Included In This Lesson
Study Tools
Outline
Pathophysiology
Liver cirrhosis is a chronic, irreversible liver disease. Inflammation and fibrosis of liver cells (hepatocytes) lead to the formation of scar tissue within the liver, which causes obstruction of hepatic blood flow and impedes proper liver function. This impaired blood flow leads to edema, ascites, esophageal varices, hemorrhoids, and varicose veins, among many other things. Since the liver is responsible for making many of the chemicals required by the body to function, breaking down and detoxifying substances and storing vitamins and minerals, many of the body’s systems fail to function when the liver is damaged.
Etiology
Liver cirrhosis is primarily caused by diseases that damage the liver and leave scar tissue in place of healthy tissue. Alcoholic liver disease (26%) and Hepatitis C (21%) are the cause behind 47% of liver cirrhosis cases in the United States. Other factors such as nonalcoholic fatty liver disease, Hepatitis B and D, autoimmune disease, and chronic heart failure with liver congestion may also result in cirrhosis.
Desired Outcome
Minimize progressive liver damage, optimize nutrition, maximize hepatic circulation, minimize and prevent respiratory complications
Cirrhosis (Liver) Nursing Care Plan
Subjective Data:
- The patient may not have symptoms
- RUQ abdominal pain
- Fatigue
- Poor appetite
- Nausea
- Itchy skin
Objective Data:
- Bruising and bleeding easily
- Confusion or memory loss
- Dependent edema
- Ascites
- Jaundice
- Dark-colored urine
- Spider-like blood vessels on the skin
- Clay-colored stool
- Asterixis (flapping hand tremor)
- Decreased reflexes
- Anemia
- Malaise
- Hepatomegaly
- Splenomegaly
Nursing Interventions and Rationales
- Complete vitals and respiratory assessment
- Monitor fluid and electrolyte balance
- Daily weights
- Assess for JVD
- Liver impairment may also affect renal function. Ascites and dependent edema may be indicators of hyponatremia.
- Increasing weight and blood pressure may indicate vascular congestion
- The decrease in weight and blood pressure may indicate the effectiveness of interventions
- Initiate bleeding precautions per facility protocol
- No straight razors
- Use a soft toothbrush and good oral hygiene
- Use stool softeners to avoid straining with bowel movements
- Promote rest to conserve energy
- Assist with paracentesis as necessary
- Administer medications appropriately
- Diuretics
- Lactulose
- Analgesics
- Blood products
- Vitamin K
- Diuretics- are often given to manage the accumulation of fluid and edema
- Lactulose- a man-made sugar that is given to help reduce the amount of ammonia in the blood and prevent hepatic encephalopathy
- Analgesics- given to manage pain; avoid acetaminophen
- Blood products- excessive bleeding and complications following surgery may require blood transfusions
- Vitamin K- helps to promote clotting and avoid complications from bleeding
- Provide adequate nutrition and education, encourage lifestyle changes
References
Transcript
Hey guys, we’re going to talk about cirrhosis and putting this into a nursing care plan. Alright, so first you have to collect all your information and all this is, is just your assessment, your gathering of your data. That’s all this is.
So, our subjective data is coming from the patient. So, a patient with cirrhosis might complain of right upper quadrant pain. They might be super tired and complain of fatigue and they might have a poor appetite. They might have some nausea or itchy skin.
Now, the nurse is going to go on and get her objective data. So, her observations, her assessment pieces. So, perhaps we noticed some easily bruised skin, confusion, some memory problems or lots of edema, dependent edema, and that horrible ascites that occurs from all that extra fluid. We might notice them to be jaundice, right? That liver is having some liver problems and with cirrhosis, that jaundice that high bilirubins happens. I had a patient once that was literally as yellow as a highlighter from cirrhosis. So, she just glowed. So, jaundice is a big one. They might have some dark colored urine happening, or the super clay colored stool.
Alright, so all of these are things that we would see or observe on our assessment as a nurse on a patient with cirrhosis. Now, we’re going to take this data and we’re going to analyze it. So, analyze the information to help us diagnose and prioritize. So, what’s the problem? Well, for our hypothetical patient, we can say that the lab work is off. Maybe we’re seeing some high ammonia levels and then we also on our patient, see some horrible ascites. Our problem is also that our patient is an alcoholic, why not? We’ll just add that to it. Okay, so that’s our problem. What needs to be improved? What we need to do is improve the ammonia levels right? Those high ammonia levels are going to cause some confusion and not be good for the patient. We need to improve the swelling, that ascites, which is so uncomfortable for the patient and perhaps offer some education on alcohol and other items to help this patient. So, what’s our priority? Well, our priority again, cirrhosis is there, it has already happened, but we can prevent further damage and then bring our ammonia levels down.
Okay, so now ask yourself the how questions. So, how do we know it is a problem? So, this is where you link your data. So, always with any care plan, you’re going to link the data, link your assessment findings here. So, our data that we’ve linked, the ascites, we have the lab work showing the ammonia levels, we see jaundice, things like that. So, we’re linking our data together.
How are we going to address it? So, we’re going to monitor. Monitor some lab work, monitor the fluid electrolyte balance. We’re going to give some diet education, we can give some meds to help. So, for instance, the diuretics that are often given to manage that accumulation of the fluid and edema, lactulose, which is that sugary drink that they will drink to get their ammonia levels out of their bloodstream and lower them ammonia, so those things are just some things that we can do to address the problem. And how am I going to know that it gets better? Well, because it’s kind of a chronic thing, right? We’re not going to completely cure this patient, but we can reduce the symptoms. So, things like the ammonia will come down. The ascites maybe will improve depending on whatever we’re tackling as our problem. We’ll know it gets better because that will get better. So, we’re going to reduce the symptoms and prevent worsening of the problem.
Alright, let’s translate. So, our high level nursing concepts. So, there are so many for this one. I think for cirrhosis, so the ones I’m gonna pick are lab values, fluid balance, and then I always love some patient education. Alright, let’s look into this. So, we’re going to take our nursing care plan, form, whatever you use, you got your problems, your priorities, the assessment pieces from the patient, and that you have assessed your intervention to fix this data. Your why, your rationale as to why this intervention should work and then what you expect to see happen.
Alright, so we have lab values, fluid balance and patient education. So, first our lab values. So, for this patient, we have high ammonia and we are noting that the patient is also anemic. So, we can give some lactulose, right? That’s going to help bring down the ammonia levels and then put some iron into the diet or give iron supplements.
Now, our rationale… So, our why, well, the lactulose is going to remove excess ammonia and then put some iron into the diet, giving some iron supplements needed for red blood cell production. Our expected outcomes… We are going to have ammonia levels lowered and the anemia improves so our lab values will look better. Our fluid balance… So, this patient had data of some edema and some ascites occurring. Our interventions… Some diuretics to get rid of that fluid, daily weights and maybe a paracentesis, of course, if the provider orders, we’re not just going to stick a needle in the belly, but we can assist. So our rationale… The diuretics will remove the excess fluid. We can do daily weights to monitor this progress and then the paracentesis to reduce ascites. So overall, our expected outcome for this will be to improve the edema Siamese and improve the vascular congestion occurring.
Our patient education… So this patient, we said that they are an alcoholic and they’re malnourished, right? Well, one, if you’re an alcoholic you’re usually malnourished. Then two, these patients just, you know, they have that loss of appetite and even though they’re super swollen and can be overweight, that doesn’t mean that they’re well-nourished.
So, our interventions… We might need to talk about some rehab or dependency education on the importance of not drinking, because we want to prevent further problems, and a low sodium and low fat diet. The rationale is, because this is going to prevent further damage, right? So, our expected outcomes as always with patient education is what the patient is going to verbalize or demonstrate and understand.
Alright, let’s look at our key points here for care plans. So, first collect your information. This is going to be your assessment data that’s subjective, and the objective data. Then you’re going to analyze, that’s going to help you diagnose and prioritize, ask your how questions so you can plan, implement and evaluate, and then translate. So, our concise terms, our concepts, and then use whatever form you prefer, so that you can transcribe and get it all on paper.
Alright guys, that was it for cirrhosis. Check out all our nursing care plans that we have available and the awesome videos on NURSING.com. Now, go out and be your best selves today and as always, happy nursing!
Miriam Wahrman, MSN/Ed, RNC-MNN 
Nichole Weaver, MSN/Ed, RN, CCRN 
