CIRRHOSIS OF LIVER

INTRODUCTION
Cirrhosis of the Liver , the largest internal organ in the
body, is essential in keeping the body functioning properly.
It removes or neutralizes poisons from the blood, produces
immune agents to control infection, and removes germs and
bacteria from the blood. It makes proteins that regulate
blood clotting and produces bile to help absorb fats and fat-
soluble vitamins. You cannot live without a functioning
liver. In cirrhosis of the liver, scar tissue replaces normal,
healthy tissue, blocking the flow of blood through the organ
and preventing it from working as it should. Cirrhosis is the
twelfth leading cause of death by disease, killing about
26,000 people each year. Also, the cost of cirrhosis in terms
of human suffering, hospital costs, and lost productivity is
DEFINITION

•Cirrhosis of liver is a chronic progressive disease

characterized by fibrosis and nodule formation.

•Chronic liver damage from a variety of causes leading to

scarring and liver failure.

•Hepatitis and chronic alcohol abuse are frequent causes. Liver

damage caused by cirrhosis can't be undone, but further
damage can be limited.

•Cirrhosis is a chronic degenerative disease in which normal

liver cells are damage and are the replaced by scar tissue.
CAUSES

Cirrhosis has many causes. In the United States, chronic alcoholism and
hepatitis C are the most common ones.

Alcoholic liver disease. To many people, cirrhosis of the liver is

synonymous with chronic alcoholism, but in fact, alcoholism is only one
of the causes. Alcoholic cirrhosis usually develops after more than a
decade of heavy drinking. The amount of alcohol that can injure the
liver varies greatly from person to person. In women, as few as two to
three drinks per day have been linked with cirrhosis and in men, as few
as three to four drinks per day. Alcohol seems to injure the liver by
blocking the normal metabolism of protein, fats, and carbohydrates.

Chronic hepatitis C. The hepatitis C virus ranks with alcohol as a major

cause of chronic liver disease and cirrhosis in the United States.
Infection with this virus causes inflammation of and low grade damage
Chronic hepatitis C. The hepatitis C virus ranks with alcohol
as a major cause of chronic liver disease and cirrhosis in the
United States. Infection with this virus causes inflammation of
and low grade damage to the liver that over several decades
can lead to cirrhosis.

 Chronic hepatitis B and D. The hepatitis B virus is probably

the most common cause of cirrhosis worldwide, but it is less
common in the United States and the Western world. Hepatitis
B, like hepatitis C, causes liver inflammation and injury that
over several decades can lead to cirrhosis. Hepatitis D is
another virus that infects the liver, but only in people who
already have hepatitis B.
Autoimmune hepatitis. This disease appears to be caused by
the immune system attacking the liver and causing
inflammation, damage, and eventually scarring and cirrhosis.

 Inherited diseases. Alpha-1 antitrypsin deficiency,

hemochromatosis, Wilson disease, galactosemia, and glycogen
storage diseases are among the inherited diseases that interfere
with the way the liver produces, processes, and stores
enzymes, proteins, metals, and other substances the body
needs to function properly.

 Nonalcoholic steatohepatitis (NASH). In NASH, fat builds

up in the liver and eventually causes scar tissue. This type of
hepatitis appears to be associated with diabetes, protein
malnutrition, obesity, coronary artery disease, and treatment
with corticosteroid medications.
Blocked bile ducts. When the ducts that carry bile out of the
liver are blocked, bile backs up and damages liver tissue. In
babies, blocked bile ducts are most commonly caused by
biliary atresia, a disease in which the bile ducts are absent or
injured. In adults, the most common cause is primary biliary
cirrhosis, a disease in which the ducts become inflamed,
blocked, and scarred. Secondary biliary cirrhosis can happen
after gallbladder surgery if the ducts are inadvertently tied off
or injured.

Drugs, toxins, and infections. Severe reactions to

prescription drugs, prolonged exposure to environmental
toxins, the parasitic infection schistosomiasis, and repeated
bouts of heart failure with liver congestion can all lead to
cirrhosis.
SYMPTOMS

Many people with cirrhosis have no symptoms in the early

stages of the disease. However, as scar tissue replaces healthy
cells, liver function starts to fail and a person may experience
one or more of the following symptoms:
• exhaustion
• fatigue
• loss of appetite
• nausea
• weakness
• weight loss
• abdominal pain
• spider-like blood vessels (spider angiomas) that develop on
the skin
• As the disease progresses, complications may develop. In
People may experience:

•Pain areas: in the abdomen

•Gastrointestinal: bleeding, dark stool from digested blood,
fluid in the abdomen, nausea, passing excessive amounts of
gas, vomiting blood, or water retention
•Whole body: fatigue, loss of appetite, or reduced hormone
production
•Skin: web of swollen blood vessels in the skin or yellow skin
and eyes
•Weight: weight gain or weight loss
•Also common: bleeding, bruising, dark urine, enlarged veins
around belly button, itching, mental confusion, muscle
weakness, shortness of breath, swelling, swelling in
extremities, or swollen veins in the lower oesophagus.
COMPLICATION

 Loss of liver function affects the body in many ways. Following are
the common problems, or complications, caused by cirrhosis.

 Edema and ascites. When the liver loses its ability to make the protein
albumin, water accumulates in the legs (edema) and abdomen (ascites).

 Bruising and bleeding. When the liver slows or stops production of

the proteins needed for blood clotting, a person will bruise or bleed
easily. The palms of the hands may be reddish and blotchy with palmar
erythema.

 Jaundice. Jaundice is a yellowing of the skin and eyes that occurs

when the diseased liver does not absorb enough bilirubin.

 Itching. Bile products deposited in the skin may cause intense itching.
 Toxins in the blood or brain. A damaged liver cannot remove toxins
from the blood, causing them to accumulate in the blood and eventually
the brain. There, toxins can dull mental functioning and cause
personality changes, coma, and even death. Signs of the buildup of
toxins in the brain include neglect of personal appearance,
unresponsiveness, forgetfulness, trouble concentrating, or changes in
sleep habits.

Sensitivity to medication. Cirrhosis slows the liver's ability to filter

medications from the blood. Because the liver does not remove drugs
from the blood at the usual rate, they act longer than expected and build
up in the body. This causes a person to be more sensitive to medications
and their side effects.

 Portal hypertension. Normally, blood from the intestines and spleen is

carried to the liver through the portal vein. But cirrhosis slows the
normal flow of blood through: the portal vein, which increases the
pressure inside it. This condition is called portal hypertension.
 Insulin resistance and type 2 diabetes. Cirrhosis causes resistance to
insulin. This hormone, produced by the pancreas, enables blood glucose
to be used as energy by the cells of the body. If you have insulin
resistance, your muscle, fat, and liver cells do not use insulin properly.
The pancreas tries to keep up with the demand for insulin by producing
more. Eventually, the pancreas cannot keep up with the body's need for
insulin, and type 2 diabetes develops as excess glucose builds up in the
bloodstream.

 Liver cancer. Hepato cellular carcinoma, a type of liver cancer

commonly caused by cirrhosis, starts in the liver tissue itself. It has a
high mortality rate.

Problems in other organs. Cirrhosis can cause immune system

dysfunction, leading to infection. Fluid in the abdomen (ascites) may
become infected with bacteria normally present in the intestines.
Cirrhosis can also lead to impotence, kidney dysfunction and failure, and
osteoporosis.
DIAGNOSIS

Laboratory tests. Your provider may order blood tests to check for
signs of liver malfunction, such as high bilirubin levels or certain
enzymes. To evaluate kidney function, your blood is checked for
creatinine. Your blood count would be measured. You'll be screened for
the hepatitis viruses. Your international normalized ratio (INR) is also
checked for your blood's ability to clot.

Based on history and blood test results, your provider may be able to
diagnose the underlying cause of cirrhosis. Blood tests also can help
identify how serious cirrhosis .

Imaging tests. Certain imaging tests, including transient or magnetic

resonance elasto graphy (MRE), may be recommended. These
noninvasive imaging tests look for hardening or stiffening of the liver.
Other imaging tests, such as MRI, CT and ultrasound, also may be done.
Biopsy. A tissue sample, called a biopsy, is not necessarily needed for
diagnosis. However, your provider may use it to find out how severe
liver damage is and what's causing it

Certain imaging test, including transient or magnetic resonance elasto

graphy (MRE), may be recommended

 These noninvasive imaging tests look for hardening or stiffening of

the liver.

 Other imaging tests, such as MRI , CT and ultrasound, also may be

done. Biopsy.

 The doctor may diagnose cirrhosis on the basis of symptoms,

laboratory tests, the medical history, and a physical examination. For
example, during a physical examination, the doctor may notice that the
liver feels harder or larger than usual and order blood tests that can show
whether liver disease is present.
TREATMENT

Self care

Low sodium diet

A low sodium diet is a diet that includes no more than 1,500
to 2,400 mg of sodium per day.
The human minimum requirement for sodium in the diet is
about 500 mg per day,[2] which is typically less than one-sixth
as much as many diets "seasoned to taste". For certain people
with salt-sensitive blood pressure or diseases such as
Ménière's disease, this extra intake may cause a negative
effect on health.

Avoid alcohol
May be harmful aggravate certain condition.
Medication

Diuretic: Taking medicine that helps eliminate extra water

from the body. It's also prescribed to treat high blood pressure.

Ammonia reducer: Reduces the amount of ammonia in the

body.

Beta blocker: Slows heart rate and decreases blood pressure.

When taken in eye-drop form, it reduces eye pressure.

Antibiotics: Stops the growth of or kills bacteria.

Antiviral drug: Reduces viruses' ability to replicate.

Medical procedure

Rubber band ligation: Tying off a dilated or bleeding blood

vessel with a rubber band to block its blood supply. This
causes it to dry up and fall off.

Therapeutic endoscopy: Using a lighted medical instrument

to see inside the body and provide treatment. For example, to
stop bleeding or remove a foreign object.

Transjugular intrahepatic portosystemic shunt: Placing a

tube (stent) in the liver to relieve a backup of blood in the
veins.
Surgical procedure

Liver transplantation: Surgical replacement of

a diseased liver with some or all of a healthy
liver from a donor.
SPECIALISTS

Transplant Hepatologist: Focuses on end stage liver disease and liver

transplant patients.

Hepatologist: Focuses on liver, gallbladder and biliary tree disorders.

Gastroenterologist: Focuses on the digestive system and its disorders.

Infectious Disease Doctor Treats infections, including those that are

tropical in nature.

Primary Care Provider (PCP): Prevents, diagnoses and treats diseases.

Emergency Medicine Doctor: Treats patients in the emergency

department.
NURSING DIAGNOSIS

1.Ineffective Tissue Perfusion

Cirrhosis is characterized by liver damage and liver cell death,
and the formation of scar tissue that affects liver function and
results in a significant decrease in liver perfusion.
Nursing Diagnosis: Ineffective Tissue Perfusion

Related to:
•Disease process
•Excessive alcohol use
•Hepatitis
•Genetic disorders
•Bile duct abnormalities
•Toxic medications
As evidenced by:

•Easy bruising
•Bleeding
•Jaundice
•Edema to the extremities
•Ascites
•Abdominal pain
•Confusion/altered LOC
•Skin abnormalities

Expected outcomes:
•Patient will demonstrate liver enzymes, coagulation factors,
and blood cell counts within acceptable limits.
•Patient will remain free from jaundice, ascites, and bleeding.
Assessment:

1. Assess for any symptoms of ineffective liver tissue perfusion.

Damage to the liver cells often does not exhibit any symptoms until the liver has
decompensated and may include loss of appetite, jaundice, fatigue, bruising, and more.

2. Perform an abdominal assessment.

Liver cirrhosis is associated with hepatomegaly in the early stages and abdominal
ascites in the late stage. Abdominal assessment will show a distended abdomen and an
enlarged liver on palpation.

3. Assess and review laboratory test results.

Serum levels of AST and ALT are elevated because the enzymes are released into the
bloodstream during hepatic inflammation. As the liver deteriorates, the hepatic tissues
will be unable to create an adequate inflammatory response, resulting in the levels of
AST and ALT normalizing.

4. Assess diagnostic imaging results.

CT or MRI scans can visualize tumors or masses and fibrosis of the liver. A Doppler
ultrasound can help view blood vessels in the liver. Liver elastography can detect
cirrhosis and other complications such as portal hypertension and esophageal varices.
Interventions:

1. Administer diuretics as indicated.

Diuretic therapy is a first-line treatment option for patients with liver cirrhosis and
edema. Ursodiol is also prescribed to treat primary biliary cirrhosis.

2. Measure and monitor the patient’s abdominal girth.

Abdominal distention due to ascites and hepatomegaly is common in patients with liver
cirrhosis. Monitoring the abdominal girth will determine the effectiveness of the
therapy or the progression of the patient’s condition.

3. Prepare and assist in surgical interventions as indicated.

Surgical intervention is indicated for patients with advanced cases of liver cirrhosis. If
the liver ceases to function properly, a liver transplant may be indicated.

4. Monitor the mental status.

As the liver becomes unable to detoxify waste, toxins build up in the blood. High
ammonia levels affect brain function and cause confusion, reduced LOC, and
personality changes. Medications like lactulose are given to help excrete ammonia.

5. Monitor the patient for signs and symptoms of bleeding.

Patients with liver cirrhosis are at risk for bleeding, thrombosis, and bruising. This can
2.Risk For Impaired Skin Integrity

Liver cirrhosis compromises skin integrity from fluid build-up,

accumulation of bile salts, and bleeding.
Nursing Diagnosis: Risk For Impaired Skin Integrity

•Related to:

•Accumulation of bile salts causing jaundice

•Fluid build up causing edema and ascites
•Bleeding leading to spider angiomas
•Poor nutrition

As evidenced by:

•A risk diagnosis is not evidenced by signs and symptoms as the problem

has not occurred. Nursing interventions are directed at prevention.
Expected outcomes:

•Patient will remain free from skin breakdown

•Patient will monitor for worsening edema and ascites and alert their
provider
•Patient will implement two strategies to prevent skin breakdown

Assessment:

1. Perform a skin assessment.

Perform a thorough skin assessment and reassess regularly. Monitor for
bruising, papules, nodules, and edema that are common with liver
cirrhosis. Note the color of skin and eyes which signals jaundice.

2. Assess nutritional status.

Assess the patient’s nutritional and fluid intake. Patients with cirrhosis
often have a lack of appetite and are malnourished, lacking vitamins and
nutrients.
Interventions:

1. Prevent skin tearing or shearing.

The skin may be susceptible to tearing due to edema and poor elasticity.
Take care in moving, turning, and performing hygiene care.

2. Prevent edema.
Preventing edema in cirrhosis may be difficult as it is a symptom of the
problem. The patient can decrease fluid buildup by restricting salt,
avoiding alcohol, and taking diuretics.

3. Monitor post paracentesis.

The fluid build-up that occurs in the abdomen is due to portal
hypertension; high pressure in the portal vein causing fluid to leak into
the peritoneum. A paracentesis removes the fluid by drawing it out with
a needle. This usually only results in temporary relief of symptoms and
is a recurring problem. The nurse should monitor the puncture site for
any signs of infection.
4. Control itching.
A buildup of bile salts that causes jaundice also causes itching.
The patient needs to avoid scratching to prevent skin
breakdown. Avoid the use of hot water and harsh soaps when
bathing. Calamine lotion may help ease itchiness. Administer
Benadryl or hydroxyzine to relieve the histamine response.

5. Treat malnutrition.
Improve nutrition to prevent weight loss and cachexia that
increases the risk of skin breakdown. Increase protein and
nutrient intake. Provide a nighttime snack to prevent
fasting/catabolism. Enternal nutrition may be necessary.
3.Acute Confusion

When the liver is damaged and isn’t able to detoxify substances, those
toxins build up in the blood and affect brain function.
Nursing Diagnosis: Acute Confusion

Related to:

•Hepatic encephalopathy (HE)

•Accumulation of ammonia in the blood

As evidenced by:

•Confusion
•Agitation
•Slurred speech
•Lethargy
•Impaired decision making
Expected outcomes:

•Patient will remain alert and oriented to person, place, and

time
•Patient will initiate lifestyle behaviors to prevent recurrence
(abstaining from alcohol use)

Assessment:

1. Monitor serum ammonia levels.

While ammonia levels may not always prove HE, they can be
monitored for improvement or worsening.

2. Review EEG, MRI, or CT scans.

Ruling out of the possibilities of other causes such as tumors
can lead to proper diagnosis and treatment.
Interventions:

1. Administer lactulose.
Lactulose is a laxative that rids the body of ammonia and
toxins through frequent bowel movements.

2. Prevent falls and injury.

Due to the cognitive effects of HE, patients are at risk for falls
and other injuries. Ensure the bed alarm is on at all times and
the patient is supervised and assisted with ambulating and
other ADLs.

3. Reorient as needed.
Provide reorientation to person, place, time, and situation
frequently to reduce confusion and maintain a sense of reality.
4. Educate on lifestyle changes.
Managing cirrhosis can prevent HE. Patients should be
advised to avoid alcohol, take prescribed medications to treat
their liver disease, and maintain a healthy diet.

5. Decrease stimuli.
Prevent increasing confusion and agitation by providing a
calm, quiet environment and promoting relaxation.
4.Ineffective Breathing Pattern

Liver cirrhosis is associated with abdominal fluid accumulation and

distention, increasing pressure on the diaphragm, making it harder for
the patient to breathe. Advanced liver cirrhosis results in
hepatopulmonary syndrome that causes shortness of breath and
significantly low blood oxygen levels.
Nursing Diagnosis: Ineffective Breathing Pattern

Related to:

•Disease process
•Ascites
•Organ enlargement
•Increased intra-abdominal pressure
•Hepatopulmonary syndrome
•Abdominal discomfort or pain
•Fatigue
As evidenced by:

•Dyspnea
•Tachypnea
•Cyanosis
•Orthopnea
•Hyperventilation
•Hypoxemia
•Hypoxia

Expected outcomes:

•Patient will demonstrate a normal breathing pattern without

respiratory distress.
•Patient will report the ability to breathe comfortably while
sitting or lying flat.
Assessment:

1. Assess the patient’s respiratory status.

Regular respiratory rate is between 10-20 breaths per minute. A rate that
exceeds 30 beats per minute, along with other significant physiological
changes, can signal respiratory distress.

2. Assess and auscultate breath sounds.

Abnormal breath sounds like crackles and wheezes can indicate a
developing complication like atelectasis, accumulation of fluids, and
infection.

3. Assess the patient’s level of consciousness.

Ineffective breathing patterns, along with hypoxemia due to liver
cirrhosis or hepatopulmonary syndrome, can affect other body systems
like the central nervous system and cause changes in mentation.
Interventions:

1. Position the patient for comfort.

Patients may experience dyspnea on exertion or when lying flat due to
ascites, splenomegaly, or hepatomegaly. Allow the patient to remain
upright to facilitate breathing.

2. Encourage the use of pillows for support.

Promoting comfort using supportive pillows under the arms and chest
can help patients with liver cirrhosis breathe comfortably.

3. Evaluate and monitor ABGs and oxygen saturation.

Any alterations in ABG and oxygen saturation values can signal
respiratory complications and enable prompt interventions.
4. Provide supplemental oxygen as indicated.
Supplemental oxygen via nasal cannula can help treat hypoxia
due to ineffective breathing patterns. This will also promote
adequate oxygenation to the liver and reduce symptoms of
dyspnea.

5. Prepare the patient for surgical interventions.

Surgical interventions like abdominal paracentesis can help
relieve abdominal pressure associated with liver cirrhosis and
fluid accumulation, enabling the patient to breathe
comfortably.