Morning sickness is ‘misleading and inaccurate’ term that needs rebranding

The common term “morning sickness” is misleading and should instead be described as nausea and sickness in pregnancy, according to UK researchers. Their analysis of symptom diaries kept by 256 pregnant women indicated that it was inaccurate to describe nausea and vomiting in pregnancy as…

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Nurse home visits could boost childhood vaccination levels, survey suggests

Home visits by practice nurses could be a popular method of increasing uptake of routine childhood immunisation at a time when parents are reluctant to go to surgeries in person, a survey suggests. A survey of parental attitudes towards childhood vaccinations, carried out by pharmaceutical…

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Respiratory nurses teach Covid patients to monitor at home in ‘virtual ward’

Nurses are teaching patients recovering from Covid-19 how to use pulse oximeters at home, so they have the opportunity of being discharged early. The move means patients can monitor and report their oxygen levels to the respiratory nursing team at South Tees Hospitals NHS Foundation…

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Trust bids farewell to dedicated nurse who considered colleagues ‘second family’

Bradford Teaching Hospitals NHS Foundation Trust has announced the death of a “much loved and well known” nurse after a long battle with cancer. It said Raquel Policarpio, 51, who was a staff nurse on Ward 11 at Bradford Royal Infirmary, died in June and…

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Obstetric and Gynecological Nursing Quiz Series - 12

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Warning over risk to diabetes patients amid imminent lockdown easing

Not enough is being done to keep people with long-term conditions safe, according to a leading charity, which highlighted that people with diabetes make up 26% of UK coronavirus deaths. Guidance for clinically vulnerable people, and employers, remains unclear, warned Diabetes UK, which is calling…

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Virtual placements helping student nurses who are Covid-19 ‘shielding’

Virgin Care has created what it believes is the UK's first online placement scheme for student nurses so they can complete their courses on time, in spite of coronavirus shielding challenges. Under the initiative, around 20 student nurses in Essex are attending what the provider…

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Government urged to put mental health ‘at centre’ of Covid-19 recovery plans

The UK government has been urged to put mental health “at the very centre” of its coronavirus recovery plans, after results of a new survey revealed the stark impact the pandemic has had on people’s mental wellbeing. The call comes from national mental health charity…

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Universities given more time to fill nursing course places

Higher education providers have been handed a further three weeks to fill nursing and midwifery course places, as well as the option to increase numbers. The move to extend the date for course applications, announced by the government on Monday afternoon, comes just hours ahead…

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South Coast care home provider extends its nursing associate programme

Care home provider Colten Care has announced that it has added six trainees to its nursing associate programme, which it says represents the “latest chapter in its investment in nursing”. Six of its existing healthcare assistants and senior carers are set to begin their first…

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District nurse features in Rankin portrait to mark NHS anniversary

A district nurse from Midlands Partnership NHS Foundation Trust is to feature in a series of portraits taken by acclaimed photographer Rankin as a thank you to health service staff for their efforts during the Covid-19 crisis. Anne Roberts, who is based at Bentlee Health…

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Student nurses to have paid placement contracts honoured, HEE confirms

Student nurses in England who signed up to paid clinical placements during the coronavirus pandemic will receive payments until the agreed end of their contract, new guidance has clarified. It has been confirmed in writing that student nurses who opted-in to the paid clinical placement…

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One of UK’s first Asian chief nurses to join Guy’s and St Thomas’

Guy’s and St Thomas’ NHS Foundation Trust has announced the appointment of Avey Bhatia as its next chief nurse, taking over from Dame Eileen Sills. Dame Eileen is stepping down, having been in the role of chief nurse at Guy’s and St Thomas’ since 2005.…

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A&E nurse discharged from hospital after nine-week Covid-19 ordeal

A senior accident and emergency nurse has been cheered and clapped out of hospital by his colleagues, after weeks of life-saving coronavirus treatment. Franco Palo, a senior charge nurse at Northwick Park Hospital, has thanked his nursing peers who had been “so kind and supportive”…

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Labour proposes new mental health care package for NHS and care staff

A care package is needed to support the mental health of three million NHS and care staff, according to the Labour Party. The move follows calls by Nursing Times to provide health and social care nursing staff with dedicated mental health support, as part of…

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Mental Health Nursing Quiz Series - 15

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Watch: Infection prevention in the community during the Covid-19 crisis

Nursing Times has produced a series of videos on infection control and coronavirus, featuring interviews with nurses on different aspects of the subject. In our fourth video interview in the series, we are talking about the issue of infection prevention in the community during the…

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Community Health Nursing Quiz Series - 13

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Pharmacology Quiz Series - 14

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New network launched to support and elevate LGBTQ+ nurses

A new project is underway to improve the career prospects and workplace experiences of nurses and other health and care staff from the LGBTQ+ community. The NHS Confederation has today launched the Health and Care LGBTQ+ Leaders Network in a bid to make the NHS…

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NHS nurse workforce in England increases by 12,000 in year

The number of full-time equivalent nurses working in the NHS in England has increased by more than 12,000 over the past year, according to new figures. However, it was also revealed that the number of health visitors during the same time period had fallen by…

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ONS figures lay bare ‘heart-breaking’ Covid-19 nurse death toll

More than 100 nurses who had Covid-19 have died across England and Wales this year, according to new data from the Office for National Statistics. The ONS confirmed that nurses had “statistically significantly higher rates of death involving Covid-19” compared with the general population. "The…

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Watch: Glove use, hand hygiene and Covid-19

Nursing Times has produced a series of videos on infection control and coronavirus, featuring interviews with nurses on different aspects of the subject. In our third video interview in the series, we are talking about glove use, hand hygiene and Covid-19. Our guest is Julie…

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Medical-surgical Nursing Quiz Series - 17

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Nursing regulator sets out plans to restart fitness to practice cases

The Nursing and Midwifery Council has set out a series of regulatory and education “changes”, including the restarting of physical fitness to practise hearings, as the UK moves towards a “new normal”. The proposed measures, to be reviewed by the NMC’s governing council next week,…

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Nearly all cancer patients given name of nurse specialist last year, finds survey

Most patients diagnosed with cancer during 2019 were given the name of a clinical nurse specialist who would support them through their treatment, marking a small improvement on the year before. The results of the 2019 National Cancer Patient Experience Survey were published today and…

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Nurse replaces nurse as chief executive of Wiltshire acute trust

Stacey Hunter, a former nurse who has held a succession of management roles in Yorkshire, has been announced as the new chief executive of Salisbury NHS Foundation Trust. She has recently been working at the Yorkshire and Humber Nightingale Hospital, one of the temporary facilities…

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Wound assessment app wins financial support from Welsh Government

A wound assessment app that scans wounds and shares images with tissue viability nurses and district nurses for further assessment is among a range of technology receiving funding in Wales. Five digital health initiatives have been awarded funding as part of a £150,000 “call to…

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Nurses invited to first ever ‘virtual pride’ for LGBT+ NHS staff on Friday

Health service workers from across the county are being invited to enjoy an “unprecedented online celebration” of the LGBT+ community this Friday evening, NHS England has announced. To mark the time of year when thousands of people would ordinarily be gearing up for pride season,…

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UK nursing expert to oversee project to secure legacy of global nursing campaign

An international nursing expert has been given the task of securing the legacy of a major campaign to increase the profile and status of nursing around the globe. The International Council of Nurses (ICN) has appointed Susan Williams to oversee the transition and integration of…

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Fundamental of Nursing Quiz Series - 14

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Senior Northern Ireland nurses looking at care home learning from Covid-19

A new group, including senior nursing representatives, has been established in Northern Ireland to take forward a review on what can be learnt from “care home experiences of Covid-19”. Plans for an initiative on care home experiences were first announced earlier this month by health…

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First ever nurse president appointed at occupational health organisation

Professor Anne Harriss has been announced as the first nurse president of the Society of Occupational Medicine. She has promised to highlight the importance of health in the workplace, which she said the coronavirus pandemic had shone a light on. “Covid-19 has highlighted the importance…

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Student nurse issues open letter calling for apology from minister

A second-year student nurse has written an open letter demanding an apology from the care minister for what he condemned as an "unworthy depiction" of what he and his peers do. James Savage, a mental health nursing student at Liverpool John Moores University, pictured above,…

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MPs to debate petitions on ‘recognising and rewarding’ nurses

A parliamentary debate is scheduled to take place tomorrow in response to calls for nurses and their colleagues to be given a pay rise for their efforts during the coronavirus pandemic and beyond. On Thursday MPs are set to debate a series of e-petitions submitted…

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New nursing app for managing drug-resistant TB side effects

Nurses across the globe can now benefit from a new app designed to help them identify and manage patient side effects related to drug-resistant tuberculosis (DR-TB) treatment. The International Council of Nurses (ICN) has today launched a new mobile app, which is centred on a…

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Psychology Quiz Series - 13

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Watch: Covid-19 in care homes and older people

Nursing Times has produced a series of videos on infection control and coronavirus, featuring interviews with nurses on different aspects of the subject. In our second video interview in the series, we are talking about the issue of Covid-19 in care homes and older people.…

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Building the Nightingale hospitals: Engineering on the fast track

Fires, flooding and snow are usually the driver for military aid in the UK but the Covid-19 pandemic triggered one of the largest national military responses – the building of the temporary Nightingale hospitals. Claire Smith reports. Clinical staff have been described as being on…

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Routine testing of health and care workforce to be extended in Scotland

The Scottish Government has announced that further groups of health and care staff are to also receive weekly testing for coronavirus as well as care home staff. Staff who work in specialist cancer services, or provide long-term care for the elderly, as well as staff…

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RCN president joins call for rapid review to prepare for second wave of Covid-19

A second wave of Covid-19 outbreaks in the UK is a “real risk” and plans must be put in place to prepare, a group of health leaders including the president of the Royal College of Nursing, has warned. Professor Anne Marie Rafferty is among the signatories…

The post RCN president joins call for rapid review to prepare for second wave of Covid-19 appeared first on Nursing Times.

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Union calls for action on inequalities to protect BAME staff from Covid-19

A major union has written to the prime minster calling on the government to act “immediately” to protect black, Asian and minority ethnic (BAME) workers in the UK from Covid-19. Unison said the government must take action by “closing gaps” that created health inequalities and…

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Covid-19 helping change perception of social care nursing, says NMC chief

The coronavirus pandemic is helping to “bust the myth” that social care nurses are less skilled than their counterparts in the NHS, according to the head of the UK's nursing regulator. Andrea Sutcliffe, chief executive and registrar of the Nursing and Midwifery Council, pictured above,…

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Student nurse applications up 6% in the UK but many courses not yet full

Applications to study nursing in the UK are up 6% compared with the last academic year, latest official figures reveal. Data from the Universities and Colleges Admissions Service (UCAS) released today showed that 45,430 people had applied to a nurse degree by the 2020 January…

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Nutrition and Biochemistry Quiz Series - 11

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NMC seeks views from profession for post-registration standards review

Nurses are being asked to share their views on what they think the Nursing and Midwifery Council’s new standards for post-registration education and practice should look like. The NMC is currently in the process of reviewing its specialist community public health nursing (SCPHN) and specialist…

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Nurse tells of ‘disturbing’ police stop and search ordeal

A London nurse embroiled in an ongoing discrimination row with police has vowed to use the traumatising experience to become “a better nurse”. Police stopped Neomi Bennett in Wandsworth last year because they said the front windows of her car were too tinted. However, she feels she…

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Controversy over letter from care minister about contribution of student nurses

The minister for care has come under fire from the nursing community and beyond for claiming that student nurses were “not deemed to be providing a service”. Helen Whately confirmed the government had “no plans” to backdate a new financial support package that is set…

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Windrush Day: Nurses demand action on racism and inequality

Action is needed to show nurses of colour that their contribution is valued and their lives matter, as opposed to words, nursing leaders have warned on the third annual Windrush Day. On this day in 1948, the first group of people arrived in Essex from…

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Watch: Uniform cleaning and coronavirus spread

Nursing Times has produced a series of videos on infection control and coronavirus, featuring interviews with nurses on different aspects of the subject. In our first video interview in the series, we are talking about the issue of uniform cleaning. Our guest is Dr Katie…

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Microbiology Quiz Series - 11

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Anatomy and Physiology Quiz Series - 11

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Nursing Management Quiz Series - 13

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Exclusive: Uncertainty over fees for students who need to extend studies

The government has failed to clarify whether student nurses facing course extensions due to Covid-19 will be hit with extra tuition fees, promising only that arrangements will be revealed “as soon as possible”. The emergence of Covid-19 caused significant disruption to nurse education with second-…

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New flagging system ‘improves nurse confidence and patient experience’

A new flagging system on patient records has been shown to improve health and care services for people with a learning disability and to also “promote confidence” among nursing staff, according to findings from a pilot scheme. The system, called Reasonable Adjustment Flag and introduced…

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College calls for nominations for its next president and deputy president

The Royal College of Nursing has announced that it is seeking nominations for the senior posts of president and deputy president. Those elected through the process will replace the current president, Professor Anne Marie Rafferty, and her deputy, Yvonne Coghill. “I would urge all those…

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Nurses asked to complete survey on uniform washing practices amid Covid-19

Nurses are being encouraged to inform a new investigation into how the coronavirus pandemic has affected the way health and care staff launder their uniforms and how they feel about washing their scrubs at home. Academics at De Montfort University Leicester are asking health and…

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CNO to lead plans to expand nursing provision in Northern Ireland care homes

Expanding the provision of nursing support for care homes in Northern Ireland should form part of a new future for the social care sector, the country’s health minister has urged. Robin Swann has announced plans for a new framework that will examine how the provision…

The post CNO to lead plans to expand nursing provision in Northern Ireland care homes appeared first on Nursing Times.

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RCN makes eight demands to help nurses rebuild services safely

The Royal College of Nursing has laid out an eight-point plan of measures that it sees as essential in supporting nurses through the next phase of the coronavirus pandemic. Timely access to funded psychological support and safe ways for nurses to report concerns about personal…

The post RCN makes eight demands to help nurses rebuild services safely appeared first on Nursing Times.

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Nursing Research Quiz Series - 16

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Labour calls for routine testing of all health and care staff each week

Routine testing of all staff in the NHS and social care sectors should be introduced to help minimise transmission of Covid-19, according to the Labour Party. Jonathan Ashworth, Labour’s shadow health and social care secretary, said he was calling for testing to expanded beyond symptomatic…

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Online auction planned to help to save Florence Nightingale museum

A special online auction is set to take place as part of a campaign to save the Florence Nightingale Museum from permanent closure. The national lockdown implemented by the government in response to the outbreak of Covid-19 means the museum has had to close to…

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Charity aims to showcase community nurse innovation during Covid-19 crisis

The Queen’s Nursing Institute has issued a call to community nurses for examples of the ways they have innovated their services and care in response to the Covid-19 crisis. While the coronavirus pandemic has presented “huge challenges” for nurses and their teams, it has also,…

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‘Supportive culture’ needed to protect nurse wellbeing, RCN leader tells MPs

A much more “supportive culture” is needed within health and care services to prevent nurses from burning out and to address the “structural inequalities” exposed by Covid-19, a nursing leader has warned. Chief executive and general secretary of the Royal College of Nursing, Dame Donna…

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East Anglian businesses donate gifts to nurses as ‘thank you’ during Covid-19

Nursing staff at a trust in East Anglia have received a range of thoughtful gifts from local business to thank them for their efforts during the coronavirus pandemic. The items donated from across 30 businesses in the King’s Lynn area will form part of a…

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Health visitor creates support team to help vulnerable families during Covid crisis

A health visitor in Surrey has been praised for her efforts in supporting the Gypsy Roma Traveller (GRT) community and homeless families during the coronavirus pandemic. Recognising common problems shared by GRT communities and homeless families, Lisa Gavin decided to combine two teams that normally…

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Nursing Education Quiz Series - 12

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Tailored Covid-19 guidance finally published for learning disabilities

Dedicated coronavirus guidance on caring for people with learning disabilities has today been published amid claims that the needs of this group had been “overlooked” during the Covid-19 crisis. Public Health England has updated its resources on working safely in care homes and they now…

The post Tailored Covid-19 guidance finally published for learning disabilities appeared first on Nursing Times.

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Plans confirmed for ending paid Covid-19 placements amid student anger

Student nurses who took up the offer to join the frontline response to Covid-19 have finally been offered some clarity about their futures, after tensions on the matter started to reach boiling point. Professor Mark Radford, pictured above, chief nurse at Health Education England, has…

The post Plans confirmed for ending paid Covid-19 placements amid student anger appeared first on Nursing Times.

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Learn more about the Covid-19: Are You OK? campaign and its aims

Nursing Times launched a new campaign – Covid-19: Are you OK? – on 8 April to highlight the mental health pressures and needs of nurses during and after the coronavirus pandemic. Concerns around lack of equipment, heightened staff shortages, coping with deployment, the risks posed…

The post Learn more about the Covid-19: Are You OK? campaign and its aims appeared first on Nursing Times.

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Child Health Nursing Quiz Series - 12

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Exclusive: How nurses stepped forward during the AIDS crisis

More needs to be done to ensure nurses today are “skilled-up” in HIV and are able to see patients beyond the virus, according to two nurses who worked during the AIDS epidemic in the UK. Nicky Perry and Geraldine Reilly have spoken to Nursing Times about…

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Workplace racism described as factor in BAME nurses’ higher virus risk

Institutional racism and bullying at work have meant that nurses from black, Asian and minority ethnic (BAME) backgrounds are “afraid to speak up” about issues that put them at a higher risk of Covid-19, such as inadequate personal protective equipment (PPE), a review has found.…

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World-first Covid-19 treatment approved for NHS use

Researchers in the UK have become the first in the world to find a treatment for Covid-19 that has been proven to save lives. Just a low dose of the steroid dexamethasone was shown to reduce death by up to one-third in hospitalised patients with…

The post World-first Covid-19 treatment approved for NHS use appeared first on Nursing Times.

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Filipino nurse in Wales who ‘loved his work’ dies with Covid-19

A “caring and compassionate” nurse who moved from the Philippines almost 20 years ago to work for the NHS in Wales has died after contracting Covid-19. Warm tributes have been paid to 51-year-old Rizal Manalo who died on Sunday, 14 June in the critical care…

The post Filipino nurse in Wales who ‘loved his work’ dies with Covid-19 appeared first on Nursing Times.

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Obstetric and Gynecological Nursing Quiz Series - 11

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Inquiry to explore reasons behind poor UK asthma outcomes

Outcomes of asthma and severe asthma cases in the UK are set to become the focus of a parliamentary review after concerns were raised that they have not been improving in recent years and are falling behind in international comparisons. The All-Party Parliamentary Group for…

The post Inquiry to explore reasons behind poor UK asthma outcomes appeared first on Nursing Times.

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Nurses offered ‘psychological first aid’ training tailored for Covid-19

Nurses and other key staff at the forefront of the coronavirus response in England are being offered training in "psychological first aid" to help them look after their own mental health and that of others during the pandemic. The free online course has been developed…

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Postcard project ‘celebrates uniqueness’ of learning disability nursing

A campaign is underway to “flood” social media this week with stories of real-life learning disability nurses and the difference they make to their patients’ lives on a daily basis. The aim is to create a “groundswell” of support for the profession during learning disability…

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Mental Health Nursing Quiz Series - 14

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‘Mobilise’ bank nurses to tackle backlog of patients, MSP urges

Bank nurses in Scotland should be utilised to help tackle a backlog of non-urgent patients whose treatments were paused or postponed due to Covid-19, an MSP has said. Scottish Liberal Democrat leader Willie Rennie said he had been contacted by bank nurses in the country…

The post ‘Mobilise’ bank nurses to tackle backlog of patients, MSP urges appeared first on Nursing Times.

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Community Health Nursing Quiz Series - 12

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Pharmacology Quiz Series - 13

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Action on BAME nurse risks coming, minister tells Nursing Times

The government is “in the process” of drawing up a plan to protect nurses who are at higher risk from Covid-19, including those from ethnic minority backgrounds, a minister told Nursing Times today during the daily coronavirus briefing. Transport secretary Grant Shapps said equalities minister,…

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CNO allegedly cut from No. 10 briefing after refusing to back Cummings

The chief nursing officer for England was dropped last-minute from one of the government's daily coronavirus briefings after she refused to publicly back the prime minister’s top aide Dominic Cummings, it has been claimed. Ruth May had been due to appear at the Downing Street…

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Report shows nurses ‘let down’ by system ‘ill-prepared’ for Covid-19

Opportunities to stockpile adequate personal protective equipment (PPE) for nurses and other staff ahead of the pandemic were “missed” and some items distributed to the NHS and social care during the peak of the crisis did not meet the government’s modelled requirement, a new report…

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Medical-surgical Nursing Quiz Series - 16

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Trust decorates hospitals with ‘thank you’ poem from lead nurse

A nurse at a London NHS trust has written a poem to say ‘thank you’ to staff and colleagues working during the coronavirus pandemic. Lead nurse for retention at Guy’s and St Thomas’ NHS Foundation Trust, Rebecca Boxall, put together the poem called '18,000 thank…

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Hallucinations in patients with seizures may point to heightened suicide risk

Hallucinatory experiences in individuals with seizures are markers of high risk for mental health disorders and suicidal behaviour, according to researchers from Ireland. They said they had identified a “particularly strong relationship” between hallucinations and suicide attempts in individuals with seizures. “It’s important to recognise…

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Hospital matron creates painting to mark community spirit during Covid-19

A painting done by a nurse to mark the community spirt shown during the coronavirus pandemic has been unveiled at the hospital where she works in the North East of England. The painting, created by matron and artist Vicki Davidson, depicts a young girl, standing…

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RCN governance review calls for ‘change in culture’ at nursing union

An independent review of the way the Royal College of Nursing is governed has today recommended that the college needs to improve its culture, accountability and member engagement. Such changes were “critical” for RCN members to have improved ownership of the way the college was run,…

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Families of Filipino nurses who died in Covid-19 to be supported by fundraiser

More than £20,000 has been raised to support families of Filipino health and care staff who died while working in the UK during the coronavirus pandemic. Fundraisers from across the globe have walked, run and exercised a combined total of 11,000 kilometres – the distance…

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Fundamental of Nursing Quiz Series - 13

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China study emphasises importance of PPE to protect nurses from Covid-19

The importance of adequate personal protective equipment (PPE) and training for health professionals to prevent Covid-19 infection has been underlined by UK and Chinese researchers. Nurses and doctors who were appropriately protected did not contract infection or develop protective immunity against the virus, according to…

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Liver Cirrhosis

Description

• Is a chronic disease that causes cell destruction and fibrosis (scarring) of hepatic tissue.
• Fibrosis alters normal liver structure and vasculature, impairing blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein.
• Complications include hyponatremia, water retention, bleeding esophageal varices, coagulopathy, spontaneous bacterial peritonitis, and hepatic encephalopathy.

    Three major forms:

1. Laennec’s (alcohol induced) Cirrhosis
   • Fibrosis occurs mainly around central veins and portal areas.
   • This is the most common form of cirrhosis and results from chronic alcoholism and malnutrition.
2. Postnecrotic (micronodular) Cirrhosis
   • Consist of broad bands of scar tissue and results from previous acute viral hepatitis or drug-induced massive hepatic necrosis.
3. Biliary Cirrhosis
   • Consist of Scarring of bile ducts and lobes of the liver and results from chronic biliary obstruction and infection (cholangitis), and is much rarer than the preceding forms.

Causes/ Risk Factors

• Cirrhosis of the liver is a chronic disease that causes cell destruction and fibrosis (scarring) of hepatic tissues. Fibrosis alters normal liver structure and vasculature, impairing blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein. Complications include hyponatremia, water retention, bleeding esophageal varices, coagulopathy, spontaneous bacterial peritonitis, and hepatic encephalopathy.
• Cirrhosis is known in three major forms. In Laennec’s (alcohol-induced) cirrhosis, fibrosis occurs mainly around central veins and portal areas. This is the most common form of cirrhosis and results from chronic alcoholism and malnutrition. Postnecrotic (micronodular) cirrhosis consist of broad bands of scar tissue and results from previous acute viral hepatitis or drug-induced massive hepatic necrosis. Biliary cirrhosis consists of scarring of bile ducts and lobes of the liver and results from chronic biliary obstruction and infection (cholangitis), and is much rarer than the preceding forms.

Pathophysiology

Assessment

1. Early complaints including fatigue, anorexia, edema of the ankles in the evening, epistaxis, bleeding gums, and weight loss.
2. In later disease:
   • Chronic dyspepsia, constipation and diarrhea.
   • Esophageal varices; dilated cutaneous veins around umbilicus (caput medusa); internal hemorrhoids, ascites, splenomegaly.
   • Fatigue, weakness, and wasting caused by anemia and poor nutrition.
   • Deterioration of mental function.
   • Estrogen-androgen imbalance causing spider angioma and palmar erythema; menstrual irregularities in women; testicular and prostatic atrophy, gynecomastia, loss of libido, and impotence in men.
   • Bleeding tendencies and hemorrhage.
3. Enlarged, nodular liver.

Diagnostic Evaluation

1. Elevated serum liver enzyme levels, reduced serum albumin.
2. Liver biopsy detects cell destruction and fibrosis of hepatic disease.
3. Liver scan shows abnormal thickening and a liver mass.
4. CT scan determines the size of the liver and its irregular nodular surface.
5. Esophagoscopy determines the presence of esophageal varices.
6. Percutaneous transhepatic cholangiography differentiates extrahepatic from intrahepatic obstructive jaundice.
7. Paracentesis examines ascitic fluid for cell, protein, and bacteria counts.

Primary Nursing Diagnosis

• Fluid volume excess related to retention

Therapeutic Intervention / Medical Management

Medical management is based on presenting symptoms.

• Treatment includes antacids, vitamins, balanced diet, and nutritional supplements; potassium-sparing diuretics (for ascites); avoidance of alcohol.
• Colchicine may increase the length of survval in patients with mild to moderate cirrhosis.

Surgical Intervention

1. Transjugular intrahepatic portosystemic shunt may be performed in patients whose ascites prove resistant. This percutaneous procedure creates a shunt from the portal to systemic cisculation to reduce portal pressure and relieve ascites.
   

   Transjugular intrahepatic portosystemic shunt

2. Orthotopic liver transplantation may be necessary.

Pharmacologic Intervention

• Provide asymptomatic relief measures such as pain medications and antiemetics.
• Diuretic therapy, frequently with spironolactone, a potassium-sparing diuretic that inhibits the action of aldosteroe on the kidneys.
• I.V albumin to maintain osmotic pressure and reduce ascites.
• Administration of lactulose or neomycin through a nasogastric tube or retention enema to reduce ammonia levels during periods of hepatic encephalopathy.

Nursing Intervention

• Observe stools and emesis for color, consistency, and amount, and test each one for occult blood.
• Monitor fluid intake and output and serum electrolyte levels to prevent dehydration and hypokalemia, which may precipitate hepatic encephalopathy.
• Maintain some periods of rest with legs elevated to mobilize edema and ascites. Alternate rest periods with ambulation.
• Encourage and assist with gradually increasing periods of exercise.
• Encourage the patient to eat high-calorie, moderate protein meals and supplementary feedings. Suggest small, frequent feedings.
• Encourage oral hygiene before meals.
• Administer or teach self-administration of medications for nausea, vomiting, diarrhea or constipation.
• Encourage frequent skin care, bathing with soap, and massage with emollient lotions.
• Keep the patient’s finger nails short to prevent scratching from pruritus.
• Keep the patient quiet and limit activity if signs of bleeding are evident.
• Encourage the patient to eat foods high vitamin C content.
• Use small gauge needles for injections and maintain pressure over injection site until bleeding stops.
• Protect from sepsis through good handwashing and prompt recognition and management of infection.
• Pad side rails and provide careful nursing surveillance to ensure the patient’s safety.
• Stress the importance of giving up alcohol completely.
• Involve the person closest to the patient, because recovery usually is not easy and relapses are common.

Documentation Guidelines

• Physical findings:Bleeding,abdominal enlargement,weight gain or loss,fluid intake and output,easy respirations,breath sounds,heart sounds,level of consciousness,gastrointestinal status (nausea,vomiting,anorexia, diarrhea),color of skin and sclera
• Laboratory results:White blood cell count, hemoglobin and hematocrit, albumin, serum electrolytes,ALT,AST
• Nutrition:Tolerance of diet,appetite,ability to maintain body weight
• Response to treatment:Medications,surgery,pericentesis

Discharge and Home Healthcare Guidelines

• ALCOHOL ABUSE TREATMENT. Emphasize to the patient with alcoholic liver cirrhosis that continued alcohol use exacerbates the disease. Stress that alcoholic liver disease in its early stages is reversible when the patient abstains from alcohol. Encourage family involvement in alcohol abuse treatment. Assist the patient in obtaining counseling or support for her or his alcoholism.
• FOLLOW-UP. Encourage the patient to seek frequent medical follow-up. Visits from a community health nurse to monitor the patient’s progress and to help with any questions or problems at home are also helpful.
• SUPPORT GROUPS. Refer the patient to an alcohol support group or liver transplant support group.

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.

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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.

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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.

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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.

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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.

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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.

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Nursing Diagnosis

• Disturbed Body Image/Self-Esteem

May be related to

• Biophysical changes/altered physical appearance
• Uncertainty of prognosis, changes in role function
• Personal vulnerability
• Self-destructive behavior (alcohol-induced disease)

Possibly evidenced by

• Verbalization of change/restriction in lifestyle
• Fear of rejection or reaction by others
• Negative feelings about body/abilities
• Feelings of helplessness, hopelessness, or powerlessness

Desired Outcomes

• Verbalize understanding of changes and acceptance of self in the present situation.
• Identify feelings and methods for coping with negative perception of self.

Nursing Interventions

• Discuss situation and encourage verbalization of fears and concerns. Explain relationship between nature of disease and symptoms.
  • Rationale: Patient is very sensitive to body changes and may also experience feelings of guilt when cause is related to alcohol or other drug use.
• Support and encourage patient; provide care with a positive, friendly attitude.
  • Rationale: Caregivers sometimes allow judgmental feelings to affect the care of patient and need to make every effort to help patient feel valued as a person.
• Encourage family/SO to verbalize feelings, visit freely and participate in care.
  • Rationale: Family members may feel guilty about patient’s condition and may be fearful of impending death. They need nonjudgmental emotional support and free access to patient. Participation in care helps them feel useful and promotes trust between staff, patient, and SO.
• Assist patient/SO to cope with change in appearance; suggest clothing that does not emphasize altered appearance (color of clothes, etc).
  • Rationale: Patient may present unattractive appearance as a result of jaundice, ascites, ecchymotic areas. Providing support can enhance self-esteem and promote patient sense of control.
• Refer to support services. Counselors, psychiatric resources, social service, clery and alcohol treatment program may help.
  • Rationale: Increased vulnerability and concerns associated with this illness may require services of additional professional resources.

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Nursing Diagnosis

• Deficient Knowledge

May be related to

• Lack of exposure/recall; information misinterpretation
• Unfamiliarity with information resources

Possibly evidenced by

• Questions; request for information, statement of misconception
• Inaccurate follow-through of instructions/development of preventable complications

Desired Outcomes

• Verbalize understanding of disease process/prognosis, potential complications.
• Correlate symptoms with causative factors.
• Identify/initiate necessary lifestyle changes and participate in care.

Nursing Interventions

• Review disease process and prognosis and future expectations.
  • Rationale: Provides knowledge base from which patient can make informed choices.
• Refer to dietitian or nutritionist.
  • Rationale: Patients with cirrhosis needs close observation and sound nutritional counseling.
• Stress importance of avoiding alcohol. Give information about community services available to aid in alcohol rehabilitation if indicated.
  • Rationale: Alcohol is the leading cause in the development of cirrhosis.
• Inform patient of altered effects of medications with cirrhosis and the importance of using only drugs prescribed or cleared by a healthcare provider who is familiar with patient’s history.
  • Rationale: Some drugs are hepatotoxic (especially narcotics, sedatives, and hypnotics). In addition, the damaged liver has a decreased ability to metabolize all drugs, potentiating cumulative effect and/or aggravation of bleeding tendencies.
• Review procedure for maintaining function of peritoneovenous shunt when present.
  • Rationale: Insertion of a Denver shunt requires patient to periodically pump the chamber to maintain patency of the device. Patients with a LeVeen shunt may wear an abdominal binder and/or engage in a Valsalva maneuver to maintain shunt function.
• Assist patient identifying support person(s).
  • Rationale: Because of length of recovery, potential for relapses, and slow convalescence, support systems are extremely important in maintaining behavior modifications.
• Emphasize the importance of good nutrition. Recommend avoidance of high-protein/salty foods, onions, and strong cheeses. Provide written dietary instructions.
  • Rationale: Proper dietary maintenance and avoidance of foods high in sodium and protein aid in remission of symptoms and help prevent ammonia buildup and further liver damage. Written instructions are helpful for patient to refer to at home.
• Stress necessity of follow-up care and adherence to therapeutic regimen.
  • Rationale: Chronic nature of disease has potential for life-threatening complications. Provides opportunity for evaluation of effectiveness of regimen, including patency of shunt if used.
• Discuss sodium and salt substitute restrictions and necessity of reading labels on food and OTC drugs.
  • Rationale: Minimizes ascites and edema formation. Overuse of substitutes may result in other electrolyte imbalances. Food, OTC and/or personal care products (antacids, some mouthwashes) may contain sodium or alcohol.
• Encourage scheduling activities with adequate rest periods.
  • Rationale: Adequate rest decreases metabolic demands on the body and increases energy available for tissue regeneration.
• Promote diversional activities that are enjoyable to patient.
  • Rationale : Prevents boredom and minimizes anxiety and depression.
• Recommend avoidance of persons with infections, especially URI.
  • Rationale: Decreased resistance, altered nutritional status, and immune response (leukopenia may occur with splenomegaly) potentiate risk of infection.
• Identify environmental dangers: exposure to hepatitis.
  • Rationale: Can precipitate recurrence.
• Instruct patient/SO of signs and symptoms that warrant notification of health care provider: increased abdominal girth; rapid weight loss/gain; increased peripheral edema; increased dyspnea, fever; blood in stool or urine; excess bleeding of any kind; jaundice.
  • Rationale: Prompt reporting of symptoms reduces risk of further hepatic damage and provides opportunity to treat complications before they become life-threatening.
• Instruct SO to notify health care providers of any confusion, untidiness, night wandering, tremors, or personality change.
• Rationale: Changes (reflecting deterioration) may be more apparent to SO, although insidious changes may be noted by others with less frequent contact with patient.
  

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