Cirrhosis-Overview. Cirrhosis
End Stage Liver Disease as a result of extensive scarring of liver caused by necrotic injury or
chronic reaction to inflammation over a prolonged period of time
Normal liver replaced with fibrotic tissue that lacks function, impairs blood, lymph flow
Portal & periportal areas of liver primarily involved, affecting liver’s ability to handle flow of bile
Development of new bile channels causes an overgrowth of tissue and liver
scarring/enlargement. Jaundice often the result
Three Causes/Types-Alcoholic, Biliary (obstruction), Posthepatic (Chronic hepatitis, unknown)
Subjective Data
Fatigue, weight loss
Abdominal pain, distention
Pruritus (severe itching)
Confusion
Difficulty thinking
(Build-up of waste products in
blood & brain
Liver’s inability to ↓ ammonia
levels)
Personality/mentation
changes
Emotional lability, euphoria,
Possible depression
Objective Data
GI bleeding-enlarged veins (varices) develop and burst-cause
vomiting and passing of blood in bowel movements
Hematochezia (↓GI bleed-bright red) Melena (↑GI Bleed-dark)
↓synthesis of prothrombin, deteriorating hepatic function
Ascites–bloating/swelling in abdomen/legs d/t fluid build-up
Dependent peripheral edema of extremities and sacrum
Jaundice (yellowing of skin) and icterus (yellowing of eyes)
Petechiae (round, pinpoint red-purple lesions), ecchymosis
(large yellow/purple blue bruises)
Palmar erythema (redness, warmth of palms of the hands)
Spider angiomas (red lesions, vascular in nature and
branches radiating on nose, cheeks, upper thorax, shoulders)
Asterixia (liver flapping tremor-coarse tremor characterized
by rapid, nonrhythmic extension/flexion of wrists/fingers)
Fector hepaticus (liver breath)-fruity or musty odor
Lab tests
Serum Liver enzymes-elevated initially
ALT (Alanine aminotransferase) N-8-20units/L
AST (Aspartate aminotransferase) N-5-40 units/L
ALP (Alkaline phosphatase) N-42-128 units/L
ALT, AST-elevated d/t hepatic inflammation
ALP-↑ in cirrhosis d/t intrahepatic biliary obstruction
Serum Bilirubin-elevated
Bilirubin-direct, (conjugated) elevated N-0.1- 0.3 mg/dL
Bilirubin-indirect, (unconjugated) elevated N-0.2-08 mg/dL
Bilirubin-total, elevated N-0.1-1.0mg/dL
Risk Factors
Alcohol abuse
Chronic viral hepatitis
(Hepatitis B, C, D)
Autoimmune hepatitis
Steatohepatitis
(Fatty liver)
Damage to liver from
drugs, toxins and
infections
Chronic biliary
cirrhosis
Cardiac Cirrhosis
(R heart failure)
Obesity, DM
Diagnostics
Abdomen Films
Ultrasound-visualize possible hepatomegaly, ascites,
spleen enlargement
Liver Biopsy-most definitive-identifies progression and
extent of cirrhosis
EGD-detect esophageal varies
Hematological tests
CBC, Platelets ↓ secondary to anemia
PT/INR prolonged d/t decreased synthesis of prothrombin
Ammonia levels (N-15-110 mg/dL) ↑ with hepatocellular injuryprevents conversion of ammonia to urea for excretion
Serum creatinine levels may increase (N-0.6-1.2 mg/dL) d/t failing
kidney function as a result of advancing liver disease
Nursing Care
Respiratory-monitor 02 sats, RR, HOB ↑ 30° for ascites
Skin-pruritis causes scratching-apply lotion.
Use warm water over hot
Vital Signs
I&O
Monitor fluid volume excess
Restrict fluids, sodium, weight daily
Neuro-monitor for deteriorating mental status and
dementia associated w/hepatic encephalopathy
Nutrition-high calorie, high protein (unless hepatic
encephalopathy) supplemental vitamins, folic acid, iron
GI-presence of ascites, measure abdominal girth
Pain-administer analgesic and antispasmodics prn
Observe for bleeding-give blood FFP, Platelets
Monitor trends in H&H, PT/INR, aPTT
Treatments
Medications
Diuretics to decrease ascites, edema
Proton pump inhibitors, H2receptor blockers-↓ gastric acid,
risk of gi bleed
Lactulose-to promote excretion of ammonia via stool
Neomycin, Flagyl to remove intestinal bacteria which produces
ammonia
Collaborative
Dietary consult-low protein diet for hepatic encephalopathy
Referral to Alcohol Anonymous
Therapeutic Procedures
Paracentesis-relieve ascites
Sclerotherapy/variceal band ligation-decrease risk of hemorrhage
TIPS-control ascites and variceal bleeding
Surgical bypass shunt
Liver transplant
Complications
Portal Hypertension-impaired circulation of blood
through liver (back up effect)
Ascites-fluid accumulation in abdomen
Splenomegaly-enlarged spleen-affects RBC, WBC, Plts
Esophageal Varies-d/t portal htn-collateral circulation
development-potential for hemorrhage
Hepatorenal syndrome-renal failure
Spontaneous Bacterial Peritonitis-life threatening
infection without obvious cause
Acute graft rejection post liver transplant
s/s
Tachycardia, upper right flank pain, jaundice, liver
failure from lab results
Bilirubin levels ↑in cirrhosis d/t inability of liver to excrete bilirubin
Serum proteins & serum albumin-↓ d/t lack of hepatic synthesis
N-3.5-5g/dL