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790 UNIT EIGHT Understanding the Gastrointestinal, Hepatic, and Pancreatic Systems
Some evidence shows supplementation with branched-
chain amino acids (isoleucine, leucine, and v aline) may
delay the progression of cirrhosis. Branched-chain amino
acids do not require oxidation by the liver and are available
for direct use by other tissues. A special formula for oral
or enteral feeding is Hepatic-Aid II®.
Nutritional Care for Patients With Hepatic
Encephalopathy
Hepatic encephalopathy is associated with increased serum
levels of ammonia caused by the li ver’s inability to degrade
ammonia to urea. Ammonia is toxic to all cells, including
those of the li ver and the brain. The goal of nutritional
management of patients with hepatic encephalopathy is to
promote protein synthesis by supplying ample amounts of
amino acids. Only in cases of se vere protein intolerance
should protein be restricted and then for as short a time as
possible with supplemental branched-chain amino acids
administered until normal protein intake is resumed.
Complication of Alcoholic Liver Disease:
Wernicke-Korsakoff Syndrome
This disorder of the central nervous system, caused by thiamin
deficiency, is diagnosed mainly in alcoholics b ut also occa-
sionally in malnourished patients with no history of alcohol
abuse, including women with hyperemesis gravidarum.
Wernicke’s encephalopathy is an acute neuropsychiatric
condition caused by inadequate thiamin supplied to the brain.
When caused by dietary deficiency, it can usually be successfully
treated with oral or subcutaneous thiamin and rarely progresses
to Korsakoff’s psychosis, the result of damage to the brain tissue.
Thiamin given at this stage will not re verse the effects. These
patients display an abnormal mental state in which memory and
learning are affected out of all proportion to other cogniti ve
functions in an otherwise alert and responsive patient.
Nursing Process for the Patient With Acute Liver
Failure and Cirrhosis
DATA COLLECTION. A complete history and physical
assessment are done. Be alert to subjective symptoms of liver
dysfunction, such as abdominal pain, anorexia, nausea, severe
itching, and dull, aching RUQ pain. Note objective evidence
of liver problems, such as jaundice, light-colored stools,
ascites, ecchymosis (bruising) of the skin, GI bleeding, and
any evidence of alterations in thought processes, such as
confusion, disorientation, or inability to make decisions.
NURSING DIAGNOSES, PLANNING, AND IMPLEMENTATION.
Common nursing diagnoses for patient with cirrhosis include
the following.
Excess Fluid Volume related to portal hypertension (ascites)
EXPECTED OUTCOME: Fluid volume will be controlled as evi-
denced by stable weight and abdominal girth within normal
limits for the patient.
• Weigh the patient on admission and daily to measure fluid
retention.
• Measure and record the patient’s abdominal girth (circum-
ference) daily to monitor ascites. Mark the place where
you measured so the same site will always be measured
during subsequent assessments.
• Report any weight gain or increase in girth promptly so
treatment can be ordered and complications minimized.
• Monitor the patient’s vital signs and lung sounds; report
changes and any evidence of difficulty breathing or
changes in mental status promptly to detect fluid overload.
• Measure all intake and output to accurately detect fluid
overload.
• Maintain a low-sodium diet and order fluid restrictions to
reduce fluid retention.
• Administer ordered diuretics as scheduled to reduce fluid
volume.
• If IV fluids or albumin have been ordered, assist in careful
monitoring of the rate of infusion to prevent or detect
fluid overload.
Imbalanced Nutrition: Less Than Body Requirements related
to anorexia and impaired metabolism of needed nutrients
EXPECTED OUTCOME: The patient’s (dry) weight will be
within normal limits for height.
• Monitor weight; report unexpected (nonfluid) weight loss
so timely intervention can be implemented.
• Monitor serum prealbumin, total protein, vitamin, and
mineral levels because these may be better indicators of
nutrition if nutritional status is masked by fluid overload
in weight measurement.
• Offer frequent mouth care to increase comfort and make
food more palatable.
• Make sure that odors and other unpleasant stimuli are
eliminated to prevent further worsening of appetite.
• Offer the patient frequent, small, high-calorie meals
to reduce feeling of fullness that can occur with larger
meals.
• Administer vitamins or supplements as ordered to correct
deficiencies.
Pain related to abdominal pressure
EXPECTED OUTCOME: The patient will state pain level is
acceptable.
• Monitor pain level using a 10-point scale and WHAT’S
UP? questions to guide treatment.
• Give analgesics as ordered to control pain. Lower doses
may be needed for the patient with liver dysfunction.
• Encourage nondrug pain relief activities, such as distraction,
imagery, and relaxation to possibly decrease the need for
analgesics.
Risk for Disturbed Thought Processes related to elevated
ammonia levels
EXPECTED OUTCOME: The patient will remain alert and ori-
ented to person, place, and time.
• Assess the patient’s level of consciousness and orientation
often to allow prompt treatment.
• Assess neuromuscular function by asking the patient to
hold his or her arms out straight in front and steady.