliary obstruction in the liver and common bile duct (gallbladder stones)

8. necrosis from hepatotoxins or viral hepatitis

9. Congestive heart failureMTCAT '10

11. attempts at regeneration eventually result to fibrosis and a small nodular liver

12. hepatic function is slowly impaired

13. obstruction of venous channels blocks hepatic blood flow and cause portal hypertensionMTCAT '10

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18. aching or heaviness in right upper quadrant

19. weakness & fatigueMTCAT '10

21. bilirubin (N=0-0.9mg/dl),

22. AST (N=4.8-19U/L)

23. ALT (N= 2.4-17U/L)

24. Serum alkaline phosphatase (N=30-40U/L)

25. Ammonia (plasma) (N= 15-45umol/L)

26. intermittent jaundice, pruritus

27. edema, ascites, prominent abdominal wall veins

28. Ecchymosis, bleeding tendencies

29. anemia

30. Infection

31. Gynecomastia, testicular atrophy

32. Neurologic changes MTCAT '10

34. due to:

35. intravascular colloidal pressure

36. capillary hydrostatic pressure

37. Na and H2O retention

38. Failure of the liver to metabolize aldosteroneMTCAT '10

40. fatigue

42. diuretic therapy (furosemide/ spironolactone)

43. Paracentesis– for diagnosis or when fluid volume compromise comfort & breathingMTCAT '10

45. fluid & Na restriction

46. monitor I/O, daily wt.

47. measure abd. girth every shift

48. maintain on high-Fowlers for max. respiration

49. support abdomen with pillows

51. high –fowlers position during the procedure

52. monitor pt. for hypovolemia & electrolyte imbalance

53. observe puncture wound for leakage & signs of infectionMTCAT '10

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 tractMTCAT '10

56. Pathogenesis of Hepatic Encephalopathy BRAIN LIVER Toxic N2 metabolites From Intestines MTCAT '10

58. LOC – lethargy progressing to coma

59.  mental status, confusion, disorientation

60. dullness, slurred speech

61. behavioral changes, lack of interest in grooming/ appearance

62. twitching, muscular incoordination, tremors

63. Fetor hepaticus

64. elevated serum ammonia levelMTCAT '10

67. turning to side

68. assess mental status, LOC

69. proper positioning (semi-Fowler’s)

71. prescribed medications

72. avoid constipation ( to  ammonia production by bacteria in the GIT)

73. early signs of encephalopathy (restlessness, slurred speech, dec. attention span)MTCAT '10

75. the  portal venous pressure causes blood to be forced into these vessels – become tortous and fragile

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. bleeding may also occur as a result of coughing, vomiting, sneezing, straining at stool or any physical exertion that  abdominal venous pressure MTCAT '10

79. signs/symptoms of hypovolemic shock MTCAT '10

82. Balloon tamponade MTCAT '10

83. MTCAT '10

84. esophageal variceal ligation (EVL) MTCAT '10

85. Possible Nursing Diagnoses Activity intolerance R/T fatigue, lethargy, and malaise Imbalanced nutrition R/T abdominal distention and discomfort, and anorexia Impaired skin integrity R/T pruritus from jaundice and edema High risk for injury R/T altered clotting mechanisms and altered LOC Disturbed body image R/T changes in appearance, sexual dysfunction, and role function Chronic pain R/T enlarged tender liver and ascites Fluid volume excess R/T ascites and edema formation Ineffective breathing pattern R/T restriction of thoracic excursion secondary to ascites and abdominal distention MTCAT '10

87. eliminate ingestion of toxic substances to the liver: sedatives opiates, alcohol, acetaminophen

88.  activitiesMTCAT '10

90. multiple vitamin therapy

91. restrict fluids & sodium if there is edema or ascites

92. provide mouth care before meals

94. reverse isolation

95. assess for signs of infection esp. urinary

96. encourage deep breathing/position changesMTCAT '10

98. avoid injections, apply pressure to venipuncture sites for at least 5 mins.

99. Monitor prothrombin time, bleeding time

100. Teach pt. to use soft toothbrush, avoid constipation

101. Prevent scratching from pruritus, proper skin care

102. Administer Vit. K as ordered MTCAT '10

103. Questions????? MTCAT '10

104. ASSIGNMENT: Answer situation #4 in critical thinking exercises, Brunner & Suddarth’s Textbook of Medical-Surgical Nursing, 11th Edition, 2009 Page 1341 WRITE your answers in a whole sheet of yellow paper MTCAT '10

105. Thank you... ¥Øøµ MTCAT '10