As defined by Tabers, cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrosis, scar tissue and regenerative nodules (lumps that occur as a result of a process in which damaged tissue is regenerated), leading to progressive loss of liver function (2005). Its causes and severity can vary depending on environment, social, genetic and occupational exposure.
In the U.S., the most common causes of the chronic disease are alcohol and chronic viral hepatitis but it's not limited to just those. Other causes include autoimmune which is primary biliary cirrhosis, biliary known as sclerosing cholangitis, nutritional which is fatty liver, and genetic such as Wilson's disease. According to Ackley and Ladwig, cirrhosis affects men more than women and is the twelfth leading cause of death, accounting for 27,000 deaths per year ( 2005).
Causes can vary. Many people that have cirrhosis have more then one cause of the liver damage. It is not caused by trauma, or a short damaging time period. It usually takes place over several years of chronic abuse and damage. (Ackley & Ladwig, 2008) The two major one that I will be discussing are alcohol related liver disease and chronic hepatitis C.
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With alcohol liver damage, most of the people that drink will not suffer from any type of damage. Depending on the person, the amount of alcohol that is needed to do any damage varies. For women, it take consuming two to three drinks which includes beerand wine, per day and for men, three to four drinks per day, can lead to liver damage and cirrhosis (Ackley & Ladwig, 2008). In 2007, alcohol cirrhosis related death was more frequent that any other type of cirrhosis.
For liver damage to occur there are several risk factors involved. One of course is alcoholism. Frequently consuming more alcohol than your liver can filter and pass. Next, an increasing risk factor is obesity. A 2003 study of more than 11,000 patients, published in the journal Gastroenterology, revealed that obesity increased the risk of death from cirrhosis in those who drank little or no alcohol, but not in alcoholics. Severe obesity in any case is a risk factor for liver damage and in one study, 2.3% of patients with severe obesity had signs of cirrhosis.
A third factor is chronic hepatitis C. on average 10% to 15% of patients with Hep C develop cirrhosis. A few of the following put people with Hep C at risk: 1) being a male, 2) heavy alcohol drinker 3) Also having Hep B. and 4) having a history of transfusions, that's just to list a few. The fourth factor is genetics. There are a numerous inherited disorders interfere with the way the liver produces, processes, and stores
enzymes, proteins, metals, and other substances necessary for proper functioning of the body (Chopra) .
In a person with cirrhosis they will manifestations that can be noted and observed. Although in the early stage there may not be much to look for, in the later stage several characteristic shows with cirrhosis. Characteristics such as: weakness, fatigue, loss of appetite, nausea, vomiting, weight loss, abdominal pain and bloating when fluid accumulates in the abdomen, itching spiderlike blood vessels (Boyer, 2004). As the condition continues and gets worse, severe complications can occur. In some people the manifestations of the complications can be the first sign of the disease (Boyer, 2004).
One complication after the progression of the disease is fluids retention in the legs and abdomen known as edema and ascites. Bacterial peritonitis is an infection that can result from ascites. Another complication is easily bruising and bleeding due to a decrease in the protein that is needed for clotting (Ackley & Ladwig, 2008). Jaundice is another major physical characteristic. It occurs when the diseased liver does not remove enough bilirubin from the blood, causing yellowing of the skin and whites of the eyes and darkening of the urine. Bilirubin is the pigment that gives bile its reddish-yellow color (Boyer, 2004). Hepatic encephalopathy is another complication that is severe. The
failing liver does not remove toxins from the blood and eventually accumulates in the brain (Chopra, 2007). All of the different complications are not mentioned in this paper, there are several more. I just named the few that I felt were of most importance.
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The diagnosis of cirrhosis is usually based on the presence of a risk factor for cirrhosis, such as alcohol use or obesity. It is confirmed by either/or physical examination, blood tests, and imaging. A medical history will be taken, symptoms will be noted and a thorough physical examination to observe for clinical signs of the disease will be performed by a doctor. For instance, a patient with ascites, on abdominal examination, the liver may feel hard or enlarged. The doctor will order blood tests that may be helpful in evaluating the liver and increasing the suspicion of cirrhosis. A computerized tomography (CT) scan, ultrasound, magnetic resonance imaging (MRI), or liver scan may be ordered my the doctor to view the liver for signs of enlargement, reduced blood flow, or ascites. The doctor may look at the liver directly by inserting a laparoscope into the abdomen (gastrojournal.org, 2007). A laparoscope is an instrument with a camera that relays pictures to a computer screen (Tabers, 2005).
A biopsy of the liver can confirm the diagnosis of cirrhosis but is not always a required procedure. Usually the biopsy is only done if the result might have an influence on treatment regimen (Ackley & Ladwig, 2008). The biopsy is performed with a needle inserted between the ribs or into a vein in the neck (Tabers, 2005). Precautions are taken to minimize discomfort. A tiny sample of liver tissue is examined with a microscope for scarring or other signs of cirrhosis. Sometimes a cause of liver damage other than cirrhosis is found during biopsy (Tabers, 2005).
Treatment of the disease depends on the cause and if there are any complications from it. Most of the time with treatments the goal is to slow the progression and stop and/or prevent complications. If severe complications are present, hospitalization may be necessary (Chopra, 2007). Malnutrition is common in people with cirrhosis; therefore a health diet is extremely important in all stages of the disease. Also a person with cirrhosis should not eat raw shellfish, which can contain a bacterium that causes serious infection (Boyer, 2004). Additional supplement may be needed through a nasogastric tube. A tiny tube inserted through the nose and throat that reaches into the stomach (Taber, 2005).
Clients with cirrhosis are advised not to consume any alcohol or illicit drugs of any kinds due to the damaging affects on the liver. Technically before any medication whether over the counter, vitamins, supplements or prescribed are taken, a physcians should be consulted due to its relationship with the liver (Ackley & Ladwig, 2008). Treatment also deal with the complication for cirrhosis such as diuretics for edema and
ascites, beta blocker to lower blood pressure and help with the spider veins, and some even have to undergo hemodialysis.
Diuretics are used to pull fluid from the body and excrete in the urine. But the side effects of this drug would be orthostatic hypotension, which is a dramatic drop in blood pressure when standing up. It can also lead to water and electrolyte depletion. The nurse will need to teach on sensitivity to the sun when patient is taking the medication, and to avoid tanning beds. Also the drug may cause and increase in blood sugar, so it need to be monitored daily. An increase in potassium will be needed due to it being deplete with the diuretic. (Davis, 2010).
With Beta blockers such as Metoprolol it works on beta (1) adrenoreceptors located mainly in the cardiac muscles. With higher doses, it acts on beta (2) adrenoreceptors of the bronchial and vascular smooth muscles. Some adverse reaction of this drug is a decrease in heart rate, arrhythmias, heart failure, hypotension, dizziness, difficulty breathing and headache. The nurse will need to educate the client on avoiding the use of calcium channel blockers, the drug may cause diarrhea, headache, and depression that the extended release tablet should be taken with foods or immediately after. (Davis, 2010)
Chronic pain r/t enlarged liver AEB, CT scan showing a large liver. Secondary to Cirrhosis.
Imbalanced nutrition: less than body requirements r/t loss of appetite, nausea, vomiting, AEB not eating and complains. Secondary to Cirrhosis.
Fatigue r/t malnutrition AEB, limited activity and lack of eating. Secondary to Cirrhosis
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Imbalanced nutrition: less than body requirements r/t loss of appetite, nausea and vomiting. AEB loss of weight and reported intake less than RDA. Secondary to Cirrhosis.
Definition: Intake of nutrients insufficient to meet metabolic needs (Tabers, 2005)
Client will: progressively gain weight towards desired goal weight AEB gaining 1-2 lbs a week.
Hepatic encephalopathy- a worsening of brain function that occurs when the liver is no longer able to remove toxic substances from the blood
Steatohepatitis- is a type of liver disease, characterized by inflammation of the liver with concurrent fat accumulation in liver.
Hemochromatosis- a disorder that interferes with the body's ability to break down iron. Too much iron being absorbed from GI tract.
Splenomegaly- spleen enlarges and holds white blood cells and platelets, reducing the numbers of these cells in the blood
Hepatocellular carcinoma- a type of liver cancer that occurs in people with cirrhosis.
Laparoscope- an instrument with a camera that relays pictures to a computer screen.
Ackley, B. & Ladwig,G. (2008). Nursing diagnosis handbook: an evidence
Based guide to planning care. St. Louis, Missouri: Mosby
Boyer, R (2004). Liver cirrhosis and its development. Portland, Oregon.: Multnomah Books.
Venes, D. (2005). Taber's cyclopedic medical dictionary. Philadelphia: F.A. David Co.
Author Unknown. (2010). Cirrhosis. Gastrojournal.org
Chopra, S. (2007). The Liver Book: A Comprehensive Guide to Diagnosis, Treatment, and Recovery. Amherst, New York: Prometheus Books