Introduction

The liver is an important organ in the body. It performs many critical functions, two of which are producing substances required by the body. Cirrhosis is a complication of many liver diseases that is characterized by abnormal structure and function of the liver. The diseases that lead to cirrhosis do so because they injure and kill liver cells, and the inflammation

Definition
Cirrhosis is a chronic disease characterized by replacement of normal liver tissue with diffuse brosis that disrupts the structure and function of the liver.

types
Cirrhosis of the liver, is divided into three types: alcoholic, post necrotic ,biliary cirrhosis Aicoholic cirrhosis In this type the scar tissue characteristically surround the portal areas .This is most commonly caused by chronic alcoholism and is the most common type of cirrhosis post necrotic cirrhosis In this type there are broad band of scar tissue .This is late result of previous bout of acute viral hepatitis Biliary cirrhosis In this type scarring occurs in the liver around the bile duct. This type of cirrhosis usually results from chronic biliary obstruction and infection

Causes
Alcohol Chronic viral hepatitis ( hepatitis B or hepatitis C ) Inherited (genetic) disorders * abnormal accumulation of iron (hemochromatosis) * abnormal accumulation of copper (Wilson's disease) * psychiatric disturbances and other neurological - Autoimmune hepatitis The abnormal immune activity in autoimmune hepatitis causes progressive inflammation and destruction of liver cells (hepatocytes), leading ultimately to cirrhosis. more commonly seen in women.

- Less common causes of cirrhosis include unusual reactions to some drugs and prolonged exposure to toxins. -exposure to chemicals ( carbon tetrachloride,chlorinated naphthalene,arsenic,phosphorus )

Pathophysiology
Due to causes Tissue necrosis in the liver cells Destroyed liver cells gradually replaced by scar tissues Residual normal tissue and regenerating liver tissue may Project from the constricted areas and giving like hobnail appearance Cirrhosis of liver

Clinical manifestaions
The severity of manifestation helps to catagorize the disorder as two 1) compensated cirrhosis, 2)decompensated cirrhosis

For compensated liver cirrhosis

Intermittent mild fever Palmar erythema( reddened palms ) Unexplained epistaxis Ankle edema Vague morning indigestion Abdominal pain Spleno megaly

For decompensated liver cirrhosis

Ascites

PORTAL HYPERTENSION (RESISTANCE TO BLOOD FLOW

se leakage of Plasma in liver Lymphatic

leakage of plasma out of vasculature and in to liver tissue

vasocongestion within intestinal vasculature

development of collateral venous vessels

production of Liver lymph (high protein) leakage of plasma from liver tissue into Abdominal cavity transudation of plasma in to Abdominal cavity

persistence of amine neurotransmitters

Dilation of lymph Channels draining liver

redistribution of blood fow (reduced renal perfusion)

leakage of lymph in to abdominal cavity aldosterone ASCITES

production of

leakage of osmotic gradient between lymph and extracellular fluidfluid leakage in to abdominal cavity intravascular oncotic pressure plasma out of vascular space sodium and water retetion

albumin production

Hepatocyte dysfunction

metabolism of aldosterone

Jaundice Weakness Weight loss Continuous mild fever Clubbing of fingers Purpura (due to decreased platelet count) epistaxis hypotension white nails

other signs and symptoms

liver enlargement portal obstruction ( All blood from digestive organs is collected in portal veins and carried to liver .Because a cirrhotic liver does not allow free blood passage , blood backs up in to spleen and GI tract .) infection and peritonitis gastro intestinal varices or haemorrhoids mental detoriation and cognitive function

Assessment and Diagnostic Methods

* Liver function tests - Serum alkaline phosphatase, Aspartate aminotransferase [AST] Serum glutamic oxaloacetic transaminase (SGOT), Alanine aminotransferase [ALT] [serum glutamic pyruvic transaminase (SGPT)], Serum cholinesterase, Bilirubin, *prolonged Prothrombin time, *Ultrasound scanning-(to messure density of parenchymalcells and scar tissue ) *CT scan

*MRI *Radioisotopic liver scans * ABGs, biopsy

Management
The management of the patient with cirrhosis of liver is usually based on the presenting symptoms.

Medical management * Antacid or h2 antagonist are used to decrease gastric distress and minimize the
possibility of GI bleeding. * vitamins and nutritional supplements promote healing of damaged liver cells and improve the patients general nutritional status * Potassium sparing diuretics such as spironolactone( aldactone) or triamterene (dyrenium) are used to decrease ascites * An adequate diet and avoidance of alcohol are essential *colchicine ,an anti-inflammatory agent used to treat the symptoms of gout for moderate cirrhosis

Nursing Management
* Promoting Rest

Position bed for maximal respiratory efciency; provide oxygen if needed. Initiate efforts to prevent respiratory, circulatory, and vascular disturbances.

Encourage patient to increase activity gradually and plan rest with activity and mild exercise.

* Improving Nutritional Status Provide a nutritious, high-protein diet supplemented by B-complex vitamins and others, including A, C, and K. Encourage patient to eat: Provide small, frequent meals, consider patient preferences, and provide protein supplements, if indicated. Provide nutrients by feeding tube or total PN if needed. Provide patients who have fatty stools (steatorrhea) with water-soluble forms of fatsoluble vitamins A, D, and E, and give folic acid and iron to prevent anemia. Provide a low-protein diet temporarily if patient shows signs of impending or advancing coma; restrict sodium if needed. * Providing Skin Care Change patients position frequently. Avoid using irritating soaps and adhesive tape. Provide lotion to soothe irritated skin; take measures to prevent patient from scratching the skin.

Reducing Risk of Injury

Use padded side rails if patient becomes agitated or restless. Orient to time, place, and procedures to minimize agitation. Instruct patient to ask for assistance to get out of bed. Carefully evaluate any injury because of the possibility of internal bleeding. Provide safety measures to prevent injury or cuts (electric razor, soft toothbrush). Apply pressure to venipuncture sites to minimize bleeding.

Monitoring and Managing Complications

Monitor for bleeding and hemorrhage. Monitor the patients mental status closely and report changes so that treatment of encephalopathy can be initiated promptly. Carefully monitor serum electrolyte levels are and correct if abnormal. Administer oxygen if oxygen desaturation occurs; monitor for fever or abdominal pain, which may signal the onset of bacterial peritonitis or other infection. Assess cardiovascular and respiratory status; administer diuretics, implement uid restrictions, and enhance patient positioning, if needed. Monitor intake and output, daily weight changes, changes in abdominal girth, and edema formation. Monitor for nocturia and, later, for oliguria, because these states indicate increasing severity of liver dysfunction.

follow up care

Prepare for discharge by providing dietary instruction, including exclusion of alcohol. Refer to Alcoholics Anonymous, psychiatric care, counseling, or spiritual advisor if indicated. Continue sodium restriction; stress avoidance of raw shellsh. Provide written instructions, teaching, support, and reinforcement to patient and family. Encourage rest and probably a change in lifestyle (adequate,well-balanced diet and elimination of alcohol). Instruct family about symptoms of impending encephalopathy and possibility of bleeding tendencies and infection. Offer support and encouragement to the patient and provide positive feedback when the patient experiences successes. Refer patient to home care nurse, and assist in transition from hospital to home.

Nursing Diagnosis
imbalanced nutrition less than body requirements related to Anorexia,nausea/vomiting, indigestion, ascites/Abnormal bowel function impaired skin integrity related to Poor skin turgor, skeletal prominence, presence of edema, ascites ineffective Breathing Pattern related to Intra-abdominal fluid collection (ascites)or Decreased lung expansion, accumulated secretions

High risk for Injury related to altered clotting factors (decreased production of prothrombin, fibrinogen, and factors VIII, IX, and X; impaired vitamin K absorption; and release of thromboplastin) or Portal hypertension

Knowledge Deficit related to disease condition