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Liver Cirrhosis

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Diana Jean Diokno

on 3 December 2014

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Transcript of Liver Cirrhosis

Liver Cirrhosis
Komal Ali
Elisha Alonzo
Diana Diokno
Gayane Erdoglian
Robert Goldbeck
Jaime Legarda
Isabel Ortega
Tuan Vo
Stella Nguyen
December 3, 2014
N224

Cirrhosis
A chronic progressive disease of the liver characterized by extensive degeneration and destruction of the liver parenchyma cells.
Etiology & Incidence
Laennec’s (alcohol/malnutrition induced) Cirrhosis
Risk Factors: chronic alcoholism
Most common cause of cirrhosis
Cardiac Cirrhosis
Right-sided heart failure
Biliary Cirrhosis
Primary biliary cirrhosis
Risk Factors: women between the ages of 35 and 60
Primary sclerosing cholangitis
Risk Factors: ulcerative colitis, men aged 30-40
Hepatitis
Risk Factors: autoimmune disease, exposure to toxins, multiple sex partners, IV drug use, blood transfusion
20% with Hep C and 10-20% with Hep B will develop cirrhosis
Non-alcoholic Fatty Liver Disease
Risk Factors: obesity/overweight
Cirrhosis:
9th leading cause of death in United States
3rd leading cause of death in persons between 35-65 years of age
Twice more common in men
Pathophysiology
Early Manifestations
Often asymptomatic until complications of the disease are present, usually even till the biopsy
Fatigue (only symptom seen early on in the disease)
Later Manifestations
Jaundice
Peripheral Edema
Ascites
Skin Lesions (Spider angiomas, palmar erythema)
Hematologic Problems (thrombocytopenia, leukopenia, anemia)
Endocrine Problems
Peripheral Neuropathy
COMPLICATIONS
Portal Hypertension
Esophageal and Gastric Varices
Peripheral Edema and Ascites
Hepatic Encephalopathy (i.e. confusion, asterixis, fetor hepaticus, memory loss, coma)
Hepatorenal Syndrome (azotemia, oliguria, ascites)
Diagnostic Studies
Medical Interventions
Nursing
Interventions
References
Elevated serum liver enzyme levels, reduced serum albumin.
Liver biopsy detects cell destruction and fibrosis of hepatic disease.
Liver scan shows abnormal thickening and a liver mass.
CT scan determines the size of the liver and its irregular nodular surface.
Esophagoscopy determines the presence of esophageal varices.
Percutaneous transhepatic cholangiography differentiates extrahepatic from intrahepatic obstructive jaundice.
Paracentesis examines ascitic fluid for cell, protein, and bacteria counts.

Transjugular intrahepatic portosystemic shunt
Diet
Limit protein.
decrease waste product build-up
except with persistent hepatic encephalopathy and malnutrition is a bigger concern
Limit salt intake.
reduce ascites and edema
avoid foods such as nuts, crackers, canned vegetables
avoid carbonated drinks and OTC medications high in sodium (i.e. certain anatacids)
Increased carbohydrates .
prevent hypoglycemia and catabolism
Polycose - protein free formular
minimum intake of 1500-2000 calories
3000 cal/day - high carbohydrate and moderate to low levels of fat
Liver
Functions:
Ridding the body of harmful substances in the bloodstream, including drugs and alcohol
Creation of bile- needed for digestions
Manufacturing blood proteins that aid in clotting, oxygen transport, and immune system function
Production of cholesterol
Largest Internal Organ of the Human Body
Alisi, A., Locatelli, M., & Nobili, V. (2010). Nonalcoholic fatty liver disease in children. Current Opinion In Clinical Nutrition & Metabolic Care, 13(4), 397-402. doi:10.1097/MCO.0b013e32833aae84
Doane, A. (2014). The Dilemma of Liver Transplant Allocation for Alcoholic Patients. Gastroenterology Nursing, 37(5), 318-325. doi:10.1097/SGA.00000000000000064
Flores, Y., Lang, C., Salmerón, J., & Bastani, R. (2012). Risk Factors for Liver Disease and Associated Knowledge and Practices Among Mexican Adults in the US and Mexico. Journal Of Community Health, 37(2), 403-411. doi:10.1007/s10900-011-9457-4
Hogan, M., Dentlinger, N., & Ramdin, V. (2014). Medical-surgical nursing. Boston: Pearson.
Hug, B. L., Surber, C., & Bates, D. W. (2012). Use of hepatotoxic drugs in chronic liver disease. Journal Of Patient Safety, 8(2), 45-50.
Kilbourne, B., Cummings, S., & Levine, R. (2012). Alcohol diagnoses among older Tennessee Medicare beneficiaries: race and gender differences. International Journal Of Geriatric Psychiatry, 27(5), 483-490. doi:10.1002/gps.2740
Kiser, J. (2009). Trends in the treatment of chronic hepatitis C virus infection. Journal Of Pharmacy Practice, 22(4), 405-420.
Koretz, R. L. (2014). The evidence for the use of nutritional support in liver disease. Current Opinion In Gastroenterology, 30(2), 208-214. doi:10.1097/MOG.0000000000000049
Sandhu, B., & Sanyal, A. (2006). Portal hypertension. Hospital Physician, 42(6), 13-13-8, 21-3, 36 passim.
The treatment of hepatic encephalopathy in the cirrhotic patient. (2010). Gastroenterology & Hepatology, 6(4), [1].

Clients with ascites are sodium restricted > Prevent accumulation of ascetic fluid

Administer antiemetics and diuretics as prescribed
Daily weigh and monitor I&O > Prevent dehydration and hypokalemia

Monitor for signs of impaired renal function
Oliguria
fixed specific gravity↑
increased creatinine
increased↑BUN

Measure abdominal girth > Assess progression of ascites

Provide respiratory support
High Fowler’s position and supplemental oxygen
CDB (Cough Deep Breath) and IS to prevent pneumonia
Activity as indicated

Maintain skin integrity
Remove moist linens promptly•
Encourage activity as indicated or reposition q2h
Institute bleeding precautions
• Prevent constipation
• Avoid injections
• Encourage use of soft toothbrush
• Monitor CBC, PT

Assess understanding of the illness
• Identify support system
• Assess coping skills
• Encourage Alcoholics Anonymous for those with cirrhosis secondary to alcohol dependence

NANDA
1. Imbalanced nutrition: less than body requirements related to anorexia, nausea, and impaired utilization and storage of nutrients
2. Impaired skin integrity related to peripheral edema, ascites, and pruritus
3. Excess fluid volume related to portal hypertension and hyperaldosteronism
4. Ineffective self-health management related to ineffective coping and abuse of alcohol

Patient Teachings:
Explain that cirrhosis is a chronic illness and the importance of continual health care.
Teach the symptoms of complications and when to seek medical attention to enable prompt treatment of complications.
Teach the patient to avoid potentially hepatotoxic over-the-counter drugs because the diseased liver is unable to metabolize these drugs.
Encourage abstinence from alcohol because continued use of alcohol will increase the risk of liver complications.
Instruct the patient to avoid aspirin and NSAIDs to prevent hemorrhage when esophageal or gastric varices are present.
Teach the patient to avoid activities that increase portal pressure, such as straining at stool, coughing, sneezing, and retching and vomiting. These activities may increase the risk of variceal hemorrhage in patients with portal hypertension and varices.
Prevention of Cirrhosis
QUIZ
1) What are the common causes of cirrhosis in the US (select all that apply)?
a. diabetes
b. smoking
c. alcohol
d. hepatitis c
e. obesity

2) T/F. Cirrhosis is more common in women.

3) T/F. Protein is restricted in every cirrhosis patient's diet.

4) Yes/No. i=Is there treatment for liver cirrhosis?

5) T/F. For a cirrhotic patient with ascites, sodium intake is restricted.

6)The nurse recognizes early signs of hepatic encephalopathy in the patient who
a. Manifests asterixis
b. Becomes unconscious
c. Has increasing oliguria
d. Is irritable and lethargic

7) Which manifestation may be seen in the patient with cirrhosis related to esophageal varices?
a. jaundice, peripheral edema, ascites from increased intrahepatic pressure and dysfunction
b. loss of small bile ducts and cholestasis and cirrhosis in patients with other autoimmune disorders
c. development of collateral channels of circulation in inelastic, fragile esophageal as a result of portal hypertension
d. scarring and nodular changes in the liver lead to compression of the vein and sinusoids, causing resistance of the blood flow through the liver from the portal veins
Treatment depends on the cause and severity of liver damage. The goal is to slow the progression of cirrhosis.
• Avoid alcohol
• Weight loss
• Reduce use of medications that increase the risk of liver damage and bleeding—Acetaminophen (Tylenol); Aspirin, Ibuprofen, Naproxen.
• Get immunized against/medications for hepatitis A and hepatitis B, influenza, and pneumococcus.
• Nutritional supplements
Treatment for Underlying Causes of Cirrhosis
Treatment of Cirrhosis Complications
Ascites
Following a low-sodium diet.
Diuretics and antibiotics
Albumin infusion
Paracentesis
Esophageal and Gastric Varices
Beta-blocker and vasoconstrictor medicines.
Endoscopic band ligation or sclerotherapy.
Balloon tamponade.
Transjugular intrahepatic portosystemic shunt (TIPS).
Hepatic encephalopathy
Antibiotics
Lactulose
Changes in mental function.
Limit protein intake
Take lactulose.
Avoid sedative medicines.


Receiving a liver from an organ donor (liver transplant) is the only treatment that will restore normal liver function and cure portal hypertension.

LIver
TRanspLant
Drink alcohol in moderation, if at all.
If you choose to drink alcohol and don't have liver disease or cirrhosis, do so in moderation.

Eat a healthy diet.
Choose a plant-based diet that's full of fruits and vegetables.

Maintain a healthy weight.
An excess amount of body fat can damage your liver.

Reduce your risk of hepatitis.
Sharing needles and having unprotected sex can increase your risk.

Never mix alcohol and drugs.
Some medications react with alcohol and can damage the liver.
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