Analyze Nursing Diagnoses

Nursing Diagnosis:

1. Imbalance nutrient: less than body requirement
     related inadequate diet; inability to process/digest nutrients

2. Excess fluid volume
    related to fluid retention

3. Impair skin integrity
    related to altered circulation/metabolic state, accumulation of bile salts in skin and poor skin turgor


4. Ineffective breathing pattern
     related to (ascites), decreased lung expansion from accumulated fluid and decrease energy

    
5.  Alter fluid and electrolyte imbalance
     related to portal hypertension

Actual or potential Nursing Diagnosis	Impair Skin Integrity
Related to	Altered circulation/metabolic state Accumulation of bile salts in skin Poor skin turgor
Plan and outcome	Maintain skin integrity Identify individual risk factors and demonstrate behavior/techniques to prevent skin breakdown
Nursing intervention	Inspect pressure points and skin surfaces closely and routinely. Gently massage bony prominences or areas of continued stress. Use of emollient lotions and limiting use of soap for bathing may help. Encourage and assist patient with reposition on a regular schedule. Assist with active and passive ROM exercises as appropriate  Recommend elevating lower extremities.  Keep linens dry and free of wrinkles.

Nursing Diagnosis References:
http://www1.us.elsevierhealth.com/SIMON/Ulrich/Constructor/diagnoses.cfm?disid=17
http://wps.prenhall.com/wps/media/objects/737/755395/alcoholic_cirrhosis.pdf

Nursing Care

Nursing care for patient with cirrhosis:

• Avoid infection 
• Avoid circulatory problem.
• Turn patient and encourage coughing and deep breathing every 2 hours to prevent pneumonia
• Bleeding can occur for cirrhosis, monitor the patient closely for signs of hypovolemia
• Test any stool and emesis for blood
• Monitor closely for any skin breakdown for any increased bleeding
• Apply pressure to injection sites
• Warn the patient against straining at stool, blowing nose too vigorously
• Suggest the patient use a soft toothbrush and an electric razor
• Teach patient to balance activities and rest
• Use a measuring tape to measure around the abdomen 
• Strict intake and output

Emotional care for patient with cirrhosis:

• Encourage the patient to verbalize question, anxieties, and fear
• Note any behavior or personality change
• Support for the patient and family are important to eliminate anxiety and poor self-esteem
• Involve the family members in the patient's care as a means of improving the patient's morale

Resources for patient:

•  American Liver Foundation
•  http://www.liverfoundation.org/abouttheliver/info/cirrhosis/
• Liver Cirrhosis: Toolkit for patient
• http://www.med.umich.edu/1libr/Hepatology/CirrhosisToolkit.pdf 

References:
Liver Disease Symptoms, Causes, Treatment - What is liver disease? (Continued) - MedicineNet. (2014, July 7). Retrieved April 8, 2015, from 
           http://www.medicinenet.com/liver_disease/page3.htm

Cirrhosis. (2014, August 16). Retrieved April 8, 2015, from http://www.mayoclinic.org/diseases-conditions/cirrhosis/basics/definition/con-20031617

Chronic Liver Disease and Cirrhosis. (2015, February 6). Retrieved April 8, 2015, from http://www.cdc.gov/nchs/fastats/liver-disease.htm

Treatment Information

The treatment for cirrhosis is mostly to stop or delay of disease process, minimize the damage to liver cells, and reduce complication.

In early cirrhosis, it may be possible to minimize damage to the liver by treating the underlying cause. The options include:

•  For cirrhosis caused by alcohol abuse should try to stop drinking to halt the progression of cirrhosis. 
• If it is cause by hepatitis, the doctor will likely to prescribe steroids or antiviral drugs to reduce liver cell injury.
• People with cirrhosis caused by nonalcoholic fatty liver disease may become healthier if they lose weight and control their blood sugar levels.
• Sometimes doctor might prescribe some medication to reduce symptoms such as 
• A drugs called diuretics are used to to reduce edema and ascites (fluid in the abdomen area). 
• Laxatives such as lactulose may be given to help absorb toxins and speed their removal from the intestines
• Other medications can relieve certain symptoms, such as itching, fatigue and pain. 

 For Cirrhosis complication:

• Excess fluid in your body. Edema or ascites may be managed with a low-sodium diet and medication to prevent fluid buildup in the body. More severe fluid buildup may require procedures to drain the fluid or surgery to relieve pressure.
• Portal hypertension. Blood pressure medications may control increased pressure in the veins that supply the liver (portal hypertension) and prevent severe bleeding. Your doctor will perform an upper endoscopy at regular intervals to look for enlarged veins in the esophagus or stomach (varices) that may bleed.
  If you develop varices, you likely will need medication to reduce the risk of bleeding. If you are not able to tolerate medication and have signs that the varices are bleeding or are likely to bleed, you may need a procedure (band ligation) to stop the bleeding. In severe cases, you may need a small tube — a transjugular intrahepatic portosystemic shunt (TIPS) — placed in your vein to reduce blood pressure in your liver.
  
• Infections. You may receive antibiotics or other treatments for infections. Your doctor also is likely to recommend vaccinations for influenza, pneumonia and hepatitis.
• Increased liver cancer risk. Your doctor will likely recommend periodic blood tests and ultrasound exams to look for signs of liver cancer.
• Hepatic encephalopathy. You may be prescribed medications to help reduce the buildup of toxins in your blood due to poor liver function.

Liver transplant surgery

In advanced cases of cirrhosis, when the liver ceases to function, a liver transplant may be the only treatment option. A liver transplant is a procedure to replace your liver with a healthy liver from a deceased donor or with part of a liver from a living donor. Cirrhosis is the most common reason for a liver transplant.
Extensive testing is needed before a liver transplant to ensure that a candidate is in good enough health to have the transplant operation. Additionally, transplant centers typically require some period of abstinence from alcohol, often at least six months, before transplantation for people with alcohol-related liver disease.

References:
Chronic Liver Disease and Cirrhosis. (2015, February 6). Retrieved April 8, 2015, from http://www.cdc.gov/nchs/fastats/liver-disease.htm 
Cirrhosis. (2014, August 16). Retrieved April 8, 2015, from http://www.mayoclinic.org/diseases-conditions/cirrhosis/basics/definition/con-20031617

Diagnosis Information

Diagnosis

People with early-stage cirrhosis of the liver usually don't have symptoms. Often, cirrhosis is first detected through a routine blood test or checkup. Your doctor may order one or more tests or procedures to diagnose cirrhosis.
Laboratory tests:

• Liver function. Doctor will draw blood to check for you liver function such as your  bilrubin, a liver funcion enzyme. If it is elevated, further diagnosis needed 
• Kidney function. Doctor will look for a blood test call creatinine, that is to see your kidney function.
• Tests for hepatitis B and C. is a blood test to see if there is any hepatitis viruses.
• Clotting. Your international normalized ratio (INR) is checked for your blood's ability to clot, because that your liver help doing blood clot in your body

Imaging and other tests:

Magnetic resonance elastography (MRE). This noninvasive advanced imaging testdetects hardening or stiffening of the liver.

 



• CAT: the doctor might order CAT scan which is aspecial X-ray tests that produce cross-sectional images of the body using X-rays and a computer to take imagin of your liver.

• Ultrasound : is to produce image that uses high-frequency sound waves to produce images of structures within your body

• Biopsy. your doctor might take some sample called biopsy to  identify the severity, extent and cause of liver damage.

References:
Chronic Liver Disease and Cirrhosis. (2015, February 6). Retrieved April 8, 2015, from http://www.cdc.gov/nchs/fastats/liver-disease.htm
Cirrhosis. (2014, August 16). Retrieved April 8, 2015, from http://www.mayoclinic.org/diseases-conditions/cirrhosis/basics/definition/con-20031617

Signs and Sympoms

Signs and Symptoms

Cirrhosis often has no signs or symptoms until liver damage is extensive. When signs and symptoms do occur, they may include:

• Yellowing of the skin (jaundice) due to the accumulation of bilirubin in the blood.

 

• Weakness
• Short of Breath
• Bleeding easily
• Bruising easily
•  Fatigue
• Loss of appetite.
• Itching.
• Easy bruising from decreased production of blood clotting factors by the diseased liver.
• Itchy skin
• Fluid accumulation in your abdomen (ascites)
• Loss of appetite
• Nausea
• Swelling in your legs
• Weight loss
• Fatigue.
• Confusion, drowsiness and slurred speech (hepatic encephalopathy)

References:
Chronic Liver Disease and Cirrhosis. (2015, February 6). Retrieved April 8, 2015, from http://www.cdc.gov/nchs/fastats/liver-disease.htm 
Cirrhosis. (2014, August 16). Retrieved April 8, 2015, from http://www.mayoclinic.org/diseases-conditions/cirrhosis/basics/definition/con-20031617

Etiology/Pathophysiological

Pathophysiology

Your liver plays an critical function in the body, it produce bile, break down cholesterol in the small intestine during digestion, produce certain proteins for blood clotting, store extra glucose and iron as needed, convert harmful ammonia to urea to excreted in the urine, clearing the blood of drug and other substances, produce immune factors to resist infection, clearing of bilirubin (buildup of bilirubin, the skin and eyes turn yellow and the liver is the only organ in the body that can easily replace damaged cells, but if loss of the liver function that can cause significant damage to the body.

Cirrhosis are mostly cause by Hepatitis C, Hepatitis B and alcoholism. As mentioned before, the liver in the body is the only organ can easily replace damage cells, however if the liver is chronically get damage from diseases, the normal liver cells will replaced by scar tissue, when scar tissue build up it will eventually preventing the liver from functioning properly. The scar tissue blocks the flow of blood through the liver and slows the processing of nutrients, hormones, drugs, and naturally produced toxins. It also slow the production of proteins and other substances made by the liver. 

References:

Liver Disease Symptoms, Causes, Treatment - What is liver disease? (Continued) - MedicineNet. (2014, July 7). Retrieved April 8, 2015, from http://www.medicinenet.com/liver_disease/page3.htm

Cirrhosis. (2014, August 16). Retrieved April 8, 2015, from http://www.mayoclinic.org/diseases-conditions/cirrhosis/basics/definition/con-20031617

Chronic Liver Disease and Cirrhosis. (2015, February 6). Retrieved April 8, 2015, from http://www.cdc.gov/nchs/fastats/liver-disease.htm

  

Epidemiological Information

Cirrhosis Epidemiological 

Although liver cirrhosis is an important public health concern, the epidemiological is often unknown.  The reason is that people with cirrhosis often diagnosis with Hepatitis B or alcoholism, and people with cirrhosis often goes asymptomatic until the end stage of liver disease. So it is hard to know when people started with cirrhosis or from the underlying disease such as hepatitis and alcoholism begin. However, according to CDC some incidence with cirrhosis in the U.S was recorded. There is estimated to be 360 cases per year per 100,000 of population in the U.S. with cirrhosis, and it is the 11th leading cause of death in the U.S, but there has been 25% decline since 1980, possibly due to reduced alcohol consumption, hepatitis B Vaccination, improved supportive care and liver transplantation. Cirrhosis is accounted for more than 30,000 deaths per year in the U.S and is one of the lading causes of death in people over aged 65 years.

The graph below show liver cirrhosis in the U.S, the darker the green color show more incident, the lighter the color such as white show less incident of cirrhosis.

Beside liver disease, there are some other factor could contribute with cirrhosis, such as:

• Increases with age
• Etiology dependent
• In women there is greater likelihood of progression to cirrhosis than in men from ingesting the same amount of alcohol
• People from Asia and sub-Saharan Africa have high rates of chronic hepatitis B and C infection

References: 

Chronic Liver Disease and Cirrhosis. (2015, February 6). Retrieved April 7, 2015, from http://www.cdc.gov/nchs/fastats/liver-disease.htm


Scaqlione, S., Kliethermes, S., Gao, G., Shoham, D., Durazo, R., Luke, A., & Volk, M. (2014). The Epidemiology of Cirrhosis in the United States: A Population-based Study. National Center for Biotechnology Information, U.S. National Library of Medicine, 4(49), 265-354.