Liver cirrhosis is the scarring of the liver from liver diseases. The advancement of liver disease to cirrhosis is irreversible. The most common causes include:
- Alcoholic liver disease. Years of alcohol abuse damage the liver over time.
- Fatty liver disease. A buildup of fat in the liver caused by obesity and diabetes. Excessive alcohol intake can also be a factor.
- Hepatitis. Inflammation to the liver.
The liver plays vital roles in the body including metabolism, detoxification, digestion, storage of vitamins and minerals, production of clotting factors, and more.
Complications include edema and ascites, enlargement of the spleen, bleeding from pressure in the veins, infections, malnutrition, and the buildup of toxins causing hepatic encephalopathy.
In this article:
- Nursing Process
- Nursing Assessment
- Nursing Interventions
- Nursing Care Plans
- Dysfunctional Family Processes: Alcoholism
- Ineffective Breathing Pattern
- Ineffective Tissue Perfusion
- Risk For Impaired Skin Integrity
Nursing Process
The treatment of liver cirrhosis is serious and complex. Nurses will be involved in the symptom management of patients with cirrhosis including paracentesis procedures, controlling cognitive manifestations of hepatic encephalopathy, promoting proper nutrition, and preparing for liver transplantation. Patients with liver cirrhosis often require education and emotional support in managing the complications of their disease.
Nursing Assessment
The first step of nursing care is the nursing assessment, during which the nurse will gather physical, psychosocial, emotional, and diagnostic data. In this section we will cover subjective and objective data related to liver cirrhosis.
Review of Health History
1. Note the patient’s general symptoms.
Initially, symptoms are nonspecific, but as the liver becomes impaired, signs and symptoms include coagulopathy (hepatic synthetic function), variceal bleeding (portal hypertension), and impaired liver detoxification capacity (hepatic encephalopathy). It may appear early as:
2. Look for signs of worsening cirrhosis.
Late symptoms of liver cirrhosis include:
- Changes in mentation
- Easy bruising and bleeding
- Itchy skin (pruritus)
- Jaundice
- Light-colored stools
- Blood in the stool
3. Investigate abdominal pain further.
Pain from liver cirrhosis is described as sharp or dull throbbing in the right upper abdomen, just below the ribs. In addition to ascites, cirrhosis-related liver and spleen enlargement can produce generalized abdominal pain and discomfort.
4. Identify the patient’s risk factors.
These are the modifiable risk factors of liver cirrhosis:
- Obesity is linked to fatty liver disease (a common and reversible liver disease). Chronic liver disease brought on by obesity frequently progresses to cirrhosis.
- Sedentary lifestyle raises the risk of non-alcoholic fatty liver disease (NAFLD).
- Diet rich in fats and containing raw or undercooked meat or seafood can increase the risk of liver cirrhosis.
- Smoking accelerates the development of cirrhosis caused by the hepatitis B virus and increases fibrosis in those with chronic hepatitis C.
- Alcohol consumption can lead to hepatitis, which causes swelling and inflammation in the liver. It can eventually lead to liver cirrhosis (the last stage of alcoholic liver disease), marked by the liver’s scarring. Cirrhosis results in permanent damage.
5. Check for a history of hepatitis.
Hepatitis B and hepatitis C viruses are common causes of cirrhosis. It frequently advances from inflammation to irreversible, permanent scarring (cirrhosis).
6. Obtain the patient’s medical history.
Other than alcoholic liver disease, fatty liver disease, and hepatitis, other causes of liver cirrhosis include:
- Medications (methotrexate or isoniazid)
- Autoimmune hepatitis
- Cholestasis:
- Primary biliary cholangitis (bile duct destruction)
- Primary sclerosing cholangitis (bile duct hardening and scarring)
- Biliary atresia (poorly formed bile ducts found in infants)
- Alagille syndrome (a genetic syndrome in which bile accumulates in the liver due to limited ducts to drain the bile)
- Metabolic:
- Hemochromatosis (iron buildup in the body)
- Wilson’s disease (copper in the liver)
- Alpha-1 antitrypsin deficiency
- Inherited disorders of glucose metabolism (such as galactosemia or glycogen storage disease)
- Cystic fibrosis (a genetic disease that produces sticky, thick mucus that accumulates in the lungs and pancreas)
- Infection (such as syphilis or brucellosis)
- Chronic heart failure
- Amyloidosis (abnormal protein buildup in the liver resulting in disrupted liver function)
Physical Assessment
1. Perform a thorough physical examination.
Note the following symptoms of liver cirrhosis:
- General: fever, fatigue, unintended weight loss, muscle wasting (cachexia)
- CNS: decreased mentation and memory
- HEENT: yellowish sclera of the eyes
- Respiratory: decreased oxygen saturation,ventilation-perfusion mismatch, decreased pulmonary diffusion capacity, and rapid breathing (hyperventilation)
- Gastrointestinal: loss of appetite, nausea, portal hypertension, enlarged liver and spleen, swelling of abdominal veins, accumulation of fluid in the abdomen (ascites), blood in the stool
- Genitourinary: brownish or orange discoloration of urine, light-colored stool, greasy stool (steatorrhea)
- Reproductive: absence of sex drive, enlarged breasts (gynecomastia), shrunken testicles in men; premature menopause in women
- Hematologic: easy bruising and bleeding, folate deficiency anemia, hemolytic anemia, overactive spleen, pancytopenia (low RBCs, WBCs, and platelets)
- Lymphatic: swelling (edema) in the lower extremities
- Integumentary: yellowish discoloration of the skin (jaundice), itchy skin (pruritus), redness in the palms of hands (palmar erythema), spider-like blood vessels with small, red spots on the skin (telangiectasia or spider angioma)
2. Palpate the liver.
Palpation will show enlargement, tenderness, and possible masses.
3. Check the body’s compensation for liver cirrhosis.
Clinical compensation or decompensation of cirrhosis will determine the presence of symptoms and the stage of the disease. Patients with compensated cirrhosis are frequently asymptomatic. Lab results, physical exams, or imaging tests may unintentionally reveal cirrhosis. As opposed to this, patients with decompensated cirrhosis exhibit signs and symptoms due to liver malfunction and portal hypertension.
Diagnostic Procedures
1. Collect blood samples for lab work.
Blood tests look for indicators of liver disease, such as:
- Elevated liver enzymes
- Elevated bilirubin levels
- Creatinine for kidney function
- Complete blood count (low RBCs, WBCs, platelets)
- Hepatitis virus testing
- Elevated prothrombin time (PT)
- International normalized ratio (INR)
2. Check the liver markers.
Gamma-glutamyl transferase (GGT) is an enzyme found mainly in the liver. High levels of GGT in the blood signal liver disease or damage to the bile ducts.
3. Assess for synthetic hepatic function indicators.
PT and serum albumin are accurate indicators of synthetic hepatic function. Albumin is reduced because the liver synthesizes it. Prothrombin time (PT) is high as the liver’s function declines due to coagulation factor deficiencies and bilirubin.
4. Review the imaging scan findings.
- Computed tomography (CT scan) reveals vascular lesions and tumors.
- Ultrasound shows nodules and increased liver echogenicity, which is present in cirrhosis.
- Duplex Doppler ultrasound helps check the patency of the hepatic, portal, and mesenteric veins.
- Magnetic resonance imaging (MRI) scan can visualize iron and fat buildup in the liver.
- Transient elastography (Fibroscan) is a non-invasive technique that uses high-velocity ultrasound pulses. It measures liver stiffness, which is correlated with fibrosis.
- Endoscopic retrograde cholangiopancreatography (ERCP) assesses issues with the bile ducts.
- Upper endoscopy visualizes enlarged veins (varices) or bleeding in the esophagus, stomach, or intestines.
5. Prepare for a biopsy.
A liver biopsy is considered the gold standard for cirrhosis diagnosis, grading (inflammation), and staging (fibrosis) of cirrhosis.
Nursing Interventions
Nursing interventions and care are essential for the patients recovery. In the following section you’ll learn more about possible nursing interventions for a patient with liver cirrhosis.
Treat the Underlying Cause
1. Reduce the development of complications.
By treating the underlying cause of early cirrhosis, the liver’s damage may be reduced, and complications may be prevented.
2. Encourage the patient to act on alcohol dependency.
Individuals with cirrhosis brought on by excessive drinking should attempt to quit. Suggest an alcohol addiction treatment program and resources.
3. Achieve the ideal weight.
Losing weight and managing blood sugar levels may improve the health of those with cirrhosis brought on by non-alcoholic fatty liver disease.
4. Control viral hepatitis.
Hepatitis C is treated with antiviral medications, and advances in treatment can cure the virus.
5. Manage the symptoms.
Medication may considerably slow the development of cirrhosis for those with primary biliary cholangitis who receive an early diagnosis. Other medications are administered to alleviate itching, fatigue, and pain.
6. Improve malnutrition.
Patients often struggle with anorexia due to symptoms and ascites. Improving the diet through increased calories and protein is vital. This can be achieved through 5-6 small meals per day and a high-protein and carbohydrate nighttime snack.
7. Anticipate the possibility of TPN use.
Advise total parenteral nutrition (TPN) for patients who cannot receive enough calories by mouth or maintain tube feedings. The TPN solution contains enough fat emulsions to prevent essential fatty acid insufficiency.
8. Manage pain.
In patients with cirrhosis, NSAIDs, and aspirin should not be used as they can cause GI bleeding and renal insufficiency. Instead, low-dose acetaminophen is permitted. Opioid analgesics are not contraindicated but must be used with caution.
Prevent Complications
1. Prevent accumulation of fluid in the body.
Ascites and swelling may be managed with a low-sodium diet and diuretics that stop the body from retaining fluid. Ascites may require paracentesis to remove fluid from the abdomen.
2. Manage portal hypertension.
The elevated pressure in the veins that supply the liver is known as portal hypertension. It can be controlled by some blood pressure medications (such as beta blockers or nitrates), preventing severe bleeding.
3. Control bleeding varices.
Bleeding varices may require a band ligation or sclerotherapy procedure. Both procedures can stop or lessen the risk of bleeding. Other surgical procedures divert blood flow through the portal venous system to relieve pressure. These include a transjugular intrahepatic portosystemic shunt or distal splenorenal shunt.
4. Excrete toxins from the blood.
The cirrhotic liver cannot filter waste and toxins from the blood effectively. This causes a buildup of toxins in the brain, known as hepatic encephalopathy, that causes confusion, disorientation, drowsiness, and irritability. Lactulose is given to remove toxic ammonia from the body.
5. Assist with liver transplantation.
Liver transplantation should be considered at the first signs of hepatic decompensation. Though not every patient is a candidate, survival rates and quality of life after liver transplant have greatly increased in recent years.
Prevent Further Liver Damage
1. Encourage alcohol cessation.
Emphasize not to consume alcohol, regardless of whether cirrhosis was brought on by prolonged alcohol consumption or another condition. Alcohol use may exacerbate the existing liver disease.
2. Limit salt intake.
The body may retain fluid due to too much salt, increasing swelling in the legs and abdomen. Limit salt intake, and instead of using salt for seasoning the food, use natural ingredients like herbs.
3. Assist the patient in preparing a meal plan.
Malnutrition can occur in those who have cirrhosis. A balanced diet includes a range of fruits and vegetables to help the patient in treatment and recovery. Promote lean proteins like fish, poultry, or lentils. Never consume raw seafood.
4. Prevent infections.
It is more challenging to fight off infections if cirrhosis is present. Remind the patient to avoid being around ill persons and to wash their hands frequently. Instruct against needle-sharing to prevent obtaining or transmitting hepatitis. Educate the patient about vaccinations against pneumonia, influenza, and hepatitis A and B.
5. Be cautious with medications.
The cirrhotic liver has a harder time processing medications. Advise the patient to consult their healthcare provider before using any medications, even over-the-counter ones. Never take ibuprofen and aspirin. Aminoglycoside antibiotics, proton-pump inhibitors, some anticonvulsants, and some medications used to treat high cholesterol should be avoided.
6. Teach the patient when to seek urgent medical attention.
Educate the patient on scenarios when to seek urgent medical attention, such as:
- Signs of increased bleeding
- Worsening jaundice
- Difficulty breathing
- Increased swelling/ascites
- Changes in mentation
- Changes in the level of consciousness
Nursing Care Plans
Once the nurse identifies nursing diagnoses for liver cirrhosis, nursing care plans help prioritize assessments and interventions for both short and long-term goals of care. In the following section you will find nursing care plan examples for liver cirrhosis.
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
- Lack of coordination
- Difficulty concentrating
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.
Dysfunctional Family Processes: Alcoholism
Alcoholic liver disease is a common cause of liver cirrhosis that occurs from years of heavy drinking.
Related to:
- Heavy alcohol use
As evidenced by:
Physical effects of long-term alcohol use on the liver:
- Portal hypertension
- Ascites
- Jaundice
- Splenomegaly
- Poor nutrition
Emotional/psychological symptoms:
- Denial of addiction
- Anxiety/depression
- Guilt
- Social Isolation/loneliness
- Marital problems
- Financial issues
- Disrupted family roles
- Unresolved grief
- Ineffective coping
- Knowledge deficit
Expected outcomes:
- Patient will verbalize an understanding of the long-term effects of alcohol use on the liver
- Patient will agree to rehabilitation or Alcoholics Anonymous for support with addiction
- Patient will verbalize the consequences of alcohol use and identify necessary steps for change
Assessment:
1. Assess for withdrawal.
Withdrawal symptoms must be closely monitored and treated. Delirium tremens (DTs) can result in seizures and is life-threatening. The nurse can administer benzodiazepines to manage these symptoms with caution so as not to worsen hepatic encephalopathy if present.
2. Monitor lab work.
Assess for alcohol abuse through specific liver enzymes such as AST, ALT, and GGT. GGT levels are most sensitive in detecting excessive alcohol consumption.
3. Assess support system involvement.
Assess for the effect of alcoholism and liver cirrhosis on family dynamics. Inquire about support from a spouse, family members, or friends or a lack thereof.
Interventions:
1. Reduce alcohol cravings.
Medications are available to assist with alcohol addiction. Disulfiram is FDA-approved to treat alcoholism. Topiramate is effective in decreasing cravings and withdrawal symptoms. Baclofen is effective in promoting alcohol abstinence in patients with cirrhosis.
2. Refer to rehabilitation or AA.
Addressing the underlying addiction is necessary to manage the disease. Patients should be provided resources for addiction counseling, Alcoholics Anonymous, as well as inpatient or outpatient rehab programs.
3. Coordinate with a dietician.
Cirrhosis and alcoholism result in malnutrition. Patients are often deficient in folate, vitamin B6, vitamin A, thiamine, and zinc. Treating malnutrition depends on the severity of the disease and can be difficult. Assessment and treatment by a dietician may be necessary.
4. Prepare for liver transplantation.
Cirrhosis cannot be cured and a liver transplant is the only treatment for end-stage liver disease. To qualify for a liver transplant, the patient must be committed to abstaining from alcohol.
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
- Anxiety
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.
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 lead to life-threatening complications such as esophageal varices, which can rupture. Constant monitoring for signs and symptoms of bleeding enables prompt treatment and may significantly reduce problems with inadequate tissue perfusion.
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. Enteral nutrition may be necessary.
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