{ "name": "Liver Cirrhosis", "slug": "liver-cirrhosis", "url": "https://nursingplex.com/care-plans/liver-cirrhosis", "category": "Gastrointestinal", "summary": "End-stage liver scarring with ascites, varices and encephalopathy risk.", "nursing_diagnoses": [ "Excess fluid volume", "Risk for bleeding", "Acute confusion", "Imbalanced nutrition" ], "overview": [ "Cirrhosis is the end stage of chronic liver injury, in which functioning hepatocytes are replaced by fibrotic scar and regenerative nodules. The distorted architecture obstructs blood flow through the liver, raising pressure in the portal system, while the loss of working cells destroys the liver's synthetic, detoxifying and metabolic functions. Common causes include chronic alcohol use, hepatitis B and C, and non-alcoholic fatty liver disease linked to obesity and diabetes.", "Two problems drive nearly every complication. Portal hypertension forces blood into collateral channels, producing esophageal and gastric varices, splenomegaly with thrombocytopenia, caput medusae and hemorrhoids, and it pushes fluid into the peritoneum as ascites. Hepatocellular failure means less albumin (worsening ascites and edema), fewer clotting factors (bleeding and a prolonged INR), unconjugated and conjugated bilirubin accumulation (jaundice and pruritus), impaired drug and hormone metabolism, and failure to convert ammonia to urea.", "The most dangerous acute events are variceal hemorrhage, spontaneous bacterial peritonitis, hepatic encephalopathy and hepatorenal syndrome. Rising ammonia produces the neurologic picture — from subtle personality and sleep changes and asterixis to stupor and coma — and is precipitated by GI bleeding, constipation, infection, dehydration, high protein loads and hypokalemia." ], "key_facts": [ { "label": "Encephalopathy treatment", "text": "Lactulose, titrated to two or three soft stools daily, traps ammonia in the gut for excretion; rifaximin reduces ammonia-producing bacteria. Diarrhea means the dose is too high." }, { "label": "Bleeding risk", "text": "Prolonged PT and INR from lost clotting factors plus thrombocytopenia from splenic sequestration. Use small-gauge needles, hold pressure longer, and avoid IM injections and rectal manipulation." }, { "label": "Variceal emergency", "text": "Hematemesis or melena is life-threatening — establish large-bore access, give volume and blood products, and prepare for octreotide, banding or balloon tamponade." }, { "label": "Ascites management", "text": "Sodium restriction, spironolactone with a loop diuretic, daily weight and abdominal girth, and paracentesis with albumin replacement for large-volume removal." }, { "label": "Avoid", "text": "Alcohol entirely, acetaminophen beyond strict limits, NSAIDs (bleeding and renal risk) and sedatives, which the failing liver cannot clear and which mask encephalopathy." } ], "nursing_priorities": [ "Prevent and rapidly manage variceal bleeding.", "Control ascites and edema while protecting renal perfusion.", "Detect and treat hepatic encephalopathy early.", "Prevent infection, especially spontaneous bacterial peritonitis.", "Maintain nutrition and skin integrity in a catabolic, jaundiced patient.", "Eliminate hepatotoxins and support abstinence from alcohol." ], "assessment": { "subjective": [ "Fatigue, weakness and anorexia with early satiety", "Nausea, abdominal fullness, discomfort and increasing belt or waist size", "Generalized itching, especially at night", "Confusion, forgetfulness, sleep reversal or family reports of personality change", "Easy bruising, nosebleeds or bleeding gums", "Shame, guilt or hopelessness related to alcohol use or prognosis" ], "objective": [ "Jaundiced sclerae and skin, dark urine and clay-colored stools", "Ascites with a distended, taut abdomen, fluid wave and rising girth measurement", "Peripheral edema, weight gain and dyspnea from diaphragmatic pressure", "Spider angiomas, palmar erythema, caput medusae, gynecomastia and testicular atrophy", "Asterixis, fetor hepaticus, slurred speech, disorientation and a rising ammonia level", "Elevated AST, ALT, alkaline phosphatase and bilirubin; low albumin; prolonged PT and INR", "Thrombocytopenia, anemia and leukopenia from hypersplenism", "Hematemesis, melena, hypotension and tachycardia with variceal bleeding", "Fever, abdominal tenderness and worsening encephalopathy suggesting peritonitis" ], "related_factors": [ "Portal hypertension with collateral circulation and varices", "Hypoalbuminemia lowering plasma oncotic pressure", "Impaired synthesis of clotting factors and platelet sequestration in the spleen", "Failure to convert ammonia to urea, producing neurotoxicity", "Bile salt deposition in the skin causing pruritus", "Anorexia, altered metabolism and impaired fat-soluble vitamin absorption", "Impaired drug and hormone clearance" ] }, "goals": [ "No episode of gastrointestinal bleeding occurs during the admission.", "Abdominal girth and daily weight decrease or stabilize toward the target.", "The patient remains oriented with no asterixis and passes two to three soft stools daily on lactulose.", "Skin remains intact with reported reduction in itching.", "The patient maintains or gains weight on the prescribed diet.", "The patient verbalizes complete abstinence from alcohol and accepts a referral for support." ], "interventions": [ { "title": "Prevent and respond to bleeding", "points": [ "Monitor PT, INR, platelets and hemoglobin, and inspect gums, stool, urine, emesis and puncture sites for blood each shift.", "Use a soft toothbrush and electric razor, avoid IM injections and rectal temperatures, and apply prolonged pressure after any needlestick.", "Avoid NSAIDs and aspirin, and teach the patient not to strain at stool or lift heavily — both raise portal pressure.", "Give non-selective beta blockers as ordered to lower portal pressure prophylactically.", "For active hematemesis or melena, position the patient upright with the head turned to prevent aspiration, establish two large-bore IVs, give fluids and blood products as ordered, and prepare for octreotide, endoscopic banding or balloon tamponade." ] }, { "title": "Manage ascites and fluid volume", "points": [ "Weigh daily and measure abdominal girth at a marked point at the same time each day.", "Restrict sodium as ordered and enforce fluid limits when hyponatremia is present.", "Give spironolactone with a loop diuretic as ordered, tracking potassium closely in both directions.", "Position in semi-Fowler's to ease breathing, and monitor oxygen saturation with a tense abdomen.", "Assist with paracentesis: empty the bladder first, take baseline vitals and girth, monitor for hypotension and bleeding after, and give albumin as ordered when large volumes are removed." ] }, { "title": "Reduce ammonia and protect the brain", "points": [ "Give lactulose as ordered and titrate to two or three soft stools per day; document stool count as a drug effect, not just a bowel record.", "Assess orientation, handwriting and asterixis every shift — subtle change appears before overt confusion.", "Treat precipitants aggressively: constipation, GI bleeding, infection, dehydration, hypokalemia and sedatives.", "Provide adequate protein from vegetable and dairy sources per dietitian guidance rather than severe restriction, which worsens muscle wasting.", "Implement safety measures — bed low, side rails as appropriate, frequent reorientation, and supervision during ambulation." ] }, { "title": "Prevent infection", "points": [ "Monitor temperature, white count, abdominal tenderness and mental status for spontaneous bacterial peritonitis; a low-grade change may be the only sign.", "Send ascitic fluid for cell count and culture during paracentesis as ordered and give prophylactic antibiotics when prescribed.", "Use strict hand hygiene and aseptic technique; cirrhotic patients are functionally immunocompromised.", "Encourage hepatitis A and B, influenza and pneumococcal vaccination." ] }, { "title": "Support nutrition and skin", "points": [ "Offer small, frequent, high-calorie meals with a bedtime snack to limit overnight catabolism.", "Supplement fat-soluble vitamins, thiamine, folate and zinc as ordered.", "Bathe with cool water and mild soap, apply emollients, keep nails short, and give prescribed antipruritics or bile acid sequestrants for itching.", "Reposition every two hours and pad bony prominences; edematous, jaundiced skin breaks down quickly." ] }, { "title": "Address alcohol use and coping", "points": [ "Discuss alcohol without judgment, state plainly that complete abstinence is the only intervention that changes the trajectory, and monitor for withdrawal with a standardized scale.", "Refer to addiction services, counseling and peer support programs.", "Involve family in teaching, since encephalopathy limits what the patient will retain.", "Discuss transplant evaluation criteria and advance care planning when appropriate." ] } ], "patient_teaching": [ "Stop all alcohol completely — this is the single most important change you can make.", "Take lactulose even though it causes stools; aim for two to three soft stools daily and call if you have none or many watery ones.", "Weigh yourself daily and measure your abdomen; report rapid gain or increasing tightness.", "Follow the low-sodium diet and read labels on canned, frozen and restaurant food.", "Avoid ibuprofen, naproxen, aspirin and sedatives, and never exceed the acetaminophen limit your provider gives you.", "Use a soft toothbrush and electric razor and report black stools, vomiting blood, or bruising that spreads.", "Have a family member watch for confusion, sleepiness at odd hours, personality change or hand tremor and bring you in.", "Keep vaccinations current and go to the emergency department for fever, severe abdominal pain, vomiting blood or new confusion." ] }