LIVER

CIRRHOSIS
 Nursing Diagnosis Patient goal Nursing intervention
imbalanced Nutrition: less patient will : 1. Assess for (presence of conditions that can interfere
than body requirements • Nutritional Status NOC with food intake/client’s risk for malnutrition /ability to
Demonstrate progressive chew, swallow, and taste )
weight gain toward goal. 2. Evaluate total daily food intake
relates to : Experience no further signs
• Inability to ingest food of malnutrition 3. Assist or encourage client to eat
• inability to digest food 4. Recommend or provide small, frequent meals
• Abdominal cramping 5. Recommend sitting in upright position to eat.
Evidenced By : 6. Encourage intake of plenty of fluids throughout the day
Evidenced By : • Pay attention to food and 7. Limit such high-salt foods
• Insufficient interest in food; food eat normal amounts 8. Provide assistance with activities as needed
aversion; food intake less than • Normal laboratory studies
recommended daily allowances;
satiety immediately after ingesting
food
• Abnormal laboratory studies
 Nursing Diagnosis Patient goal Nursing intervention
excess Fluid Volume patient will : 1. noting positive balance intake in excess of output.
relates to : • Demonstrate Weigh daily, and note trends.
• ascites, hepatorenal stabilized fluid 2. Weigh daily or as prescribed and document changes,
syndrome noting both gains and losses
volume
3. Monitor BP and CVP, if available.
4. Assess respiratory status, noting increased respiratory
Evidenced By : rate and dyspnea.
Evidenced By : 5. Auscultate lungs, noting diminished or absent breath
• Compromised regulatory • stable weight, vital sounds.
mechanism- decreased signs within client’s 6. Monitor for cardiac dysrhythmias
plasma proteins Excess normal range, and 7. Assess degree of peripheral and dependent edema
sodium and fluid intake free of edema 8. Measure abdominal girth.
9. Provide frequent mouth care
10. Monitor serum albumin and electrolytes, particularly
potassium and sodium
11. Monitor serial chest x- rays.
12. Restrict sodium and fluids
 Nursing Diagnosis Patient goal Nursing intervention
Impaired Skin Integrity patient will : 1. Inspect skin surfaces and pressure points routinely.
relates to : • Maintain skin 2. Use emollient lotions and limit the use of soap for bathing.
ascites and obisty integrity. 3. Encourage and assist with repositioning on a regular
schedule
Evidenced By : 4. Recommend elevating lower extremities
Evidenced By : 5. Keep linens dry and free of wrinkles.
• Impaired circulation
• Circulation is 6. Discuss itching with the client, addressing areas involved and
• Inadequate nutrition;
intact the time of day when the client is most uncomfortable
alteration in metabolism
7. Offer comfort measures
• Changes in skin turgor,
• Adequacy of 8. Encourage or provide, perineal care following urination and
skeletal prominence bowel movement
nutrition
9. Use pressure- relieving devices
10. Administer medications, such as cholestyramine (Questran)
 Nursing Diagnosis Patient goal Nursing intervention
Ineffective Breathing Pattern patient will : 1. Assess (respiratory rate, depth, and effort)
(dyspnea) • Maintain effective 2. Auscultate breath sounds, noting crackles, wheezes, and
• relates to : respiratory pattern rhonchi.
3. Investigate changes in the level of consciousness
antitrypsin deficiency and be free of
4. Keep the head of the bed elevated. Position the client
dyspnea and on the side
Evidenced By : cyanosis 5. Encourage frequent repositioning, deep-breathing
• Hypoventilation [ascites exercises, and coughing, as appropriate.
with decreased lung Evidenced By : 6. Monitor temperature. Note the presence of chills
expansion] Fatigue • Effective ventilation increased coughing, and changes in the color or
character of sputum
7. measurements, and chest x- rays
8. Provide supplemental oxygen (O2 )
 Nursing Diagnosis Patient goal Nursing intervention
disturbed Body Image patient will : 1. Discuss situation and encourage verbalization of
relates to : • Verbalize fears and concerns. Explain relationship between
• Alteration in self- understanding of nature of disease and symptoms
perception changes and 2. Support and encourage client; provide care with a
• Alteration in body function acceptance of self in positive, friendly attitude
the present situation. 3. Encourage family/SO to verbalize feelings, visit
• Identify feelings and freely, and participate in care.
Evidenced By : methods for coping 4. Assist client/SO to cope with change in
• Alteration in view of one’s with a negative appearance; suggest clothing that does not
body; negative feeling perception of self emphasize altered appearance, such as use of
about body Evidenced By : red, blue, or black clothing
• Change in social • positive feeling 5. Refer to support ser vices, such as counselors,
involvement; fear of about one's body psychiatric resources, social ser vice, clergy, and
reaction by others alcohol treatment program.
 Nursing Diagnosis Patient goal Nursing intervention
risk for Infection patient will : 1. Identify client at risk
relates to : Be free of fever and 2. Assess (vital signs, noting onset of fever)
Chronic illness; abdominal pain 3. Evaluate body systems
immunosuppression; invasive 4. Promote safe healthcare environment
procedure Malnutrition Evidenced By: • Emphasize and practice proper handwashing
Regularity of body fluids before and after direct contact. Wear gloves
Evidenced By:
Stasis of body fluid when appropriate
• Maintain sterile technique for all invasive
procedures
• Change surgical or other wound dressings
5. Encourage deep breathing and coughing,
position changes
 Nursing Diagnosis Patient goal Nursing intervention

Knowledge deficit : Disease : Cirrhosis is a chronic disease characterized by the

replacement of normal liver tissue with diffuse
fibrosis that disrupts the structure and function of
the liver.
There are three types of cirrhosis or scarring :
• Alcoholic cirrhosis
• Alcoholic cirrhosis
• Biliary cirrhosis
 Nursing Diagnosis Patient goal Nursing intervention

Knowledge deficit : Diet : it’s important to get enough calories and high quality
protein each day. This can help prevent malnutrition
and preserve lean body mass.
The general recommendation is to eat 16–18 calories
and 0.45–0.68 grams of protein per pound (0.45 kg)
of body weight per day .
People with cirrhosis should prioritize high protein
foods and incorporate both plant- and animal-based
protein sources into their diet.
When following a liver cirrhosis diet, aim to limit any
foods and drinks that are difficult for the liver to
process.
In particular, limit your intake of foods high in
unhealthy fats such as trans fats, including fried foods
and processed snacks.
Cirrhosis can impact your liver’s ability to produce
bile, which is needed for the digestion of fats. Still,
unprocessed fat sources like nuts
You should also avoid alcohol, which can worsen liver
damage and scarring
 Nursing Diagnosis Patient goal Nursing intervention

Knowledge deficit : Diet : Because cirrhosis can impair your immune function, it’s also
best to avoid raw or undercooked meat, eggs, and seafood.

In some cases, your doctor may also advise that you limit
your intake of sodium to prevent ascites

Because cirrhosis can increase your protein needs and

impact your liver’s ability to store carbohydrates, eating
several small protein- and carb-rich meals and snacks
throughout the day may also be beneficial

Lastly, certain vitamins or minerals may help manage your

condition, since people with cirrhosis may be at a higher risk
of deficiencies in nutrients such as zinc, vitamin D, vitamin K,
and B vitamins.
 Nursing Diagnosis Patient goal Nursing intervention

Knowledge deficit : lifestyle : 1. Encourage use of soft toothbrush and electric

razor, avoiding straining for stool, forceful
nose blowing, and so forth.
2. Use small needles for injections. Apply
pressure to small bleeding or venipuncture
sites for longer than usual
3. Determine presence of factors associated with
thrombus or emboli
‫‪PREPARED BY:‬‬

‫امحد سامح مسري‬

‫عمر بشري‬
‫مصطفي هاني‬
‫زياد امحد عزيز‬
‫مجال عبدالناصر‬
‫عبداهلل حسني‬
‫عبدالرمحن علي‬
‫أسامة عبداجلواد‬
‫عبداهلل جويدة‬
‫حممد علي فرج‬