MEDICAL SURGICAL NURSING

LESSON PLAN ON
LIVER CIRRHOSIS

SUBMITTED TO, SUBMITTED BY,

SUBMITTED ON,
GENERAL OBJECTIVES :

At the end of the lecture, the group of student will be able to gain in depth of knowledge
regarding Liver cirrhosis.

SPECIFIC OBJECTIVE :

At the end of the lecture, the group of student will be able to gain in depth of knowledge
about,

1. To introduce topic.
2. To define the liver cirrhosis.
3. Explain incidence of liver cirrhosis.
4. Explain types of liver cirrhosis.
5. Explain causes of liver cirrhosis.
6. Explain pathophysiology of liver cirrhosis.
7. Explain clinical manifestation of liver cirrhosis.
8. Explain complication of rheumatic heart disease.
9. Explain diagnostic evaluation of liver cirrhosis.
10. Explain medical management of liver cirrhosis.
11. Explain surgical management of liver cirrhosis
12. Discuss nursing management of liver cirrhosis.
13. To summarize the topic.
14. To conclude the topic.
TIME SPECIFIC CONTENT TEACHING AUDIO EVALUATION
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LEARNING AIDS
ACTIVITY
2 min To introduce INTRODUCTION :
topic.
The word ‘cirrhosis’ is a neologism
that derives from Greek Kirrhos,
meaning “tawny” ( the orange – yellow
colour of the diseased liver ).
It is a chronic disease in which
there has been diffuse destruction and
fibrotic regeneration of hepatic cells.
It results in hepatic insufficiency
and portal hypertension.
Cirrhosis is a consequence of
chronic liver disease characterized by
replacement of liver tissue by fibrous
scar tissue as well as regenerative
nodules.

2 min To define DEFINITION :

liver
cirrhosis. Cirrhosis of liver is a chronic,
progressive disease characterized by
widespread fibrosis ( scaring ) and
nodule formation. Cirrhosis occurs
when the normal flow of blood, bile and
hepatic metabolites is altered by
fibrosis.

2 min Explain INCIDENCE :

incidence of
liver ✓ Cirrhosis is the 8th leading cause
cirrhosis. of death in United states.
✓ Around 20% of patients with
Chronic HCV and 10% - 20% of
patients with chronic HBV
develop cirrhosis.

2 min Describe TYPES :

types of liver
cirrhosis. There are four types of cirrhosis.

1. Alcoholic Cirrhosis :
 Most common, due to chronic

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 alcoholism, Scar tissue characteristically
surrounds the portal area.

2. Postnecrotic Cirrhosis :
There are broad bands of scar tissue due
to late results of acute viral hepatitis,
postintoxication with industrial
chemicals.

3. Biliary cirrhosis :
Scaring occurs around bile duct in liver,
Results of chronic biliary obstruction
and infection.

4. Cardiac cirrhosis :
Associated with severe right sided long
term heart failure, fairly rare.

3 min Explain CAUSES :

causes of
liver ✓ Chronic ( long term ) viral
cirrhosis. infections of the liver ( hepatitis
types A and C )
✓ Fatty liver associated with
obesity and diabetes
✓ Alcohol abuse
✓ Primary biliary cirrhosis
✓ Primary Sclerosing Cholangitis
✓ Biliary atresia
✓ Cystic fibrosis
✓ Hemochromatosis ( iron
overload )
✓ Wilson’s disease ( copper
diposition )
✓ Budd cherry syndrome,
( occlusion of hepatic vein )
✓ Galactosemia or glycogen
storage disease ( elevated level
of galctose )
✓ Autoimmune hepatitis
✓ Medication such as
methotrexate, acetamino
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✓ Alagille syndrome
✓ Infection such as syphilis
✓ Amyloidosis ( deposition
amyloid protein )

4 min Explain PATHOPHYSIOLOGY :

pathophysio
– logy of Due to etiological factors
liver
cirrhosis.
Diffuse destruction and regeneration of
liver cell

Formation of fibrous tissue

Destroyed liver cell are replaced

gradually by scar tissue yield fibrosis.
Cirrhosis damage liver tissue

Obstruction of blood, lymph and bile

flow

Hepatic insufficiency.

8 min Explain CLINICAL MANIFESTATION :

clinical
manifestation Early manifestation :
of liver ✓ The onset of cirrhosis is
cirrhosis. insidious.
✓ Early symptoms is fatigue.

Later Manifestation :
✓ Liver failure
✓ Portal hypertension
✓ Jaundice
✓ Ascites
✓ Peripheral edema
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✓ Skin lesion
✓ Hematological disorders
✓ Endocrine disturbances
✓ Peripheral neuropathies.

Systemic clinical manifestation :

Neurological :
✓ Hepatic encephalopathy
✓ Peripheral encephalopathy
✓ Asterixis

Gastrointestinal :
✓ Anorexia
✓ Dyspepsia
✓ Nausea, vomiting
✓ Change in bowel habits
✓ Gastritis
✓ Dull abdominal pain
✓ Esophageal and gastric vertices

Reproductive :
✓ Amenorrhea
✓ Testicular atrophy
✓ Gynecomastia
✓ Impotence with loss of libido
( sexual desire )
✓ Loss of axilla and pubic hair
✓ Vaginal bleeding ( older women)

Intengumentory :
✓ Jaundice
✓ Spider angioma
✓ Purpura
✓ Petechiae
✓ Palmar erythema

Metabolic :
✓ Hypokalemia
✓ Hyponatremia
✓ Hypoalbuminemia
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Hematologic :
✓ Anemia
✓ Leukopenia
✓ Splenomegaly
✓ Throbocytopenia
✓ Coagulation disorders

Cardiovascular :
✓ Fluid retension
✓ Ascites
✓ Peripheral edema

5 min Explain DIAGNOSTIC EVALUATION :

diagnostic
evaluation of 1. History collection
liver 2. Physical examination
cirrhosis.
3. Elevated liver enzymes :
Such as AST, ALT, GGT, ALP.
Increased serum bilirubin.

4. Liver ultrasound to assess the

severity of cirrhosis.

5. Liver biopsy to identify liver

cell changes and alterations in
the lobular structure.

6. Prolonged prothrombin time

7. Complete blood count

8. Serum electrolytes

9. Esophagogastroduodenoscopy
also known as upper endoscopy.

10. CT scan

11. Decreased cholesterol level due

to abnormal fat metabolism
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12. Paracentesis to examine ascitis
fluid for cell cell, protein,
bacterial counts.

13. PTC ( percutaneous transhepatic

cholangiography )

5 min Discuss COMPLICATION :

complication
of liver 1. Bruising and bleeding :
cirrhosis. Due to decreased production of
coagulation factors.

2. Jaundice :
Due to decreased processing of
bilirubin.

3. Itching ( pruritus ) :
Due to bile products deposited in the
skin.

4. Hepatic encephalopathy :
The liver does not clear ammonia and
related nitrogenous substances from the
blood, which are carried to the brain,
affecting cerebral functioning : neglect
personal appearance, unresponsiveness,
forgetfulness, changes in sllep habits.

5. Sensitivity to medication :
Due to decreased metabolism of the
active compounds.

6. Hepatocellular carcinoma :
Is primary liver cancer, a frequent
complication of cirrhosis. It has a high
mortality rate.

7. Portal hypertension :
Blood normally carried from the
intestines and spleen through the hepatic
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Portal vein flows more slowly and the
pressure increase; this lids to following
complications :

Ascites : fluid leaks through the

vasculature into the abdominal cavity.

Esophageal varices : collateral portal

blood flow through vessels in the
stomach and esophagus. This blood
vessels may become enlarged and are
more likely to burst.

PROBLEMS IN OTHER ORGANS :

Cirrhosis can cause immune system

dysfunction, leading to infection. Signs
and symptoms of infection may be
aspecific are more difficult to recognize
( eg. Worsening encephalopathy but no
fever ).

Fluid in the abdomen ( ascites ) may

become infected with bacteria normally
present in the intestines ( spontaneous
bacterial peritonitis )

Hepatorenal syndrome :
Insufficient blood supply to the kidney,
causing acute renal failure. This
complication has a very high mortality
( over 50% ).

Portopulmonary hypertension :
Increased blood pressure over the lung
as a consequence of portal hypertension.
TIME SPECIFIC CONTENT TEACHING AUDIO EVALUATION
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6 min Discuss MEDICAL MANAGEMENT :
medical
management ✓ Dietary modification : table
of liver salt, salted butter, margarine,
cirrhosis. ordinary can and frozen foods
should be avoided.
✓ The should be adequate calories
and protein ( 75 – 100 gm/day )
unless Hepatic encephalopathy
present, in which case protein is
limited.
✓ Restrict fluid.
✓ Diuretics : spironolactone,
aldosterone blocking agents.
✓ Vitamin B and fat soluble
vitamins ( A, D, E, K, )
✓ Corticosteroids drugs to
improve liver function in post
necrotic cirrhosis. Eg.
Prednisone, Azathioprine
✓ Daily weight loss should not
exceed 1 to 2 kg ( 2.2 to 4.4 lb )
in patients with ascites and
peripheral edema or 0.5 to 0.75
kg ( 1.1 to 1.65 lb ) in patients
without edema.
✓ Bed rest : useful therapy
• Upright position activation
of the rennin angiotensin –
aldosterone system and
sympathetic nervous system
results in reduced in renal
glomerular filtration and sodium
excretion and a decreased
response to loop diuretics.
• Antibiotics : Ciprofloxacin,
Rifaximin, Amoxicillin,
Ofloxacin, Ceftriaxone.
• Inj. Octreotide : bleeding for
varices
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✓ Beta – blockers : Atenolol,
Metoprolol, Timolol, Nadolol.
✓ Medication to treat alcohol
related disorders : Disulfiram,
Naltrexone, Acamprosate.
✓ Vasopressin : decrease portal
pressure
✓ Vasopressin + nitroglycerin :
decrease portal pressure
✓ Somatostatin + octreotide :
decrease bleeding.

5 min Explain SURGICAL MANAGEMENT :

surgical
management 1. Liver transplantation :
of liver Removing the liver and replacing it with
cirrhosis. a healthy donor organ is another way to
treat liver cancer or liver cirrhosis.
About 80 – 90 % of people who undergo
liver transplantation, survive.

2. Sclerotherapy :
In endoscopic sclerotherapy, a
sclerosing agent is injected through a
fiberoptic endoscope into the bleeding
esophageal varices to promote
thrombosis and eventual sclerosis.
The procedure has been used
successfully to treat acute GI
hemorrhage.

3. Esophageal banding therapy

( variceal band ligation ) :
A modified endoscope loaded withan
elastic rubber band is passed through an
overtube directly onto the varix to be
banded.
After suctioning the bleeding, the rubber
band is slipped over the tissue, causing
necrosis, ulceration, and eventual
sloughing of the varix.
TIME SPECIFIC CONTENT TEACHING AUDIO EVALUATION
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• Transjugular intrahepatic
portosystemic shunting :
Method of treating esophageal varices in
which a cannula is threaded into the
portal vein by transjugular route.
An expandable stent is inserted and
serves as an intrahepatic shunt between
the portal circulation and the hepatic
vein reducing portal hypertension.

8 min Discuss NURSING MANAGEMENT :

nursing
management ASSESSMENT :
of liver
cirrhosis. ✓ History taking : past and
present health history ( alcohol
intake, medication, infection etc)
chief complain sign and
symptoms of disease
✓ Physical examination
✓ Psychosocial assessment

Nursing Diagnosis :

1. Ineffective tissue perfusion

related to bleeding tendencies
and varices that may
hemorrhage.
Goal :
Hemorrhage will be prevented as
evidenced by absence of bleeding,
normal vital sign and urine output of at
least 0.5 ml/kg.

Intervention :
✓ Assess patient condition
✓ Monitor urine output
✓ Assess vital sign for sign of
shock
✓ Protect patient from physical
trauma to prevent hemorrhage.
✓ Monitor for bleeding from gums
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Melena, hematuria,
hematemasis.
✓ Provide stool softener to prevent
straining with rupture of varices.
✓ Advice to use soft tooth brush to
prevent gum bleeding.

2. Activity intolerance related to

bed rest, fatigue, lack of energy,
and altered respiratory function
secondary to ascites.

Goals :
The patient will maintain a balance
between rest and activity as evidenced
by the absence of fatigue.

Intervention :
✓ Assess level of activity tolerance
and degree of fatigue, lenthary,
and malaise when performing
routine ALDs.
✓ Assist with activities and
hygiene when fatigued.
✓ Encourage rest when fatigued or
when abdominal pain or
discofort occurs.
✓ Assist with selection and pacing
of desired activities and exercise.

3. Impaired skin integrity related to

pruritus from jaundice and
edema.

Goals :
Decrease potential for pressure ulcer
development; breaks in skin integrity.

Intervention :
✓ Assess degree of discomfort
related to pruritus and edema.
TIME SPECIFIC CONTENT TEACHING AUDIO EVALUATION
OBJECTIVE AND VISUAL
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ACTIVITY
✓ Note and record degree of
jaundice and extent of edema.
✓ Keep patients fingernails short
and smooth.
✓ Massage every 2 hours with
emollients; turn every 2 hours
✓ Initiate use of alternating
pressure mattress or low air loss
bed.
✓ Assess skin integrity every 4 – 8
hours.
✓ Restrict sodium as prescribed.

To SUMMARY :
3 min summarize
the topic. In this lesson plan we have
discussed, regarding introduction,
Incidence, definition liver cirrhosis,
causes, pathophysiology, , clinical
manifestation, diagnostic evaluation
and in management, medical
management, surgical management and
nursing management of liver cirrhosis
and their complications.

2 min To concluded CONCLUSION :

topic
All alcoholic patients should be
screened for alcoholic liver disease. The
diagnosis of alcoholic liver disease
requires a detailed patient history, with
supportive laboratory and imaging
studies. Liver disease is complex and
not well understood by many substance
misuse professionals. Primary care and
substance misuse professionals should
have sufficient knowledge and skills to
identify and assess alcoholic liver
disease.
 BIBLIOGRAPHY

1. Brunner and Suddarth’s Textbook of Medical –Surgical Nursing, Volume – 2, 13th

Edition, Janice L. Hinkle Kerry H. Cheever. Page No. :
2. Lewis’s Medical –Surgical Nursing, Assessment and Management of Clinical problems,
Chintamani. Page No. :
3. Essential of Medical –Surgical Nursing, BT Basavanthappa, Jaypee brothers medical
publishers (P) Ltd. Page No. :
4. Cirrhosis of liver, emedicine, available form :
www.emedicinehealth.com/cirrhosis/page8-em.htm