Case: Liver Cirrhosis Assessment:: Nursing Inference

CASE: LIVER CIRRHOSIS
ASSESSMENT:
Subjective: “Wala akong ganang kumain” as verbalized by the patient.
Objective:
 Weak in appearance
 Refusal to eat
 Weight loss
 Low serum protein levels
NURSING DIAGNOSIS:
Imbalanced nutrition: less than body requirements, related to anorexia and

possible alcohol abuse manifested by weight loss and low serum protein levels.
NURSING INFERENCE:
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.
NURSING GOAL:
After of rendering nursing intervention, the patient will gain 1 lb (0.45 kg) per
week without evidence of increased fluid retention and serum albumin levels will return
to normal range.
NURSING INTERVENTION RATIONALE

1. Assist in oral hygiene before meals.  A clean mouth enhances appetite.
2. Discuss eating habits including food  To appeal the client likes and
preferences. dislikes.
3. Serve favorite foods that are not  To stimulate the appetite.
contraindicated.
4. Prevent or minimize unpleasant  May have negative effect on
odors during meal time. appetite.
5. Serve foods that are attractive and  To stimulate the appetite.
palatable.
6. Recommend small, frequent meals.  Poor tolerance to larger meals may
be due to increased intra abdominal
pressure/ascites.
7. Restrict intake of caffeine, gas-  Aids in reducing gastric irritation
producing or spicy and excessively and abdominal discomfort that may
hot or cold foods. impair oral intake/digestion.
8. Provide assistance with activities as  Conserving energy reduces
needed. Promote undisturbed rest metabolic demands on the liver and
periods, especially before meals. promotes cellular regeneration.
EVALUATION:
After of rendering nursing intervention, the patient will gain 1 lb (0.45 kg) per
week without evidence of increased fluid retention and serum albumin levels will return
to normal range.

ASSESSMENT:
Subjective: “I feel that my tummy is getting bigger” as verbalized by the patient.
Objective:
 Weight gain
 Altered electrolyte levels
 Edema
 V/S taken as follows:
T: 37.0 °C
P: 92 bpm
R: 20 cpm
BP: 120/80 mmHg
NUSING DIAGNOSIS:
Excess fluid volume related to electrolyte imbalance and hypoalbuminemia as

manifested by ascites and peripheral edema.
NURSING INFERENCE:
Chronic liver disease develops cardiovascular abnormalities due to an increased

cardiac output and decreased peripheral vascular resistance, possibly resulting from the
release of vasodilators.
NURSING GOAL:
After 3 days of applying appropriate nursing interventions, the patient`s

abdominal girth will decrease by 1 to 2 cm per day and peripheral edema will decrease.
NURSING INTERVENTION RATIONALE

1. Measure intake and output, weight  Reflects circulating volume status.
daily and note weight gain more Positive balance/weight gain after
than 0.5 kg/day. reflects continuing fluid retention.
2. Restrict sodium and fluids as  Sodium may be restricted to
ordered. minimize fluid retention in
extravascular spaces. Fluid
restriction may be necessary to
prevent dilutional hyponatremia.
3. Monitor blood pressure.  BP elevation usually associated
with fluid volume excess but may
not occur because of fluid shifts out
of the vascular space.
4. Compare current weight with  To evaluate degree of excess.
admission and/or previously stated
weight.
5. Measure abdominal girth for  To evaluate severity of fluid
changes that may indicate retention/edema.
increasing fluid retention/edema.
6. Weigh daily or on a regular  Provides comparative baseline.
schedule.
7. Encourage bed rest when ascites is  May promote recumbency-induced
present. diuresis.
8. Administer medications as ordered  To control edema and ascites.
such as diuretics.
9. Monitor electrolytes.  To correct further imbalances.
10. Assist with Paracentesis procedure.  Done to remove ascites fluid.
EVALUATION:
After 3 days of applying appropriate nursing interventions, the patient`s

abdominal girth decreased by 1 to 2 cm per day and peripheral edema decreased. The
goal was completely met.

ASSESSMENT:
Subjective: “Ina-antok ako palagi, hindi ako makapag-isip ng maayos” as

verbalized by the patient.
Objective:
 Changes of the behavior
 Asterexis
 Impaired thinking
 Lethargy
NURSING DIAGNOSIS:
Disturbed thought processes, related to effects of high ammonia levels as

manifested by lethargy.
NURSING INFERENCE:
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.
NURSING GOAL:
After 8-10 hours of rendering nursing intervention, the patient will be alert and
oriented and serum ammonia levels are within normal range.
NURSING INTERVENTIONS RATIONALE
1. Restrict dietary protein as  Reduces source of ammonia

prescribed for transient period. (protein foods).
2. Give frequent, small feedings of  Promotes consumption of adequate

carbohydrates. carbohydrates for energy
requirements and spares protein
from breakdown for energy.
3. Protect from infection.  Minimizes risk for further increase in

metabolic requirements.
4. Keep environment warm and draft-  Minimizes shivering, which would
free. increase metabolic requirements.
5. Awaken at intervals (every 2-4 h) to  Provides stimulation to the patient

assess cognitive status. and opportunity for observing the
patient`s level of consciousness.
6. Encourage patient and family to  Promoting activities such as

participate in therapeutic strategies listening to music, relaxation
to enhance coping with episodes of techniques or preillness coping
mental deterioration. strategies can reduce anxiety.
7. Encourage patient and family to  Actively listening demonstrates

discuss feeling of fear, caring and concern.
powerlessness or emotional
distress related to patient`s mental
deterioration.
EVALUATION:
After 8 hours of rendering nursing intervention, the patient will be alert and
oriented and serum ammonia levels are within normal range.
DIAGNOSTIC EVALUATION:
 Liver biopsy – detects destruction and fibrosis of hepatic tissue.

 Liver scan – shows abdominal thickening and a liver mass.
 CT scan – determines the size of the liver and its irregular nodular surface.
 Esophagoscopy – to determine esophageal varices.
 Paracentesis – to examine ascetic fluid for cell, protein, and bacterial counts.
 PTC – differentiates extrahepatic from intrahepatic obstructive jaundice.
 Laparoscopy and liver biopsy – permit direct visualization of the liver.
 Serum liver function test – results are elevated
MEDICATIONS:
1)Lactulose.
2) Spironolactone for patients with ascites.
3) Lasix.

Case: Liver Cirrhosis Assessment:: Nursing Inference

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What are some complications of cirrhosis of the liver?

What are some complications of cirrhosis of the liver?

What nursing interventions are used to manage excess fluid volume?

What nursing interventions are used to manage excess fluid volume?

CASE: LIVER CIRRHOSIS

Subjective: “Wala akong ganang kumain” as verbalized by the patient.

Imbalanced nutrition: less than body requirements, related to anorexia and

NURSING INTERVENTION RATIONALE