Hepatic/ Liver cirrhosis

Compiled By: Mr. Ashish Roy

1. HEPATIC/LIVER CIRRHOSIS COMPILED BY : MR. ASHISH ROY (Nursing T utor)

2. INTRODUCTION LIVER CIRRHOSIS is the severe scarring of liver and poor function at last stage of chronic liver disease scarring is most often Caused by prolonged exposure in toxins. E.g., alcohol or viral infection, scarring leads to altered liver functions.

3. ANATOMY OF LIVER

4. ANATOMY OF LIVER

5. DEFINITION CIRRHOSIS IS COMPLICATION OF LIVER DISEASE WHICH INVOLVES LOSS OF LIVER CELLS AND IRREVERSIBLE SCARING OF LIVER CELLS. IT IS A CHRONIC DISEASE CHJARACVTERIZED BY REPLACEMENT OR DEGENRATIVE CHANGES IN NORMAL LIVER CELLS. TISSUE WITH DIFFUSE FIBROSIS AND NODULES THAT DISTURBS THE STRUCTUREVAND FUNCTION OF LIVER. ALSO SCAR FORMATION. OCCURS DUE TO DESTROYED HEPATOCYES.

6. TYPES POST NECROTIC CIRRHOSIS DUE TO SEVERE INFLAMMATION AND MASSIVE NECROSIS OF HEPATOCYTES CELLS. ALCOHOLIC CIRRHOSIS IT OCCURS DUE TO EXCESSIVE INTAKE OF ALCOHOL THAT LEADS TO ACCUMULATION OF FAT IN LIVER BILIARY CIRRHOSIS DUE TO BILIARY OBSTRUCTION FOR LONG TIME AND CHOLESTATSIS (STOPPAGE OF FLOW OR GROWTH) CARDIAC CIRRHOSIS MAIN CAUSE OF THIS TYPE OF CIRRHOSIS IS RIGHT SIDE CONGESTIVE HEART FAILURE.

7. ETIOLOGICAL FACTORS / CAUSES ALCOHOLISM HEPATITIS A,B,C,D HEPATOTOXIC DRUGS CHF BILIARY OBSTRUCTION DIABETES GLYCOGEN STORAGE DISEASE IMMUNOLOGICAL CAUSES

8. CLINICAL MANIFESTATIONS/ SIGNS AND SYMPTOMS EARLY SYMPTOMS DUE TO INFLAMMATION : - FEVER - PAIN - ANOREXIA - FATIGUE - NAUSEA OTHER SYMPTOMS ARE : - ODEMA - FOUL SMELL - YELLOWISH SKIN - HEPATIC ENCEPHALOPATHY - LOSS OF SENSORY FUNCTION - DIFFICULTY IN BREATHING - INCREASED SERUM NH3 ( AMMONIA ) LEVEL. - ASCITES - HYPOALBUMINEMIA - ABDOMINAL DISTENSION - INCREASED ABDOMINAL GIRTH - SPIDER ANGIOMA

9. CONTINUED SIGNS AND SYMPTOMS IF BILIARY OBSTRUCTION : - ABSENCE OF UROBILINOGEN IN DIGESTIVE TRACT - INCREASE SERUM BILIRUBIN LEVEL SO APPEAR DARK COLOUR URINE - JAUNDICE DUE TO ACCUMULATION OF BILIRUBIN UNDER SKIN. HORMONAL OBSTRUCTION : REDUCE ANDROGEN AND ESTROGEN WHICH PRODUCE ABNORMAL MENSES. - AMENORRHOEA - LOSS OF BODY HAIR - GYNECOMASTIA (UPPER SWELLING ON BREAST IN MEN) BLEEDING DISORDERS : REDUCE ABSORPTION OF VITAMIN K AND REDUCE SYNTHESIS OF PROTHROMBIN

10. PATHOPHYSIOLOGY DUE TO ANY CAUSE LIKE ( ALCOHOL ABUSE, MALNUITRITION, INFECTION, DRUGS OR BILIARY OBSTRUCTION) DESTRUCTION OF HEPATOCYTES FIBROSIS / SCAR FORMATION OBSTRUCTION OF BLOOD FLOW INCREASE PRESSURE IN VENOUS AND SINUSOIDAL CHANNELS FATTY INFILTRATION FIBROSIS/ SCARRING PORTAL HYPERTENSION

11. DIAGNOSTIC EVALUATION LIVER FUNCTION TEST (LFT) ASPIRATEW AMINOTRANSFERASE ALT – ALANINE TRANSFERASE LDH – LACTATE DEHYDROGENASE USG – FOR HEPAṬOMEGALY WBC – (FOR DETERMINATION OF INFECTION ) RBC – (ANEMIA) LIVER BIOPSY – FNAC (FINE NEEDLE ASPIRATION CYTOLOGY) SERUM EXAMINATION – - INCREASE SGOT/SGPT LEVEL - LOW PROTEIN INCRTEASE BILIRUBIN LEVEL RAISED ABDOMINAL PARACENTESIS ( FOR DETERMINE PUS CELLS BACTERIAL INFECTION OR PROTEIN COMPONENT IN ACCUMULATED FLUYID -

12. COMPLICATIONS ASCITES PORTAL HYPERTENSION PERITONITIS COAGULOPATHIES

13. MANAGEMENT MEDICAL MANAGEMENT MEDICAL M,ANAGEMENT IS BASED ON PRESENTING SYMPTOMS. - ANTACIDS - ANTIEMETICS - VITAMINS AND NUTRITIONAL SUPPLEMENT - BALANCED DIET - POTASSIUM SPARRING DIURETICS (FOR ASCITES.) E.G., SPIRONOLACTONE. - AVOIDANCE OF ALCOHOL

14. DIETARY MANGEMENT PROVIDE HIGH CALORIE DIET AND LOW LIQUID DIET (800 – 1000 ml/dl ) IN HEPATIC COMA, GIVE LOW PROTEIN AND LOW SODIUM DIET. PROVIDE ALBUMIN CONTAINING FOOD. VITAMIN A,D,E,K INCLUDED WITH DIET OF THE PATIENT.

15. SURGICAL MANAGEMENT PORTAL- CAVAL SHUNT (PORTA CAVAL ANASTOMOSIS) SPLENORENAL SHUNT (SPLEENORENAL ANASTOMOSIS) - A SURGICAL TECHNIQUE IN WHICH SPLEEN VEIN IS JOINED TO THE LEFT RENAL VEIN. (MOSTLY FOR TREATIONG PORTAL HYPERTENSION). LIVER TRANSPLANTATION

16. NURSING DIAGNOSIS WITH NURSING MANAGEMENT ACTIVITY INTOLERANCE RELATED TO FATIGUE AND DISCOMFORT . Interventions: -Nurse should encourage patient to take proper rest and need to ambulation. -Instruct the patient to elevate legs to mobilize edema and ascites -Encourage for active and passive exercises to patient to promote muscle strength. - instruct to take nutritional and proper calorific diet to maintain energy level of patient.

17. Contd... RISK OF INJURY RELATED TO COAGULOPATHY Interventions: -Assess sign of bleeding, observe stools and vomiting for colour,consistency. -Instruct to avoid or limit activities if sign of bleeding show. - Administer vitamin K as prescribed. - Nurse should teach risk preventive measures e.g., - #Maintain safe environment - #Gentle blowing of nose - #Use of soft toothbrush - Encourage patient to intake of foods with high vitamin C content. - Nurse should use small gauze needles for injections and maintain pressure over puncture site until bleeding stops.

18. Contd... IMPAIRED SKIN INTEGRITY RELATED TO JAUNDICE . Interventions: - Assess and document degree of jaundice of skin and sclera. - Promote adequate nutrition. -Assess dietary intake and nutritional status. Encourage the client to adhere to a high carbohydrate diet with protein intake consistent with that recommended for hepatic encephalopathy. - Assess for adequate hydration. - Instruct patient to keep the incision site or wound site dry for five to seven days and to report any signs and symptoms of redness pain and drainage if available. - Encourage physical activity as permitted. - Teach client importance of skin integrity and its care.

19. Contd... KNOWLEDGE DEFICIT RELATED TO DISEASE CONDITION . Interventions: - Nurse should review underlying cause, disease process and prognosis to the patient. - Discuss with patient about medication regimen, schedule and possible side effect. - Instruct to avoid foods cause gastric irritations, eg., chocolate, spicy food, whole grains, raw vegetables. - Discuss and identify stress situations and how to avoid them, investigate job related issues. - Discuss avoidance of NSAIDS, forceful bleeding of nose, straining for Bowel movement,to reduces risk of bleeding in case of coagulopathy. - Instruct to eat frequent small meals. - Provide information for patient to plan for return to usual routine with untoward incidents. - Nurse should recommend gradual resumption of daily usual activities, and take proper rest to prevent fatigue and increase feeling of well-being.

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