Liver Cirrhosis Nursing Care Plan

 

Nursing Diagnosis
  • Nutrition: imbalanced, less than body requirements

May be related to

  • Inadequate diet; inability to process/digest nutrients
  • Anorexia, nausea/vomiting, indigestion, early satiety (ascites)
  • Abnormal bowel function

Possibly evidenced by

  • Weight loss
  • Changes in bowel sounds and function
  • Poor muscle tone/wasting
  • Imbalances in nutritional studies
Desired Outcomes
  • Demonstrate progressive weight gain toward goal with patient-appropriate normalization of laboratory values.
  • Experience no further signs of malnutrition.
Nursing Interventions
  • Measure dietary intake by calorie count.
    • Rationale: Provides important information about intake, needs and deficiencies.
  • Weigh as indicated. Compare changes in fluid status, recent weight history, skinfold measurements.
    • Rationale: It may be difficult to use weight as a direct indicator of nutritional status in view of edema and/or ascites. Skinfold measurements are useful in assessing changes in muscle mass and subcutaneous fat reserves.
  • Encourage patient to eat; explain reasons for the types of diet. Feed patient if tiring easily, or have SO assist patient. Include patient in meal planning to consider his/her preferences in food choices.
    • Rationale: Improved nutrition and diet is vital to recovery. Patient may eat better if family is involved and preferred foods are included as much as possible.
  • Encourage patient to eat all meals including supplementary feedings.
    • Rationale: Patient may pick at food or eat only a few bites because of loss of interest in food or because of nausea, generalized weakness, malaise.
  • Give small, frequent meals.
    • Rationale: Poor tolerance to larger meals may be due to increased intra-abdominal pressure and ascites (if present).
  • Provide salt substitutes, if allowed; avoid those containing ammonium.
    • Rationale: Salt substitutes enhance the flavor of food and aid in increasing appetite; ammonia potentiates risk of encephalopathy.
  • Restrict intake of caffeine, gas-producing or spicy and excessively hot or cold foods.
    • Rationale: Aids in reducing gastric irritation and/or diarrhea and abdominal discomfort that may impair oral intake.
  • Suggest soft foods, avoiding roughage if indicated.
    • Rationale: Hemorrhage from esophageal varices may occur in advanced cirrhosis.
  • Encourage frequent mouth care, especially before meals.
    • Rationale: Patient is prone to sore and/or bleeding gums and bad taste in mouth, which contributes to anorexia.
  • Promote undisturbed rest periods, especially before meals.
    • Rationale: Conserving energy reduces metabolic demands on the liver and promotes cellular regeneration.
  • Recommend cessation of smoking. Provide teaching on the possible negative effects of smoking.
    • Rationale: Reduces excessive gastric stimulation and risk of irritation and may lead to bleeding.
  • Monitor laboratory studies: serum glucose, prealbumin and albumin, total protein, ammonia.
    • Rationale: Glucose may be decreased because of impaired gluconeogenesis, depleted glycogen stores, or inadequate intake. Protein may be low because of impaired metabolism, decreased hepatic synthesis, or loss into peritoneal cavity (ascites). Elevation of ammonia level may require restriction of protein intake to prevent serious complications.
  • Maintain NPO status when indicated.
    • Rationale: Initially, GI rest may be required in acutely ill patients to reduce demands on the liver and production of ammonia and urea in the GI tract.
  • Refer to dietitian to provide diet high in calories and simple carbohydrates, low in fat, and moderate to high in protein; limit sodium and fluid as necessary. Provide liquid supplements as indicated.
    • Rationale: High-calorie foods are desired inasmuch as patient intake is usually limited. Carbohydrates supply readily available energy. Fats are poorly absorbed because of liver dysfunction and may contribute to abdominal discomfort. Proteins are needed to improve serum protein levels to reduce edema and to promote liver cell regeneration. Note: Protein and foods high in ammonia (gelatin) are restricted if ammonia level is elevated or if patient has clinical signs of hepatic encephalopathy. In addition, these individuals may tolerate vegetable protein better than meat protein.
  • Provide tube feedings, TPN, lipids if indicated.
    • Rationale: May be required to supplement diet or to provide nutrients when patient is too nauseated or anorexic to eat or when esophageal varices interfere with oral intake.
Nursing Diagnosis
  • Fluid Volume excess

May be related to

  • Compromised regulatory mechanism (e.g., syndrome of inappropriate antidiuretic hormone [SIADH], decreased plasma proteins, malnutrition)
  • Excess sodium/fluid intake

Possibly evidenced by

  • Edema, anasarca, weight gain
  • Intake greater than output, oliguria, changes in urine specific gravity
  • Dyspnea, adventitious breath sounds, pleural effusion
  • BP changes, altered CVP
  • JVD, positive hepatojugular reflex
  • Altered electrolyte levels
  • Change in mental status
Desired Outcomes
  • Demonstrate stabilized fluid volume, with balanced I&O, stable weight, vital signs within patient’s normal range, and absence of edema.
Nursing Interventions
  • Measure I&O, weigh daily, and note gain of more than 0.5 kg/day.
    • Rationale: To assess circulating volume status, developing or resolution of fluid shifts, and response to therapeutic regimen. Positive balance/weight gain often reflects continuing fluid retention. Note: Decreased circulating volume (fluid shifts) may directly affect renal function and urine output, resulting in hepatorenal syndrome.
  • Monitor BP (and CVP if available). Note JVD and abdominal vein distension.
    • Rationale: BP elevations are usually associated with fluid volume excess but may not occur because of fluid shifts out of the vascular space. Distension of external jugular and abdominal veins is associated with vascular congestion.
  • Assess respiratory status, noting increased respiratory rate, dyspnea.
    • Rationale: Indicative of pulmonary congestion.
  • Auscultate lungs, noting diminished breath sounds and developing adventitious sounds.
    • Rationale: Increasing pulmonary congestion may result in consolidation, impaired gas exchange, and complications.
  • Monitor for cardiac dysrhythmias. Auscultate heart sounds, noting development of S3/S4 gallop rhythm.
    • Rationale: May be caused by HF, decreased coronary arterial perfusion, and electrolyte imbalance.
  • Assess degree of peripheral edema.
    • Rationale: Fluids shift into tissues as a result of sodium and water retention, decreased albumin, and increased antidiuretic hormone (ADH).
  • Measure abdominal girth.
    • Rationale: Reflects accumulation of fluid (ascites) resulting from loss of plasma proteins/fluid into peritoneal space. Note: Excessive fluid accumulation can reduce circulating volume, creating a deficit (signs of dehydration).
  • Encourage bedrest when ascites is present.
    • Rationale: May promote recumbency induced diuresis.
  • Provide frequent mouth care; occasional ice chips (if NPO).
    • Rationale: Decreases sensation of thirst.
  • Monitor serum albumin and electrolytes (particularly potassium and sodium).
    • Rationale: Decreased serum albumin affects plasma colloid osmotic pressure, resulting in edema formation. Reduced renal blood flow accompanied by elevated ADH and aldosterone levels and the use of diuretics (to reduce total body water) may cause various electrolyte shifts/imbalances.
  • Monitor serial chest x-rays.
    • Rationale: Vascular congestion, pulmonary edema, and pleural effusions frequently occur.
  • Restrict sodium and fluids as indicated.
    • Rationale: Sodium may be restricted to minimize fluid retention in extravascular spaces. Fluid restriction may be necessary to correct dilutional hyponatremia.
  • Administer salt-free albumin/plasma expanders as indicated.
    • Rationale:Albumin may be used to increase the colloid osmotic pressure in the vascular compartment (pulling fluid into vascular space), thereby increasing effective circulating volume and decreasing formation of ascites.

Administer medications as indicated:

  • Diuretics: spironolactone (Aldactone), furosemide (Lasix)
    • Rationale: Used with caution to control edema and ascites, block effect of aldosterone, and increase water excretion while sparing potassium when conservative therapy with bedrest and sodium restriction does not alleviate problem.
  • Potassium
    • Rationale: Serum and cellular potassium are usually depleted because of liver disease and urinary losses.
  • Positive inotropic drugs and arterial vasodilators.
    • Rationale: Given to increase cardiac output/improve renal blood flow and function, thereby reducing excess fluid.
Nursing Diagnosis
  • Skin Integrity, risk for impaired

Risk factors may include

  • Altered circulation/metabolic state
  • Accumulation of bile salts in skin
  • Poor skin turgor, skeletal prominence, presence of edema, ascites
Desired Outcomes
  • Maintain skin integrity.
  • Identify individual risk factors and demonstrate behaviors/techniques to prevent skin breakdown.
Nursing Interventions
  • 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.
    • Rationale: Edematous tissues are more prone to breakdown and to the formation of decubitus. Ascites may stretch the skin to the point of tearing in severe cirrhosis.
  • Encourage and assist patient with reposition on a regular schedule. Assist with active and passive ROM exercises as appropriate.
    • Rationale: Repositioning reduces pressure on edematous tissues to improve circulation. Exercises enhance circulation and improve and/or maintain joint mobility.
  • Recommend elevating lower extremities.
    • Rationale: Enhances venous return and reduces edema formation in extremities.
  • Keep linens dry and free of wrinkles.
    • Rationale: Moisture aggravates pruritus and increases risk of skin breakdown.
  • Suggest clipping fingernails short; provide mittens/gloves if indicated.
    • Rationale: Prevents patient from inadvertently injuring the skin, especially while sleeping.
  • Provide perineal care following urination and bowel movement.
    • Rationale: Prevents skin excoriation breakdown from bile salts.
  • Use alternating pressure mattress, egg-crate mattress, waterbed, sheepskins, as indicated.
    • Rationale: Reduces dermal pressure, increases circulation, and diminishes risk of tissue ischemia.
  • Use calamine lotion and provide baking soda baths. Administer medications (as indicated) such as cholestyramine (Questran), hydroxyzine (Atarax), diphenhydramine (Benadryl).
    • Rationale: May be soothing and can provide relief of itching associated with jaundice, bile salts in skin.
Nursing Diagnosis
  • Breathing Pattern, risk for ineffective

Risk factors may include

  • Intra-abdominal fluid collection (ascites)
  • Decreased lung expansion, accumulated secretions
  • Decreased energy, fatigue
Desired Outcomes
  • Maintain effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs and vital capacity within acceptable range.
Nursing Interventions
  • Monitor respiratory rate, depth, and effort.
    • Rationale: Rapid shallow respiration or presence of dyspnea may appear because of hypoxia and/or fluid accumulation in the abdomen.
  • Auscultate breath sounds, noting crackles, wheezes, rhonchi.
    • Rationale: May indicate developing complications. Presence of adventitious breath sounds may reflect accumulation of fluids or secretions. Absent or diminished sounds suggests atelectasis.
  • Investigate changes in level of consciousness.
    • Rationale: Changes in mentation may reflect hypoxemia and respiratory failure, which often accompany hepatic coma.
  • Keep head of bed elevated. Position on sides.
    • Rationale: Facilitates breathing by reducing pressure on the diaphragm, and minimizes risk of aspiration of secretions.
  • Encourage frequent repositioning and deep-breathing exercises and coughing exercises.
    • Rationale: Aids in lung expansion and mobilizing secretions.
  • Monitor temperature. Note presence of chills, increased coughing, changes in color and character of sputum.
    • Rationale: Indicative of onset of infection, especially pneumonia.
  • Monitor serial ABGs, pulse oximetry, vital capacity measurements, chest x-rays.
    • Rationale: Reveals changes in respiratory status, developing pulmonary complications.
  • Provide supplemental O2 as indicated.
    • Rationale: To treat or prevent hypoxia and if respirations and oxygenation is inadequate, mechanical ventilation may be required.
  • Demonstrate and assist with respiratory adjuncts: incentive spirometer.
    • Rationale: Reduces incidence of atelectasis, enhances mobilization of secretions.

Prepare for/assist with acute care procedures:

  • Paracentesis
    • Rationale: Occasionally done to remove ascites fluid to relieve abdominal pressure when respiratory embarrassment is not corrected by other measures.
  • Peritoneovenous shunt.
    • Rationale: Surgical implant of a catheter to return accumulated fluid in the abdominal cavity to systemic circulation via the vena cava; provides long-term relief of ascites and improvement in respiratory function.
Nursing Diagnosis
  • Risk for injury [hemorrhage]

Risk factors may include

  • Abnormal blood profile; altered clotting factors (decreased production of prothrombin, fibrinogen, and factors VIII, IX, and X; impaired vitamin K absorption; and release of thromboplastin)
  • Portal hypertension, development of esophageal varices
Desired Outcomes
  • Maintain homeostasis with absence of bleeding
  • Demonstrate behaviors to reduce risk of bleeding.
Nursing Interventions
  • Closely assess for signs and symptoms of GI bleeding: check all secretions for frank or occult blood. Observe color and consistency of stools, NG drainage, or vomitus
    • Rationale: The esophagus and rectum are the most usual sources of bleeding because of their mucosal fragility and alterations in hemostasis associated with cirrhosis.
  • Observe for presence of petechiae, ecchymosis, bleeding from one or more sites.
    • Rationale:Subacute disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors.
  • Monitor pulse, BP (and CVP if available).
    • Rationale: An increased pulse with decreased BP and CVP can indicate loss of circulating blood volume, requiring further evaluation.
  • Note changes in mentation and LOC.
    • Rationale: Changes may indicate decreased cerebral perfusion secondary to hypovolemia, hypoxemia.
  • Avoid rectal temperature; be gentle with GI tube insertions.
    • Rationale: Rectal and esophageal vessels are most vulnerable to rupture.
  • Encourage use of soft toothbrush, electric razor, avoiding straining for stool, vigorous nose blowing, and so forth.
    • Rationale: In the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding.
  • Use small needles for injections. Apply pressure to small bleeding and venipuncture sites for longer than usual.
    • Rationale: Minimizes damage to tissues, reducing risk of bleeding and hematoma.
  • Advice to avoid aspiring-containing products.
    • Rationale: Prolongs coagulation, potentiating risk of hemorrhage.
  • Monitor Hb/Hct and clotting factors.
    • Rationale: Indicators of anemia, active bleeding, or impending complications.

Administer medications as indicated

  • Supplemental vitamins: vitamin K, D, and C.
    • Promotes prothrombin synthesis and coagulation if liver is functional. Vitamin C deficiencies increase susceptibility of GI system to irritation and/or bleeding.
  • Stool softeners
    • Rationale: Prevents straining for stool with resultant increase in intra-abdominal pressure and risk of vascular rupture and hemorrhage.
  • Provide gastric lavage with room temperature and cool saline solution or water as indicated.
    • Rationale: In presence of acute bleeding, evacuation of blood from GI tract reduces ammonia production and risk of hepatic encephalopathy.
  • Assist with insertion and maintenance of GI tube.
    • Rationale: Temporarily controls bleeding of esophageal varices when control by other means (e.g., lavage) and hemodynamic stability cannot be achieved.
  • Prepare for surgical procedures: direct ligation (banding) or varices, esophagogastric resection, splenorenal-portacaval anastomosis.
    • Rationale: May be needed to control active hemorrhage or to decrease portal and collateral blood vessel pressure to minimize risk of recurrence of bleeding.
Nursing Diagnosis
  • Risk for acute confusion

Risk factors may include

  • Alcohol abuse
  • Inability of liver to detoxify certain enzymes/drugs
Desired Outcomes
  • Maintain usual level of mentation/reality orientation.
  • Initiate behaviors/lifestyle changes to prevent or minimize recurrence of problem.
Nursing Interventions
  • Observe for signs and symptoms of behavioral change and mentation: lethargy, confusion, drowsiness, slurring of speech, and irritability. Around patient at intervals as indicated.
    • Rationale: Ongoing assessment of behavior and mental status is important because of fluctuating nature of impending hepatic coma.
  • Review current medication regimen. Note adverse drug reactions and effects of medication to the patient.
    • Rationale: Adverse drug reactions or interactions (e.g., cimetidine plus antacids) may potentiate and/or exacerbate confusion.
  • Evaluate sleep and rest schedule.
    • Rationale: Difficulty falling or staying asleep leads to sleep deprivation, resulting in diminished cognition and lethargy.
  • Note development and/or presence of asterixis, fetor hepaticus, seizure activity.
    • Rationale: Suggests elevating serum ammonia levels; increased risk of progression to encephalopathy.
  • Consult with SO about patient’s usual behavior and mentation.
    • Rationale: Provides baseline for comparison of current status.
  • Have patient write name periodically and keep this record for comparison. Report deterioration of ability. Have patient do simple arithmetic computations.
    • Rationale: Easy test of neurological status and muscle coordination.
  • Reorient to time, place, person as needed.
    • Rationale: Assists in maintaining reality orientation, reducing confusion and anxiety.
  • Maintain a pleasant, quiet environment and approach in a slow, calm manner. Encourage uninterrupted rest periods.
    • Rationale: Reduces excessive stimulation and sensory overload, promotes relaxation, and may enhance coping.
  • Provide continuity of care. If possible, assign same nurse over a period of time.
    • Rationale: Familiarity provides reassurance, aids in reducing anxiety, and provides a more accurate documentation of subtle changes.
  • Reduce provocative stimuli, confrontation. Refrain from forcing activities. Assess potential for violent behavior.
    • Rationale: Avoids triggering agitated, violent responses; promotes patient safety.
  •  Discuss current situation, future expectation.
    • Rationale: Patient/SO may be reassured that intellectual (as well as emotional) function may improve as liver involvement resolves.
  • Maintain bedrest, assist with self-care activities.
    • Rationale: Reduces metabolic demands on liver, prevents fatigue, and promotes healing, lowering risk of ammonia buildup.
  • Identify and provide safety needs. Supervise during smoking, put bed in low position, raise side rails and pad if necessary.
    • Rationale: Reduces risk of injury when confusion, seizures, or violent behavior occurs.
  • Investigate temperature elevations. Monitor for signs of infection.
    • Rationale: Infection may precipitate hepatic encephalopathy caused by tissue catabolism and release of nitrogen.
  • Recommend avoidance of narcotics or sedatives, anti anxiety agents, and limiting or restricting use of medications metabolized by the liver.
    • Rationale: Certain drugs are toxic to the liver, whereas other drugs may not be metabolized because of cirrhosis, causing cumulative effects that affect mentation, mask signs of developing encephalopathy, or precipitate coma.
  • Eliminate or restrict protein in diet. Provide glucose supplements, adequate hydration.
    • Rationale: Ammonia (product of the breakdown of protein in the GI tract) is responsible for mental changes in hepatic encephalopathy. Dietary changes may result in constipation, which also increases bacterial action and formation of ammonia. Glucose provides a source of energy, reducing need for protein catabolism. Note: Vegetable protein may be better tolerated than meat protein.
  • Assist with procedures as indicated: dialysis, plasmapheresis, or extracorporeal liver perfusion.
    • Rationale: May be used to reduce serum ammonia levels if encephalopathy develops and other measures are not successful.