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Clinical outcomes of patients with liver cirrhosis

Methods. A convenience sample of 60 patients were randomly and alternatively divided into two equal groups: 30 for each group: Study group (I) received nursing interventions. Control group (II) exposed to routine hospital care. The study was conducted in the Medical Departments of Menoufiya University Hospital and National

Liver Institute. Menoufiya Governorate, Egypt. Six tools were utilized for data collection: Tool 1: A structured interview questionnaire which included three parts covering sociodemographic data, clinical data and patient's knowledge. Tool 2: Physical responses monitoring sheet. Tool 3: Dyspnea Analogue Scale. Tool 4: Fatigue Scale. Tool 5: Physical respiratory assessment sheet. Tool 6: Observational checklist.

Results: The ages of both groups ranged from 30 to 60 years. The majority of both groups were illiterate and farmers and came from rural area. The mean knowledge scores about disease among the study group subjects had significantly higher than those among control group subjects. The mean practice scores among the study group was higher than control group. Physical responses were improved among study group compared to control group as evident by changes in vital signs, dyspnea, edema, fatigue, skin condition, laboratory findings and drug side effects. Manifestations of respiratory infection among the study group subjects significantly decreased compared to the control group. Moreover; hospitalization periods among the study group were significantly shorter than those in the control group. The study group patients showed significantly improved compliance to regimen than those in the control group, accordingly, improvement in physical condition.

Conclusion: enrichment of patients with knowledge and skills about liver cirrhosis disease and it's management seems to have a positive effects on improvement of physical responses and can lead to improvement of clinical outcomes.

Key words: Clinical outcomes and liver cirrhosis

INTRODUCTION

Liver cirrhosis is a consequence of chronic

liver disease characterized by replacement

of liver tissue by fibrotic scar tissue as well as regenerative nodules, leading to progressive loss of liver functions. It is most commonly caused by alcoholism and hepatitis.(1) Cirrhosis represents

the final common histological pathway for a wide variety of chronic liver diseases. It is defined as diffuse hepatic process characterized by fibrosis and the conversion of normal liver architecture into structurally abnormal nodules.(2)

ISSN 1110-0834

Thirty five million individuals in the world die each year from chronic disease and the numbers are increasing steadily.(3) The progressive increase in the cost for health care in recent decades is expected to continue, in fact accelerate. Cirrhosis and chronic liver disease are the 10th leading cause of death for men and the 12th for women in the United States in 2001, killing about 27,000 people each year. Also, the cost of cirrhosis in terms of human suffering, hospital costs, and lost productivity is high. About 1.0% deaths for age group of 25-34 years and 3.7% for the age group of 35-44 and 4.2% of deaths for age 45-54 years.(4) According to the office for National Statistics in the United Kingdom, liver disease is now the fifth most common cause of

death after heart disease, stroke, chest disease and cancer.(5)

In Egypt about 85% of those infected with HCV will develop chronic hepatitis of varying severity. Nearly 20% of patients develop cirrhosis in 10-20 years and the incidence of hepatocellular carcinoma is 1- 4% per year in patients with cirrhosis.(6) The prevalence of patients admission with HCV infection in National Liver Institute Hospital has been increasing at a very high rate over the past years. In 2002, more than 90,000 patients received treatment in the National Liver Institute Hospital in out-patient clinics and inpatient services, double the number for 1999.(6) In addition, approximately 76.92% of patients admitted to the National Liver Institute Hospital for treatment at in-patient department had liver cirrhosis (Statistical Records of National Liver Institute Hospital, 2008).(7)

Patients with liver cirrhosis experience a variety of clinical manifestations depending on the duration and severity of the liver disease rather than the underlying diagnosis. In the early stage, signs and symptoms of cirrhosis are usually subtle. The patient may report slight weight loss, unexplained fever, fatigues and dull heaviness in the right upper abdomen. These symptoms are probably due to inflammation and enlargement of the liver. The liver may be palpable below the right rib margin as the disease progresses. Cirrhosis is considered as a chronic disease resulting from many causes.(8)

Patients with liver cirrhosis are usually subjected to many physical problems that should be monitored and managed. This include: ineffective breathing pattern, impaired gas exchange, fluid volume excess, activity intolerance, impaired skin integrity, risk for imbalanced fluid and electrolytes, altered nutrition less than body requirement, disturbed thought process, risk for infection and injury. Some physical body responses may lead to psychological disturbances which decrease the body abilities to cope with these physical responses.(9)

Nurses in their day to day contact with

patients have the best opportunity to asses potential problems, discuss medical regimens and give teaching about all aspects of care. These include maintaining physical activity, recognizing activity limitations, conserving energy, following dietary modification and adhering to medication schedule with attending to side effects, in addition to maintaining life style changes that best suit those patients.(10)

Assessment and intervention for fluid and electrolyte imbalance in a patient with liver cirrhosis is an important component of nursing care throughout the patient's hospitalization. The nurse should be aware of these potential imbalances by carefully monitoring the patient's clinical status, laboratory results, vital signs, intake and output, body weight, abdominal girth and degree of edema. Correction of imbalances and prevention of serious complications can lead to an increased survival

rate in patients with liver cirrhosis.(8) Delivering comprehensive care for patients with cirrhosis as denoted by Lemone et al.(11) should focus on promoting periods of wellness, encouraging self care management and preventing disease progression.

The term compliance is used to describe the patient's adherence to the therapeutic regimen. Adherence to the therapeutic regimen requires that the patients make one or more changes in their life style. The patient may need to take medications, adhere to a diet, restrict their activities, promoting rest and seeks periodic evaluation of their health status. The role of the nurse in teaching and directing the patient towards adherence behavior is a significant one. It is the responsibility of the nurse to assess all variables that may have an effect on the patients' adherence and to use this information when developing and implementing the patients teaching plan.(8)

Effective management of cirrhotic patient must be directed toward improvement of physical responses as identified by change in vital signs, decrease of dyspnea and fatigue degree, relieve of edema and ascites, improve skin condition, have normal values for serum sodium and potassium, in addition, evaluation of the patient compliance versus non compliance to the recommended therapeutic regimen. It was observed that patients with liver cirrhosis are admitted to hospital with many complications such as portal hypertension, ascites, esophageal varices, jaundice, peripheral edema and hepatic encephalopathy. Nursing research in this area has been nearly scarce despite its importance to patients' life and health care delivery system. Hence, there has been need to study the effect of protocol of care on clinical out comes of patients with liver cirrhosis.

Operational definitions:-

Clinical outcomes, means study physical responses as evident by vital signs, dyspnea, fatigue, edema, laboratory findings, respiratory changes and drug side effects.

Decompensated cirrhosis, patient usually seeks medical advice because of ascites, bleeding,

hepatic encephalopathy, jaundice, weakness, muscle wasting, weight loss, continuous mild fever (37.5-38°C), pigmented skin, clubbing of the finger, purpura over the arms, shoulders and shins, spontaneous bruising and epistaxis.

Aims of the Study

This study aimed to: determine the effect of protocol of care on clinical out comes of patients with liver cirrhosis.

METHODS

1-Material

Research Design:

The quasi-experimental research design was utilized.

Setting:

The study was conducted in the Medical Departments of Menoufiya University Hospital and National Liver Institute. Menoufiya Governorate, Egypt. Both of these places are considered representative for patients with liver cirrhosis.

Subjects:

A convenience sample of 60 adults patients were randomly and alternatively divided into two equal groups; (30) for each group:

Study group (I) received nursing interventions

Control group (II) exposed to routine hospital care.

The patients had been selected according to the following inclusion criteria:

All newly admitted adult patients within 24 hours.

Having a confirmed diagnosis of decompensated liver cirrhosis.

Conscious and willing to participate in the study.

Free from diabetes mellitus, cardiac, renal and other chronic disease.

Both groups were matched regarding to age, sex, duration of disease.

Tools:

For the purposes of the study and to collect the necessary data six tools were developed and utilized by the researchers based on review of related literature.

Tool I: A structured interview questionnaires:

An Arabic structured interviewing sheet was constructured by the researcher dependent on a review of the related literature for the purpose of data collection and it included three parts:

Part one: Sociodemographic data: It comprised: age, sex, level of education, occupation and residence area.

Part Two: Clinical data (Health history): It comprised: medical history, date of admission, diagnosis, duration of illness, previous hospitalization, reasons of admission, date of discharge and history of smoking.

Part Three: Patient's knowledge: It comprised four sections; to assess the patient's knowledge about patient self care practices regarding liver cirrhosis and its management as (rest and exercises and medications). Seven questions that assessed patients' knowledge about disease, was given a score out of fourty.

Scoring system: Each question was given marks according to points being answered by patients. For example:

Question number one was given 4 marks if the patient reported the correct and complete answer and was given 2 marks if he reported incomplete answer and zero if he reported incorrect answer.

Questions number (two, three and four) each question contain six points, patient was given six marks if he reported complete and correct answer and 3 points for incomplete answer and zero for incorrect.

Questions number (five and six) each of them contain four correct points. Each question was given 4 marks if patient reported the correct and complete answer and 2 marks for incomplete one and zero if he reported incorrect answer.

Question number seven was given 10 marks if patient reported complete and correct answer (mentioned 10 points of complications). And 5 marks if he reported 5 correct points and zero if he reported incorrect answer. The patients scores were recorded for each question individually (separately) then added and collected. So that the total scores of the patient's knowledge about disease ranged from zero to forty as a maximum score.

Tool II: Physical responses monitoring sheet: This sheet was developed by the researcher for the purpose of assessing physical response for both groups. It was designed by the researcher based on review of relevant literature. It includes 10 items, representing the following:- Vital signs, Skin condition, side effects of the prescribed medication in relation to the following drugs: lactulose and diuretics. Presence of generalized edema, pitting edema, ascites, Patient's weight, abdominal circumference and intake and output. Laboratory findings of serum sodium and potassium. Liver function as ALT (Alanine Serum transaminases), AST (Aspartate Serum transaminases) and serum Albumin.

Tool III: Dyspnea Analogue Scale: This tool

was developed by Borg.(12) It is used to provide information on the intensity of dyspnea. It is a numerical Likert scale, ranging from zero to ten, zero means (no dyspnea), while, 1 to less than (4)

(mild dyspnea) 4 to less than (7) moderate dyspnea and 7 to 10 severe dyspnea.

Tool IV: Fatigue Scale: This tool was developed

by Potter and Perry.(13) It is used to measure

fatigue. It is a numerical Likert scale and ranges from zero to ten, zero means (not tired), 1 to less than (4) means (mild exhaustion), 4 to less than (7) means (moderate exhaustion), 7 to 10 means severe exhaustion. The patient records his own feeling of exhaustion on the scale.

Tool V: Physical respiratory assessment sheet: Developed by the researcher to assess progress

in patients' respiratory status and development of chest infection. It comprised fourteen items as temperature, respiration, breathing sound, sputum, use of accessory muscles, chest expansion, cyanosis, cough, etc.

Tool V1: Observational checklist sheet: It was developed by the researcher after reviewing of the related literature and included five parts to observe patients' performance about breathing and coughing exercises, measuring intake and output, skin care, range of motion exercises and patient's compliance to therapeutic regimen.

Part one:- Breathing and coughing exercises. It is used to evaluate patient performance for breathing and coughing exercises. It was composed of 8 steps, total marks sixteen for all steps. Each patients step was given 2 marks if done correctly and 1 mark if incorrectly, while zero if he did not perform.

Part two:- Intake and output. It is used for measuring intake and out put correctly, Patients were given 2 marks if he measure correctly and 1 mark if incorrectly, while zero if he did not perform.

Part three:- Skin care. It is used to evaluate patient skin care. A score one illustrate that the patient does not follow the instruction of skin care correctly, a score two was given to correct skin care, while zero indicate that he did not perform the care or follow the instructions

Part four: Range of motion exercises: It is used to evaluate range of motion exercises. It was composed of flexion and extension for the following joints, neck, shoulder, Elbow, hip, knee, dorsiflexian and planter flexion for ankle joint. The total score of the patients about range of motions exercises for all joints were ranged from 0 as to thirteen as a maximum score. This range of motion exercises were performed by the patient and evaluated 3 times pre-test, post-test and before discharge.

Part five: Patient's compliance: It is used to assess patients' compliance to the prescribed regimen. It included the following items: adherence to medication, diet, rest and daily activity, exercise and follow up.

II-Methods

Written Approval: An official permission to carry out the study was obtained by the researcher from responsible authorities after an explanation of the purpose of the study.

Tools development: Tools 1,2 and 5 were constructed by the researcher after reviewing

the relevant literature and were tested for

content validity by 5 experts in medical surgical nursing and medical specialist, modification were done accordingly to ascertain relevance and completeness.

Protection of patient's rights and consent (Patient consent): After permission to carry out the study a written consent was obtained from patients to participate in the study. Confidentiality was assured for each participants.

A pilot study: A pilot study was conducted on 10% of the study sample (6 patients) to evaluate the developed tools and a designed booklet for clarity and applicability, and then necessary modifications were carried out. The data was obtained from the pilot study not included in the actual study.

Data collection:-Data collection extended from the first January 2007 to the end of September 2007. Patient who agreed to participate in the study and fulfilling the inclusion criteria were included in the study. A convenience sample of 60 patients were divided randomly and alternatively into two equal groups:

The study group (I): received nursing interventions for managing the disease.

The control group (II): exposed to routine hospital care. according to the usual hospital routine

and without interference from the researchers, assessment sheet were filled for them by the researchers using the designed tools.

The researchers initiated data collection by using the pre-test Questionnaire, in which the studied patients were interviewed by the researcher using the structured interview. Each patient in both groups (study and control) was interviewed individually to fill the knowledge assessment sheet. The pre-test used to assess patient knowledge and self care regarding liver cirrhosis and it's management using tool 1.

Every patient in both groups (study and control) was physically assessed using the physical responses monitoring sheet tool 11, Dyspnea Analogue Scale tool 111, Fatigue Scale tool 1V and respiratory status tool V.

The data obtained were analyzed to aid in formulating nursing management that tailored to suit patient's needs.

Study group subjects were individually given verbal instruction about definition, liver functions, causes of disease, signs, symptoms and complications. In short sessions about 45 minutes. The numbers of sessions varied according to their level of understanding of each patient, it ranged from 3 to 5 sessions.

A short session of 15 minutes was given about breathing and coughing exercise, intake and output, skin care, weighing by using a bathroom scale, abdominal girth, how to determine degree of edema. Range of Motion (ROM) exercises until the patients or significant others understanding and mastering the given practice. It ranges from 3 to 6 sessions.

Each patient in study group was contacted daily to reinforce provided knowledge and practice to respond to their question and try to help them to solve problems that might arise during hospitalization.

Patients in the study and control groups were assessed and monitored 3 times during hospitalization: on admission, immediately post intervention and before discharge using all tools.

Patients compliance to therapy regimen (in the study and control groups) were assessed on admission and after 3 months post discharge.

Statistical Analysis:

Upon completion of data collection each sheet was manually scored. Calculations were made manually. The data were presented as means and standard deviations (quantitation) as well as percentage, frequency (qualitative) chi-square tests with (Yate's correction). And t test were used. as test of significance. Friedman's test was used for comparison of changes in mean values of more than 2 situations for the same group. The 5% level of significance was adopted.(14).

RESULTS

For sociodemographic characteristic and medical history. 40.0% and 46.7% of both study and control groups were between the age groups of 50- < 60 years. A large percent (83.4%, 90.0%) of them came from rural area, and (50.0%, 41.3%) of both study and control groups were illiterate. In relation to medical history, 43.3% of study group and 50%

of control group had the disease for more than

one year. While the majority of study and control groups had hospital readmission within 1-3 months (50%, 43.3%). The minority of them had hospital readmission within 6 months or more (6.7%, 10%). About half of subjects in the study and control

group 40%, 50 % had hospital stay from 2-3 weeks. Also the majority (90%, 96.6%) of both study and control groups respectively had hospital readmission because dangerous or exacerbated problem related

to liver cirrhosis. As regards hospital stay/days,

it was longer among control group subjects than

the study group, 43.3% of the control group stayed from 15 days to less than 20 days as compared to 10% of the study group subjects. Additionally, the mean hospital stay for both groups were as follows (16.2 ± 4.16, 11.8 ± 3.38, respectively) a statistically significant difference was evident between the two groups considering hospitalization period with t = 5.53, P< 0.001).

Table (I) Demonstrates mean and standard deviation of total knowledge scores for both

study and control group through the three assessment phases (on admission, immediately post intervention and 3 months post discharge). An obvious improvement was observed in total mean knowledge scores of the study group immediately post intervention and 3 month post discharge with 68.83 ± 5.60, 79.10 ± 4.07 compared to control group as 40.86 ± 5.23, 44.33±4.62 respectively. Statistical analysis also revealed significant statistically differences between study and control groups immediately post intervention and 3 months post discharge.

Table (II) Shows mean and standard deviation of practices scores for both study and control group through the three assessment phases (on admission, immediately post intervention and 3 months post discharge). This table demonstrated, an obvious improvement in total mean practices scores of the study group in relation to (breathing and coughing exercises, range of motion exercises, skin care, measuring intake and output) immediately post intervention and 3 month post discharge with 46.73 ± 5.34, 52.96 ± 4.66 compared with control group 7.53 ± 1.61, 8.5 ± 1.61 respectively.

Table (III-a) Presents of physical responses assessment (vital signs) for both study and control group at 3 assessment phases (on admission, immediately post intervention and 3 months post discharge).The majority (93.3%) of the study group had normal pulse rate after 3 month post discharge compared to (53.3%) of the control groups. At the beginning of the study (63.3%, 66.7%) of study and control group subjects had irregular rhythm. After 3 month post discharge this percentage was reduced to (3.3%) among study group and (50%) among control group. High percentages (66.7%, 73.3%) of the study group have tachypnea before discharge this percentages decreased to (6.7%) among study group and (50%) among control group subjects. Irregular respiratory pattern and deep shallow respiration on admission were (73.3%, &70%) among both groups, and gradually decreased to (6.7%, 6.7%) among study group subjects after 3 month post discharge

as compared to (53.3 %, 53.3%) of the control group. The majority (96.7%) of study group

subjects had normal blood pressure after 3 month post discharge as compared to (46.7%) of control group. A significant statistically differences were demonstrated between study and control group in relation to the above mentioned variables.

Continue table (III-b) Presents of physical responses assessments (general) for both study

and control groups at 3 assessment phases (on admission, immediately post intervention and 3 months post discharge).It was found that, before intervention 56.7%, 60% of study and control group had lower limb edema and this percentage was reduced to (10%) among study group as compared to 36.7% among control group after 3 month post discharge. As regards ascites, at the beginning it was found that 83.3%, 90% of study and control group respectively had ascites, while after 3 month post discharge this percentages decreased to 13.3% among study group as compared to 53.3% among control group. In relation to, the severity of edema, at the beginning it was found that 23.3%, 20% of study and control groups respectively had + 2 of edema and 16.7%, 3.3 % of study and control groups respectively had + 3 of edema while after 3 month post discharge it was noted that high majority (90%) of study group had no edema as compared to 53.3% of control group.

As regards body weight, immediately post intervention 60%, 43.3% of study and control

groups had body weight lower than the base. While after 3 month post discharge it was found that

93.3% of study group had body weight lower than the base as compared to 46.7% of control group. A highly significant statistical differences were found between study and control group in relation to the above mentioned variable. Table (III-c) revealed that, dyspnea in the first assessment was found in 46.6% of the study group and 43.3% of control group had moderate dyspnea., while the second assessment revealed that 56.7 of study group and 30% of control group had slight dyspnea as well 3 month post discharge 90% of study group had no dyspnea as compared to 23.3% of control group. the results revealed statistically significant differences to the above mentioned variables.

Table (IV) Demonstrates of drug side effect

as reported by both study and control groups

through the three assessment phases (on admission, immediately post intervention and 3 months post discharge). As regards the fluid volume depletion

in the first assessment it was found that, 66.7% of the study group and 76.7% of the control group

had no fluid volume depletion. Immediately after intervention 83.3% of both study and control groups had no fluid volume depletion, while after 3 month post discharge 96.7% of the study group and 86.7% of the control groups had no fluid volume depletion. Concerning the hypokalemia in the first assessment, 66.7% of the study group and 70% of the control group had no hypokalemia, but immediately after intervention 90% of the study group and 76.7% of the control group had no hypokalemia. After 3 month post discharge 100% of the study group and 83.3% of the control group had no hypokalemia. Statistically significant differences were found between both groups as regards to fluid volume depletion and hypokalemia.

Table (V-a) Shows of laboratory tests for both study and control groups through the three assessment phases (on admission, immediately post intervention and 3 months post discharge).. At first assessment 33.3 % each of study and control groups had hypernatremia (> 145) after 3 month post discharge this percentages was reduced to 6.7% among study group and 20% among control group as will as 100% of study group had normal serum potassium (3.5 - 5 MEQ) after 3 month post discharge as compared to 83.3% of control groups. A high significant statistical differences were found between study and control group in relation to the above mentioned variables.

Table (V-b) Shows Values of laboratory tests for both study and control groups (on admission and 3 months post discharge). As regards ALT, AST enzymes and serum albumin at first assessment there were, no significant differences between study and control groups, while after 3 months post discharge there were significant differences between study and control groups as regards to the ALT, AST enzymes and serum albumin.

Table (IV) Shows Comparison of compliance for both study and control groups to therapeutic regimen on admission and 3 months post discharge. As regards compliance with medication; on admission, the majority (66.7%, 83.3%) of study and control group respectively usually comply with prescribed medications. while, after 3 month post discharge majority (90%) of study groups reported that they always take medication as compared to (33.3 %) in the control group. Concerning compliance with diet, on admission, a higher percentage (73.4%, 76.7%) of study and control groups reported that they usually follow the prescribed diet, but, after 3 month post discharge a high percentage (96.7%) of study groups reported that they always follow prescribed diet as compared to small percentage (39.7%) of control groups. As related to compliance with exercises on admission, the majority (83.3 %, 80%) of study and control groups never complied with practicing exercise. After 3 month post discharge a high percentage (93.3%) of study groups reported that they always follow exercises prescribed as compared to 13.3% of control group. In relation to compliance with follow up, on admission, half (53.3%, 50%) of study and control group subjects reported that they always comply with treatment, while after 3 months post discharge, the majority (96.7%) of study group reported that they always comply as compared to 56.7% of control group. There were a significant difference between study and control group as regards to the above mentioned variables.

Table I: Mean and standard deviation of knowledge scores for both study and control group through the three

assessment phases (on admission, immediately post intervention and 3 months post discharge).

Test

Patients'knowledge about:

Study Group

No= 30

Control Group

No= 30

Test of significant

t value

P. value

X ± SD

X ± SD

Disease

On admission

Immediately post intervention

3 month post discharge

16.86 ± 4.52

28. 80 ± 4. 40

34. 43 ± 3. 28

F= 57.82 P= 0.000

15.30 ± 4.56

16.66 ± 4.88

17.96 ± 4.48

1.33

10.10

16.22

0.18

0.000*

0.000*

Rest &exercise

On admission

Immediately post intervention

3 month post discharge

12.06.±1.96

14.60 ±1.88

22.53 ±1.07

F= 59.05 P= 0.000

11.33 ±1.68

12.10 ±1.49

13 ±1.48

1.55

17.07

28.48

0.12

0.000*

0.000*

Medication

On admission

Immediately post intervention

3 month post discharge

12.06 ±1.52

20.33 ±2.05

22.13 ±1.90

F= 57.82 P= 0.000

11.30 ±1.64

11.80 ±2.04

13.10 ±2.41

1.87

16.13

16.09

0.06

0.000*

0.000*

Total Knowledge score

On admission

Immediately post intervention

3 month post discharge

41.00 ±5.77

68.83 ±5.60

79.10 ±4.07

F= 60.00 P= 0.000

37.93 ±5.38

40.86 ±5.23

44.33 ±4.62

2.12

19.98

30.87

0.03

0.000*

0.000*

* = significant F= Friedman's test P= test of significance

Table II: Mean and standard deviation of practices scores for both study and control group through the three

assessment phases (on admission, immediately post intervention and 3 months post discharge).

Practices

variable

Study Group

No= 30

Control Group

No= 30

Test of

significant

t value

P. value

X ± SD

X ± SD

Breathing and coughing exercises

On admission

Immediately post intervention

3 month post discharge

0 ± 0

12. 33 ± 2. 20

15. 10 ± 0. 92

F= 58.61 P= 0.000

0 ± 0

4.26 ± 1.28

4. 20 ± 1.29

-

17.32

37.50

-

0.000*

0.000*

Range of motion exercises

On admission

Immediately post intervention

3 month post discharge

0 0

20.86 ±2.84

23.73 ±1.76

F= 58.20 P= 0.000

0 0

0 0

0 0

-

40.11

73.84

-

0.000*

0.000*

Skin care

On admission

Immediately post intervention

3 month post discharge

2.56 ±1.22

9.66 ±1.21

11.60 ±0.56

F= 57.63 P= 0.000

2.80 ±1.39

3.46 ±1.25

4.03 ±1.09

0. 68

19.48

33.58

0.49

0.000*

0.000*

Measuring intake and output

On admission

Immediately post intervention

3 month post discharge

0 ± 0

4.13 ± 1.30

5.20 ± 0.84

F= 57.15 P= 0.000

0 0

0 0

0 0

-

17.33

33.63

-

0.000*

0.000*

Total Practices score

On admission

Immediately post intervention

3 month post discharge

2.46 ±1.30

46.73 ±5.34

52.96 ±4.66

F= 56.26 P= 0.000

2.80 ±1.39

7.53 ±1.61

8.5 ±1.61

0.95

38.47

49.34

0.03

0.000*

0.000*

* = significant F= Friedman's test P= test of significance

DISCUSSION

Liver cirrhosis results from a variety of disorders and is a major cause of morbidity and mortality worldwide, Patients with liver cirrhosis experienced a variety of clinical manifestations depending on the duration and severity of the liver disease rather than the underlying diagnosis. Nurses in their day to day contact with patients have the best opportunity to asses potential problems, discuss medical regimens and give teaching about all aspects of care, these include maintaining physical activity, recognizing activity limitations, conserving energy, following dietary modification and adhering to medication schedule, in addition to maintaining life style changes that best suit those patients.(10)

Socio - demographic characteristics of participants. The current study represented that about half of the sample were illiterates, this would be attributed to the fact that the majority of the sample were from rural areas.(15) This results are consistent with Sallam(16) who reported that more than half of the sample was illiterate(16).In relation to occupation of patients, it was found that about half of patients were farmers. This finding was supported by Sallam(16) who reported that one third of patients were farmer because farmer are more exposed to schistosomal infection and its subsequent liver dysfunction and bleeding esophageal varices.

The findings of this study also, revealed that

the majority of both sample were previously admitted to the hospital with liver cirrhosis,

while about half of the total sample had

recurrent admission within 1-3 months, minority of them were readmitted in less than one

month after hospital discharge. From the researcher point of view readmission were most commonly due to the recurrence of signs and symptoms as well as threatening complications. Re-hospitalization occurs frequently in the patient with complicated liver cirrhosis, medication related problems, lack of knowledge regarding symptoms management and non compliance.(17) This assumption appeared to be true with the sample of this study patients as patients' knowledge, self care management and compliance were found to be at very low levels as evidenced by low scores of the pretest results. Also, this may be explained by the fact that patients are usually discharged from hospital without preparing for discharge plan.

Length of hospital study. The current study revealed that length of hospital stay for the study group was shorter than for the control group this might be attribute to occurrence of some threatening complication or problems among the control group. In this respect, Grace et al.(18) suggested that patients should be observed for sign of dyspnea, fatigue, esophageal varices and hypovolemic and standard intravenous hydration should be undertaken and meticulous nursing care should be provided to avoid complication and decrease the length of hospital study.

Mean knowledge score. Canobbio(19) emphasized that patients with liver cirrhosis need education, counseling and support to enable them to adjust to their chronic illness. Results of the current study showed that knowledge mean score about liver cirrhosis among the study group were higher than those among the control group subjects. This may be attributed to theoretical sessions that were provided to study group to cover all aspects of liver cirrhosis This result also, was in-line with Mohamed(20) who recorded that cirrhotic patients with ascites had great learning needs due to the poor level of knowledge about their condition and a low level of performing the essential skills of self care and prevention of life threatening hazards of liver cirrhosis.

Practice mean score. The study group subjects recorded higher mean scores of practice than those of control group in performing breathing and coughing exercises. Performing range of motion exercise, measuring intake and output adequately, performing skin care effectively because after performing all these procedures patient feels great comfort and security, dyspnea and fatigue decreased, breathing improved, skin condition improved and threatening complication decrease. These results are supported by Holloway and Ram(21) who found that both control and study groups were having unsatisfactory practice levels before intervention. However after intervention, most of the study subjects were in good levels of practice. Similar findings were also noted by El- Sheikh(22) who found that the practice mean scores were higher among study group subjects compared to control group subjects after intervention.

Physical responses. Regarding Vital Signs, Findings of the present study showed that after nursing intervention there was improvement of respiratory rate, pulse and blood pressure among the subjects of study group as compared to control group. These results are supported by Badawy(23) who found significant differences between study and control groups regarding to respiratory rate, pulse and blood pressure after intervention.

Dyspnea. Results of the current study revealed that dyspnea was decreased among study group subjects than control group. This could be explained by teaching the patients about proper positioning, a semi-to-high fowlers position, help the patients to breath effectively, eating frequent small meals that are low in sodium and omission of gas-forming food, from the researcher point of view all these items of nursing care help in decreasing dyspnea. Our findings are supported by Gosselink(24) who investigated the effect of controlled breathing on improving dyspnea using breathing rehabilitation program exercise could improve gas exchange, increasing strength and endurance of the respiratory muscles, and optimizing the pattern of thoraco- abdominal motion.

Fatigue. The current study revealed that fatigue was decreased among the study group than the control group. Kuther(25) explained that deep breathing is a natural way to increase energy and relieve fatigue and feel more relaxed because it accelerates the intake of oxygen; relieve feelings of stress and anxiety, because it promotes obtaining oxygen that the patient needs.

Fluid balance. Findings of this study clarified that after nursing intervention, the study group had significant better fluid balance as evident by assessment of edema, ascites, body weight, intake and output. This could be explained by understanding the instruction about diet, fluid intake and output, skin care, monitoring body weight and instruction given about medication. These results are in agreement with, Myers and Bear(26) who stated that ascites and edema are effectively controlled by restriction of sodium intake. They added that low sodium diets can be made more appealing by adding salt substitutes. The patient's need for potassium must be assessed. Often the increased intake of potassium is beneficial in patients receiving diuretics therapy especially furosemide. Careful records of intake and output are kept for most patient with ascites.

Moreover, the present study revealed that side effects of diuretics less frequently happen. Their was (fluid volume depletion and hypokalemia among the study group subjects as compared to the control. This could be explained by mean knowledge score about medication that was higher among study group subjects than control group.. This is consistent with Doenges et al.(27) who stated that the nurse should explain the purpose, dosage and route of administration of any prescribed drugs as well as side effects to report to the physician or nurse. In addition, no significant difference existed between study and control group as regards to ALT, AST enzymes and serum albumin pre intervention, while after 3 months post discharge there were significant differences existed between study and control groups regards to the ALT, AST enzymes and serum albumin. The results are in-line with Sloan(28) who revealed that therapeutic diet at the very least makes the blood tests especially electrolyte levels look better and their results are in line with the results of the present study.

Compliance to therapeutic regimen. In relation to the patients compliance to therapeutic regiment as (taking medication, diet, rest, exercise, follow up of treatment with physician). There were insignificant differences between study and control groups before protocol of care as regards compliance to therapeutic regimen, while after nursing care there was an improvement in study group patients in compliance to therapeutic regimen, this could be explained by the fact that patient were given instruction about medication in all aspects as dose, route, action, side affect special precautions, also instructions given about food allowed and food that should be avoided to avoid further threatening complication, importance of rest in acute stage and gradual progression of activities and avoiding strenuous exercises, also importance of follow up of treatment after discharge was encouraged The results of pre intervention were in-line with Sallam(16) who reported that more than half of their sample had fair compliance with medication and most of them had fair compliance with nutrition while most of them had poor compliance with exercise. In addition, Sallam;(16) Comers(29) emphasis that there were statistical significant positive relationship between patients knowledge regarding nutrition, exercise and compliance with them as a total general compliance with therapeutic regimen. Also increasing patients education regarding disease and treatment modalities might enhance compliance.

Conclusions

The present study revealed that the nursing intervention given to patient with liver cirrhosis plays an important role in improving patient's knowledge and self care, and has a positive effect on physical responses and compliance to follow the prescribe regimen after discharge.

Recommendations: Based on the findings of the present study the following recommendations can be suggested:

Teaching for patients and family should be started immediately after patient admission and continued post discharge from hospital through standardized protocol of care, periodic check up to help patient to cope with change that may happen.

Booklet should be provided for each

patient containing simple pictures and information to reinforce knowledge given regarding therapeutic regimen.

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