CIRRHOSIS OUTLINE: A.

CIRRHOSIS- diffuse destruction & fibrotic regeneration of hepatic cells which decreases blood flow, scar tissue formation decreased liver fxn B. TYPES: 1. LAENNECs ak.a ALCOHOLICS, NUTRITIONAL, PORTAL CIRRHOSIS i. Fatty liverfull of fat cells, leukocytes & lymphocytes 2. POSTNECROTIC- due to autoimmune hepatitis- diffuse bands fibrotic tissue 3. BILIARY- due to biliary obstructionjaundice w/ fibrosis 4. CARDIAC- due to right-sided heart failure (core Pulmonale)liver becomes reservoir for venous blood heart cant circulate, becoming anoxicfibrosis C. MOST COMMON CAUSE---ALCOHOL INGESTION D. ETIOLOGY 1. Formation fibrotic bands of connective tissue 2. Formation of nodular appearance which blocks bile & blood flow 3. Decrease liver fxn increase liver enzymes, disturbed metabolic fxn & disturbed circulatory pathways 4. Uncompensated or compensated liver fxn E. CAUSES 1. Alcohol ingestion 2. Hepatitis 3. Biliary/cardiovascular dx 4. Drugs & toxins F. EARLY S/S CIRROSIS 1. Anorexia 2. Weight loss 3. N&V 4. Dyspepsia 5. Flatulence 6. Diarrhea/constipation

7. Fever 8. Lassitude 9. Enlarged liver & spleen, palpable liver 10. Abdominal pain

G. LATE S/S CIRRHOSIS 1. Jaundice 6. Endocrine problems: 2. Peripheral edema gynecomastia, amenorrhea, 3. Ascites hyperaldosteronism 4. Skin lesions: palmar erythema, 7. Fetor hepaticas spider angiomas, striae, 8. Asterixis ecchymosis 9. Protruding umbilicus 5. Hematologic problems: 10. Hepatic encephalopathy thrombocytopenia, leukocytopenia, anemia H. COMPLICATIONS: 1. Portal HTN and esophageal & gastric varacies- due to dilation veins of esophagus, stomach, intestines & rectum from increased sinusoid pressure 2. Peripheral edema & ascites- due to decreased colloid pressure and increased hydrostatic pressure 3. Hepatic neuropathy- due to livers inability convert ammoniaurea to be excreted in urine 4. Hepatorenal syndrome- renal failure due hepatic failureno output

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LABS & DIAGNOSTICS: 1. Liver fxn : i. Increased AST, ALT, alkaline phosphatase, PTT, serum bilirubin & globulin ii. Decreased total protein, albumin, cholesterol, & urobilirubin in stool 2. Liver biopsy 3. EGD 4. Angiography (percutaneous transhepatic portographyPTP) 5. CT scan 6. Ultrasound 7. Serum e-lytes, CBC 8. Guaiac stool 9. Barium swallow J. COLLABORATIVE CARE 1. DIET THERAPY i. NA2+ restriction ii. High carb, mod protein, low fat diet iii. Admin B-complex vitamins: thiamine, folate, cobolamin 2. REST- to pull fluid from 3rd space 3. DRUG THERAPY i. Diuretic therapy- Spironolactone (Aldactone), Diuril, Lasix to excrete fluid from 3rd space 1. i/o, daily weight, abdominal girth, e-ltyes, low Na2+ antacids ii. Paracentesis 1. Explain procedure & informed consent 2. VS, weight, allergies 3. Void before procedure 4. Assist upright position w/ feet resting comfortably 5. During monitor: VS q15, measure 7 record drainage, position semi-fowlers & maintain bedrest till VS stable iii. COMFORT MEASURES 1. Elevate HOB 2. Encourage sitting chair w/ feet up iv. PERITONOVENOUS SHUNT if indicated 1. Pre-op- Vit K & fresh frozen plasma to treat coag probs, correct e-lyts, PRBC on hand for surgery 4. MANAGE ESOPHOGEAL VARACIES i. Gastric intubation to lavage stomach (ice NS) until fluid clear ii. Esophagogastric balloon tamponade to compress bleeding 1. Deflate Q8-12hrs to prevent necrosis 2. Check balloon for leaks, keep tube taped & secure 3. Check resp distress, cut balloon ports if in distress iii. Administer blood/blood products iv. Administer vasopressin & b-blocker to reduce portal HTN v. Injection sclerotherapy 1. Assess VS & chest pain 2. Administer pain meds 3. Assess lung sounds vi. Endoscopic band ligation procedure vii. Transjugular Intrahepatic portal systemic shunt 5. MANAGE HEPATIC ENCEPHALOPATHY i. Administer antibiotics ex. Neomycin to decrease intestinal flora ii. Admin Lactulose to promote fecal excretion of fecal ammoniadilute w/ fruit juice, want 2-5 soft stools daily, watery diarrhea= too much Lactulose

K. NURSING MANAGEMENT: 1. HEALTH PROMOTION i. Avoid alcohol, Tylenol & other hepatotoxic drugs, treat alcoholism ii. Adequate nutrition iii. Tx acute hepatitis, biliary dx & r-sided heart failure 2. ACUTE INTERVENTIONS i. Rest ii. Oral hygiene before meals iii. Tx jaundice w/ Cholestyramine iv. Note colour urine & stool v. I/O, daily weight, measure girth & extremities vi. Air pressure mattress for edema, turn q2hr, cough/deep bx, ROM, elevate lower extremities vii. Diuretics 1. Check Na+, K+, Cl- & bicarb levels 2. Check s/ s fluid retention & for hypokalemia viii. Monitor bleeding tendencies: melena, hematemesis, hemorrhage, anemia, increased risk infection.