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Cirrhosis of the liver is a chronic disease that causes cell destruction and fibrosis (scarring) of hepatic tissue. Fibrosis alters normal liver structure and vasculature, impairing blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein. Complications include hyponatremia, water retention, bleeding esophageal varices. Coagulopathy, spontaneous bacterial peritonitis, and hepatic encephalopathy. Cirrhosis is a potentially life-threatening condition that occurs when scarring damages the liver. This scarring replaces healthy tissue and prevents the liver from working normally. Cirrhosis usually develops after years of liver inflammation. When chronic diseases cause the liver to become permanently injured and scarred, the condition is called Cirrhosis. Cirrhosis harms the structure of the liver and blocks the flow of blood. The loss of normal liver tissue slows the processing of nutrients, hormones, drugs, and toxins by the liver. Also, the production of proteins and other substances made by the liver is suppressed. People with cirrhosis often have few symptoms at first. The person may experience fatigue, weakness, and exhaustion. Loss of appetite is usual, often with nausea and weight loss. As liver function declines, water may accumulate in the legs and the abdomen (ascites). A decrease in proteins needed for blood clotting makes it easy for the person to bruise, bleeding or infection. In the later stages of cirrhosis, jaundice (yellow skin) may occur, caused by the buildup of bile pigment that is passed by the liver into the intestines. The liver of a person with cirrhosis also has trouble removing toxins, which may build up in the blood. Drugs taken usually are filtered out by the liver, and this cleansing process also is slowed down by cirrhosis. People with cirrhosis often are very sensitive to medications and their side effects. The doctor often can diagnose cirrhosis from the patient·s symptoms and from laboratory tests. During a
Laennec·s (alcohol induced) Cirrhosis y y Fibrosis occurs mainly around central veins and portal areas. Postnecrotic (micronodular) Cirrhosis y Consist of broad bands of scar tissue and results from previous acute viral hepatitis or drug-induced massive hepatic necrosis. In some cases. 3. and ultrasound. other tests that take pictures of the liver are performed such as the computerized axial tomography (CAT) scan. Three major forms 1. the doctor could notice a change in how your liver feels or how large it is. and is much rarer than the preceding forms . This is the most common form of cirrhosis and results from chronic alcoholism and malnutrition. Biliary Cirrhosis y Consist of Scarring of bile ducts and lobes of the liver and results from chronic biliary obstruction and infection (cholangitis).physical exam. In some cases. 2. The doctor may decide to confirm the diagnosis by putting a needle through the skin (biopsy) to take a sample of tissue from the liver. If the doctor suspects Cirrhosis. you will be given blood tests. cirrhosis is diagnosed during surgery when the doctor is able to see the entire liver. The purpose of these tests is to find out if liver disease is present.
has multiple functions. both of which are made up of thousands of lobules. beneath the diaphragm and on top of the stomach.ANATOMY AND PHYSIOLOGY: The liver is located in the upper right-hand portion of the abdominal cavity. a dark reddishbrown organ that weighs about 3 pounds. The liver regulates most chemical levels in the blood and excretes a product called ´bile. The liver processes this blood and breaks down the nutrients and drugs into forms that are easier to use for the rest of the body. The liver. The liver consists of two main lobes. All the blood leaving the stomach and intestines passes through the liver. Some of the more well-known functions include the following: . There are two distinct sources that supply blood to the liver: y y oxygenated blood flows in from the hepatic artery nutrient-rich blood flows in from the portal vein The liver holds about one pint (13 percent) of the body·s blood supply at any given moment.µ which helps carry away waste products from the liver. The hepatic duct transports the bile produced by the liver cells to the gallbladder and duodenum (the first part of the small intestine). More than 500 vital functions have been identified with the liver. These lobules are connected to small ducts that connect with larger ducts to ultimately form the hepatic duct.y II. right kidney and intestines.
Chronic hepatitis C The hepatitis C virus ranks with alcohol as a major cause of chronic liver disease and cirrhosis in the US. which form the building blocks of proteins. causes liver inflammation and injury that over several decades can lead to cirrhosis. (This glycogen can later be converted back to glucose for energy. cirrhosis of the liver is synonymous with chronic alcoholism. (The liver stores iron. alcoholism is only one of the causes.) Clearing the blood of drugs and other poisonous substances. Chronic hepatitis B and D The hepatitis B virus is probably the most common cause of cirrhosis worldwide.y y y y y y y y y y Production of bile. as few as two to three drinks per day have been linked with cirrhosis and in men. but in fact. and carbohydrates. Processing of hemoglobin for use of its iron content.) Conversion of poisonous ammonia to urea. Production of cholesterol and special proteins to help carry fats through the body. as few as three to four drinks per day. Production of certain proteins for blood plasma. Infection with this virus causes inflammation of and low grade damage to the liver that over several decades can lead to cirrhosis. Conversion of excess glucose into glycogen for storage. Alcoholic cirrhosis usually develops after more than a decade of heave drinking. III. When the liver has broken down harmful substances. but only in people who already have hepatitis B. Resisting infections by producing immune factors and removing bacteria from the blood stream. . Alcohol seems to injure the liver by blocking the normal metabolism of protein. its by-products are excreted into the bile or blood.) Regulation of blood levels of amino acids. fats.ETIOLOGY / CAUSES Alcoholic liver disease For many people. Bile by-products enter the intestine and ultimately leave the body in the feces. and leave the body in the form of urine. (Urea is one of the end products of protein metabolism that is excreted in the urine. In women. The amount of alcohol that can injure the liver varies greatly from person to person. but less common in the US and other western countries. like hepatitis C. which helps carry away waste and break down fats in the small intestine during digestion. Hepatitis B. Hepatitis D is another virus that infects the liver. Blood by-products are filtered out by the kidneys. Regulating blood clotting.
Blocked bile ducts When the ducts that carry bile out of the liver are blocked. and glycogen storage diseases are among the inherited diseases that interfere with the way the liver produces. coronary artery disease. and treatment with corticosteroid medications. fatigue Anorexia Stomatitis Urine ² tea color Stool ² clay color Amenorrhea Decrease sexual urge Loss of puic hair. a diseases in which the bile ducts are absent or injured. This type of hepatitis appears to be associated with diabetes. In adults. galactosemia.Autoimmune hepatitis This disease appears to be caused by the immune system attacking the liver and causing inflammation. Nonalcoholic steatohepatitis (NASH) In NASH. IV. Wilson disease. damage. processes. bile backs up and damages liver tissue. blocked bile ducts are most commonly caused by biliary atresia. axilla hair Hepatomegaly Jaundice Pruritus or urticaria . and eventually scarring and cirrhosis. and other substances the body needs to function properly. protein malnutrition. obesity. the most common cause is primary biliary cirrhosis. proteins. fat builds up in the liver and eventually causes scar tissue. Secondary biliary cirrhosis can happen after gall bladder surgery if the ducts are inadvertently tied off or injured. Signs and Symptoms Early Signs y y y y y y y y y y y Weakness. In babies. and scarred. blocked. a disease in which the ducts become inflamed. metals. Inherited Disease Alpha-1 antitrypsin deficiency. and stores enzymes. hemochromatosis.
which are blood vessels that enlarge to provide an alternative pathway for blood diverted from the liver. Palmar errythema GIT changes o Ascitis. Complications 1. including fluid buildup and bleeding.Late Signs y Hematological changes ² all blood cells decrease o Leukopenia ² decrease o Thrombocytopenia ² decrease o Anemia ² decrease Endocrine changes o Spider angiomas. Varices pose a high risk for rupture and bleeding because of the following characteristics: y y y They are thin-walled. 2. but it can result from other conditions. 3. In fact. some experts refer to the phases of cirrhosis as preascitic and ascitic . liver cell damage slows down blood flow. Ascites is usually caused by portal hypertension. . Once ascites occurs. They are often twisted. Ascites and Fluid Buildup Ascites is fluid buildup in the abdomen. Although ascites itself is not fatal. Swelling can also occur in the arms and legs and in the spleen. a condition called portal hypertension. bleeding esophageal varices ² due to portal Hypertension Neurological Changes y y y V. This causes a backup of blood through the portal vein. It is uncomfortable and can reduce breathing function and urination. it is a marker for severe progression. Portal Hypertension In cirrhosis. Gynecomastia o Caput medusa. In about two-thirds of patients they form in esophagus. only half of patients survive after 2 years. Variceal Bleeding One of the most serious repercussions of portal hypertension is the development of varices . Some doctors even believe that ascites signals the need for liver transplantation. They are subject to high pressure. particularly in alcoholic cirrhosis. The effects of portal hypertension can be widespread and serious.
Kidney Failure Portal hypertension can cause several secondary complications. the risk for recurrence is the same as for patients who have not had a bleeding event. may increase the risk for kidney failure.y Internal bleeding from these varices (variceal bleeding) occurs in 20 ² 30% of patients with cirrhosis. but after 6 weeks. Bacterial infection. Some experts recommend that all newly diagnosed patients be screened using endoscopy. Between 30 ² 40% of patients with cirrhosis experience bleeding. such as naproxen. Gastrointestinal Bleeding Gastrointestinal (GI) bleeding can occur from abnormal blood clotting. including kidney failure. Large veins. The risk of death from a single episode can reach 70%. It is important for patients to be screened for esophageal varices and treated with preventive beta blockers if they show signs of risk. Non-steroidal anti-inflammatory drugs (NSAIDs). Eating increases portal pressure. Factors that predict variceal bleeding include: y y y Ascites. and there is a greater risk for bleeding in the evening. Factors that can increase the danger for a bleeding episode in high-risk individuals include the following: y y y Moderate to intense exercise. which can be result of a combination of complications associated with cirrhosis. 5. 4. Screening should also be considered for all previously diagnosed patients who have not been screened but would benefit from preventive treatments. They include vitamin K deficiencies and thrombocytopenia ³ a drop in platelets (the blood cells that normally initiate the clotting process). A lesser but still significant risk occurs in the early morning. Bleeding commonly recurs within 2 weeks of the first episode. Some research now suggests that thrombocytopenia itself may be associated with more advanced liver failure. Certain times of the day. Encephalopathy. . this complication has a mortality rate of 20 ² 35%.
including those in the urinary. Even minimal hepatic encephalopathy (MHE) can have detrimental effects on functional ability. Abdominal infections are a particular problem in cirrhosis and occur in up to 25% of patients with cirrhosis within a year of diagnosis. and trouble concentrating. Sudden changes in the patient·s mental state. A combination of conditions associated with cirrhosis causes this serious complication: y y Buildup in the blood of harmful intestinal toxins. and may even increase the risk for bleeding. including agitation or confusion. may indicate an emergency condition. Symptoms of Encephalopathy. particularly ammonia. In severe cases. develop when patients are in the hospital. unresponsiveness. but one study suggested that alcoholics simply tend to have more severe cirrhosis. Early symptoms of hepatic encephalopathy include forgetfulness. and that all patients with cirrhosis be tested for MHE. respiratory. Most bacterial infections. 7. . Mental Impairment and Encephalopathy Mental impairment is a common event in advanced cirrhosis. One study suggested that MHE impairs the ability to safely drive a car. Infections Bacterial infections are very common in advanced cirrhosis. including: y y y y y y Gastrointestinal bleeding Constipation Excessive dietary protein Infection Surgery Dehydration Alcoholics with cirrhosis are believed to be at higher risk for this complication than are nonalcoholic cirrhosis. An imbalance of amino acids that affect the central nervous system.6. Other symptoms include bad fruitysmelling breath and tremor. the disease causes encephalopathy (damage to the brain). Late stage symptoms of encephalopathy are stupor and eventually coma. or gastrointestinal tracts. Encephalopathy is often triggered by certain conditions. 8. with mental symptoms that range from confusion to coma and death.
Osteoporosis About 30% of patients with chronic liver disease develop osteoporosis (loss of bone density). Hepatorenal Syndrome Hepatorenal syndrome occurs if the kidneys drastically reduce their own blood flow in response to the altered blood flow in the liver. Patients with primary biliary cirrhosis have a particularly high risk for osteoporosis. It is a life-threatening complication of latestage liver disease that occurs in patients with ascites. mental changes (delirium. but this high rate is not seen in other parts of the world. This hormone is important for delivering blood sugar and amino acids into cells and helps determine whether these nutrients will be burned for energy or stored for future use. yellowish skin. regardless of the cause of cirrhosis. Symptoms include dark colored urine and a reduction in volume. confusion). About 4% of patients with cirrhosis caused by hepatitis C develop liver cancer. one study reported an incidence of 2.9. and vomiting. Insulin resistance is a primary feature in type 2 diabetes and occurs when the body is unable to use insulin. nausea. abdominal swelling. One study found that calcitriol (a form of vitamin D) is especially helpful in preventing bone loss in patients with cirrhosis. Liver Cancer Cirrhosis greatly increases the risk for liver cancer. which is twice the usual incidence. jerking or coarse muscle movement. In Asia about 15% of people who have chronic hepatitis B develop liver cancer.) 11. (One Italian study that followed a group of hepatitis B patients for 11 years found no liver cancer over that period of time. Although few studies have been conducted on the risk for liver cancer in patients with primary biliary cirrhosis. . 12. Insulin Resistance Nearly all patients with cirrhosis are insulin resistant.3%. 10. Treating osteoporosis in patients with cirrhosis can be complicated.
Medical Management y y y y Provide asymptomatic relief measures such as pain medications and antiemetics. PTC ² differentiates extrahepatic from intrahepatic obstructive jaundice. protein. Laparoscopy and liver biopsy ² permit direct visualization of the liver. y . Orthotropic liver transplantation may be necessary. Paracentesis ² to examine ascetic fluid for cell. Liver scan ² shows abdominal thickening and a liver mass. This percutaneous procedure creates a shunt from the portal to systemic circulation to reduce portal pressure and relieve ascites.V albumin to maintain osmotic pressure and reduce ascites. Diagnostic Tests y y y y y y y y Liver biopsy ² detects destruction and fibrosis of hepatic tissue. Serum liver function test ² results are elevated VIII. Pathophysiology VII. frequently with spironolactone. and bacterial counts.VI. I. Esophagoscopy ² to determine esophageal varices. CT scan ² determines the size of the liver and its irregular nodular surface. a potassium-sparing diuretic that inhibits the action of aldosteroe on the kidneys. Diuretic therapy. IX. Administration of lactulose or neomycin through a nasogastric tube or retention enema to reduce ammonia levels during periods of hepatic encephalopathy. Surgical Interventions y Transjugular intrahepatic portosystemic shunt may be performed in patients whose ascites prove resistant.
Emphasize the importance of rest. Encourage and assist with gradually increasing periods of exercise. Encourage frequent skin care. and massage with emollient lotions. a sensible lifestyle. well-balanced diet. Discuss adverse effects of diuretic therapy. Encourage and assist withgradually increasing periods of exercise. and an adequate. Protecting Skin Integrity: y y y Note and record degree of jaundice of skin and sclerae and scratches on the body. Suggest small. Nursing Interventions Promoting Activity Tolerance: y y y Encourage alternating periods of rest and ambulation. Stress the importance of continued follow ²up for laboratory test and evaluation by a health care provider. Advise patient to keep fingernails short. Involve the person closest to the patient because recovery usually is not easy and relapses are common. Improving Nutritional Status: y y y Encourage patient to eat high calorie. bathing without soap. Patient Education and Health Maintenance: y y y y y y y y Stress the necessity of giving up alcohol completely. Encourage daily weighing for self-monitoring of fluid retention depletion. Maintain some periods of bed rest with legs elevated to mobilize edema and ascites. Urge acceptance of assistance from a substance abuse program. . frequent feedings and attractive meals in an aesthetically pleasing setting at meal time.X. moderate protein meal and to have supplementary feedings. Provide written dietary instructions.
*Blood pressure elevation usually associated with fluid volume excess but may not occur because of fluid shifts out of the vascular space. noting increased respiratory rate. Coagulopathy. and note weight gain more than 0. and hepatic encephalopathy . *Reflects circulating volume status. *Measure abdominal girth. Fibrosis alters normal liver structure and vasculature. the patient will demonstrate stabilized fluid volume and decreased edema. *Reflects accumulation of fluid (ascites) resulting from loss of plasma proteins or fluid into peritoneal space. *Auscultate lungs. and increased anti diuretic hormone (ADH). impaired gas exchange. decreased albumin. impairing blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein. Nursing Care Plan Assessment SUBJECTIVE: ´Napansin ko na lumalaki ang tiyan koµ (I feel that my tummy is getting bigger) As verbalized by the patient. *Measure intake and output. dyspnea. Intervention INDEPENDENT: Rationale Evaluation After 8 hours of nursing interventions. *Assess respiratory status. *Increasing pulmonary congestion may result in consolidation. *Monitor blood pressure. water retention. Complications include hyponatremia. Positive balance/ weight gain often reflects continuing fluid retention. noting diminished/ absent breath sounds and developing adventitious sounds. and complications. spontaneous bacterial peritonitis. *Fluid shift into tissues as a result of sodium and water retention. *Indicative of pulmonary congestion.XI. Inference Cirrhosis of the liver is a chronic disease that causes cell destruction and fibrosis (scarring) of hepatic tissue. weigh daily. the patient was able to demonstrate stabilized fluid volume and decreased edema. *Assess degree of peripheral/ dependent edema.3 P: 89 R: 20 BP: 120/80 Diagnosis Fluid volume excess related to compromise d regulatory mechanism. OBJECTIVE: y Anasarca y Weight gain y Altered electrolyte levels y Oliguria V/S taken as follows: T: 37. . bleeding esophageal varices.5 kg/day. Planning *After 8 hours of nursing interventions.
*To correct further imbalances. recumbencyinduced diuresis. *To control edema and ascites.*Encourage bed rest *May promote when ascites is present. *Monitor electrolytes. COLABORATIVE: *Administer medications as indicated. . Such as diuretics.
RN . CORONEL. GREGORIO SUBMITTED TO: GENELYN GRACE G.WESLEYAN UNIVERSITY PHILIPPINES CABANATUAN CITY COLLEGE OF NURSING CASE STUDY OF LIVER CIRRHOSIS SUBMITTED BY: JOEY R.
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