What is cirrhosis of the liver?

Cirrhosis of the liver is a chronic disease that causes cell destruction and fibrosis (scarring) of hepatic tissue. 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. Cirrhosis is a potentially life-threatening condition that occurs when scarring damages the liver. This scarring replaces healthy tissue and prevents the liver from working normally. Cirrhosis usually develops after years of liver inflammation. When chronic diseases cause the liver to become permanently injured and scarred, the condition is called Cirrhosis. Cirrhosis harms the structure of the liver and blocks the flow of blood. The loss of normal liver tissue slows the processing of nutrients, hormones, drugs, and toxins by the liver. Also, the production of proteins and other substances made by the liver is suppressed. People with cirrhosis often have few symptoms at first. The person may experience fatigue, weakness, and exhaustion. Loss of appetite is usual, often with nausea and weight loss. As liver function declines, water may accumulate in the legs and the abdomen (ascites). A decrease in proteins needed for blood clotting makes it easy for the person to bruise, bleeding or infection. In the later stages of cirrhosis, jaundice (yellow skin) may occur, caused by the buildup of bile pigment that is passed by the liver into the intestines. The liver of a person with cirrhosis also has trouble removing toxins, which may build up in the blood. Drugs taken usually are filtered out by the liver, and this cleansing process also is slowed down by cirrhosis. People with cirrhosis often are very sensitive to medications and their side effects. The doctor often can diagnose cirrhosis from the patients symptoms and from laboratory tests. During a physical exam, the doctor could notice a change in how your liver feels or how large it is. If the doctor suspects Cirrhosis, you will be given blood tests. The purpose of these tests is to find out if liver disease is present. In some cases, other tests that take pictures of the liver are performed such as the computerized axial tomography (CAT) scan, and ultrasound. The doctor may decide to confirm the diagnosis by putting a needle through the skin (biopsy) to take a sample of tissue from the liver. In some cases, cirrhosis is diagnosed during surgery when the doctor is able to see the entire liver. What are the causes of the inflammation that leads to cirrhosis of the liver?

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Alcohol excess: the rate of cirrhosis in a country is directly related to the average alcohol consumption in that country. Half of all cases of cirrhosis are due to alcohol excess. Chronic viral hepatitis: the two important viruses are hepatitis B and hepatitis C. Cirrhosis due to hepatitis B is common in Africa and Asia. Hepatitis C is increasing in importance both in Europe and the US. Hepatitis A (infectious hepatitis) does not cause cirrhosis. Primary biliary cirrhosis: this is an uncommon disease mainly affecting women. It is not due to alcohol. For some reason the body mounts an attack on the liver in patients with primary biliary cirrhosis. Autoimmune chronic active hepatitis: another uncommon condition that results in the body's immune system attacking and destroying liver cells. Drugs and chemicals: a number of drugs and chemicals can cause liver damage but few cause cirrhosis. Certain specialised drugs need monitoring for their effect on the liver. Metabolic and inherited disorders: These are a number of uncommon conditions that allow the accumulation of toxins in the liver. The commonest ishaemochromatosis, which causes excess deposits of iron in the liver. What are the symptoms of liver cirrhosis? The symptoms will depend on how much damage has occurred to the liver. In the early stages there may be no symptoms at all and the disease may be discovered as a result of an investigation for another illness. As the disease progresses, tiredness, weakness, lack of energy, loss of appetite, nausea and weight loss may develop. In the later stages the liver is struggling to perform all its functions and any or all of the following symptoms may be present. Jaundice: this is the yellowing of the skin (jaundice) and the eyes due to the failure of the liver to remove a substance called bilirubin from the blood. Nail changes: the shape and appearance of the nails may change. They may be more curved (clubbing) and they may be white rather than pink. Skin changes: about a quarter of patients will have darkening of the skin. Fluid retention: this is common at some stage in cirrhosis. An important function of the liver is to rid the body of excess fluid through the kidneys and when it fails, fluid gathers in the legs (oedema) or in the abdomen (ascites). Abnormal blood vessels: the commonest abnormality is a spider naevus, which is a spot surrounded by fine blood vessels. A red face is also common.

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Easy bruising: nosebleeds and easy bruising occur as a result of abnormal blood vessels and delayed clotting because the liver does not make enough clotting proteins. y Enlargement of breasts in men: the liver destroys the female sex hormones and in cirrhosis these accumulate and cause enlargement of the breasts and shrinking of the testes in men. In the very late stages of the disease, serious complications may occur. These include vomiting of blood, either from ulcers in the stomach or from leakingvaricose veins in the lower end of the oesophagus (gullet). This is serious and requires hospital treatment. The liver is responsible for removing poisonous substances from the blood. In cirrhosis, the blood may bypass the liver and these poisonous substances pass to the brain where they may result in alteration in brain function, causing confusion, drowsiness and finally coma. This is called hepatic encephalopathy. This is also serious and requires hospital treatment. Who is at risk?

The more alcohol a person drinks, the more likely they are to develop cirrhosis. Women seem to be more susceptible than men. It is therefore advisable to restrict alcohol consumption to 28 units a week for men and 21 units a week for women (a unit of alcohol is a single measure of spirits, a half pint of ordinary beer or lager or a standard size glass of wine). y Patients who have ongoing infection with hepatitis B or hepatitis C virus. y Patients with primary biliary cirrhosis or autoimmune chronic active hepatitis. y Patients with metabolic or inherited disorders. How can cirrhosis of the liver be prevented?

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Limit the intake of alcohol (see above). Alcoholics should seek help. Precautions should be taken to avoid getting hepatitis and if it is contracted it is important that it is treated. Avoid contact with toxic chemicals at work. How is cirrhosis of the liver diagnosed? If a clinical examination creates a suspicion of cirrhosis of the liver, the diagnosis may be supported by the analysis of blood samples. Although it may be confirmed by an ultrasound examination, it may be necessary to perform a liver biopsy to obtain tissue samples from the liver. This may also give information on the underlying cause of the cirrhosis. Good advice If alcohol excess and dependence is the cause, you must stop drinking alcohol immediately. Once alcohol has damaged the liver, then the liver cells are vulnerable to even small amounts of alcohol. Seek help from friends, family and any of the organisations that specialise in helping people with alcohol problems. Your doctor will be able to help. Activity Try to lead an active life. This may be difficult because of the tiredness and weakness but it is worth persevering. If your legs are swollen, it may be helpful to raise them while you are resting. Food

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Avoid all alcohol intake. Eat a well-balanced, high-protein diet (only in consultation with your doctor). Avoid adding salt to meals. Salt may be used in small amounts in cooking. In the later stages, the amount of protein you eat may be reduced from time to time (on the advice of your doctor). Vitamin and mineral supplements may be necessary. Possible complications

Impotence in men. This is a combination of the effects of alcohol and cirrhosis. Severe internal bleeding from ruptured varicose veins in the stomach or oesophagus. This is serious and requires hospital treatment. y Liver cancer, which occurs at a late stage in a number of patients with cirrhosis. y Blood poisoning, due to infection of the excess fluid in the abdomen (ascites). Future prospects The gradual destruction of the liver can be stopped by removing the cause. This underlies the advice on alcohol. Treatment is available for chronic hepatitis B virus infection and also for chronic hepatitis C virus infection. Iron overload can be treated by removing blood on a regular basis. Autoimmune chronic active hepatitis can be treated with steroids to suppress the immune system and prevent it attacking the liver cells.

Although the damage may not be repaired, the symptoms can be relieved and controlled. If treatment is started early, the sufferer may be able to lead an almost normal life. If the cause is not removed, however, the formation of scar tissue and destruction of the liver structure will continue, ultimately resulting in liver failure and death. How is cirrhosis of the liver treated? Apart from removing the cause, cirrhosis of the liver cannot be treated. The emphasis is therefore on dealing with and reducing the complications of the disease. The following approaches are used: y water tablets (diuretics) for the treatment of fluid retention in the legs (oedema) or abdomen (ascites). y vitamins and mineral supplements. y calorie supplements (usually sugar-based drinks) to maintain nutrition. y laxatives (usually a syrupy solution called lactulose) to prevent constipation and to reduce the chances of the poisonous substances from the bowel bypassing the liver and reaching the brain, causing drowsiness, confusion and coma (hepatic encephalopathy). y some patients who have had bleeding from ruptured varicose veins in the lower oesophagus may be put onto a drug called propranolol, which reduces the pressure in those veins and lowers the chances of them bleeding again. y finally, liver transplantation may be considered in patients with end-stage cirrhosis. The steps in making the diagnosis of cirrhosis may include the following:

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Blood tests - To check whether the liver is functioning normally. Lab findings can be normal in cirrhosis, however. Ultrasound, CT scan, or radioisotope scan - To look for signs of cirrhosis within or on the surface of the liver Laparoscope - A very tiny camera inserted through a small slit in the abdomen to view the liver directly Liver biopsy - Removing tissue from the liver and studying it under a microscope to identify fibrosis and scarring. Biopsy is the only way diagnosis can be 100% certain NURSING MANAGEMENT A. IDEAL y Vital Signs monitored every 2 hours.

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Intake and Output monitored every hour. Monitored and documented Nasogastric tubing output every hour . Medication given as prescribed by the physician. Facilitate completion of NPO diet required. NGT patency checking prior to medication done Assessment for any alterations in body comfort and report immediately to the physician. NGT feeding done and medication. Assessment for any profuse gum bleeding and note for the colour discharge, include odor. Education for the significance of medication given Encouraging the client to do exercise at a minimal level to promote circulation. Lifestyle modification: weight reduction (body mass index [BMI] goal <25), reduction of dietary sodium to less than 2.4 g/day, DASH diet (i.e., diet high in fruits and vegetables, reduced saturated and total fat), aerobic physical activity >30 minutes most days of the week, tobacco avoidance, increased dietary potassium and calcium, moderation of alcohol consumption. Use of self BP monitoring. Home measurement device should be checked regularly for accuracy. Mean self measured BP >135/85 is generally considered to be hypertensive

B. ACTUAL CARE GIVEN

Independent: y Assess for any significant findings on the abdominal size -to provide a basis of proper and comfortable positioning

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Assess for any discomfort related to pain at the right side of the body- to provide a basis of proper and comfortable positioning. Monitor intake and output closely(hourly)- to monitor any improvement or worsening of patients condition Regulate IVF to ordered flow rate- to prevent overload and under load of fluid intake. Provide side rails. - to promote patients safety Encourage the client to urinate if feeling of voiding is present.- to alleviate urinary distention Educated the client and the SO about the significance of urination.- to provide information about the significance of voiding in relation to its underlying condition Bedside care done-to promote comfort and safety of the clients condition. Position the patient in a Fowlers or Semi Fowlers position with pillows - Relieves pressure on diaphragm. -Observe for manifestations like crackles or increased respiration.- Identifies fluid in the lungs Monitor vital signs every 2 hours- to identify any changes in patients health status. Encourage the client to inhale and exhale exercise. - To alleviate breathing difficulty. Use light, cool clothing which promotes evaporation. Keep clothing and bed dry. - Minimizes irritation and itching Keeping the environment cool.- Minimizes itching Avoid activities that promote sweating. Minimizes itching Keep nails short and smooth.- Prevents breaking skin integrity when scratching Reposition patient every 2 hour.- Relieves pressure over bony prominences

Dependent: y Medications were given as prescribed, lactulose 30 ml, metronidazole 500mg 1 tab TID via NGT. To alleviate clients condition as prescribed by the physician.- to promote wellness and alleviate the existing problem.

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Instructed the So to maintain Nothing Per Orem Diet (NPO) as recommended given since Gastrointestinal function are impaired due to abdominal distention.- to reduce gastric irritation. Administer Oxygen as ordered.- to alleviate breathing difficulty and assist the need of air by the client.

PROBLEMS ENCOUNTERED DURING THE IMPLEMENTATION OF NURSING CARE There was no huge problem encountered upon assessment and interviewing the client. He welcomes me warmly as her student nurse and actively participates and response to every question asked. But there were times that my client does not want to be interrupted since she was busy with something computing about her business flow while she was in the hospital. The significant others of my client was also responsive and has a sense of humour that made the whole interviewing session a successful one. Generally, I described my client as a participative type of person and cooperative and really understand my responsibilities and part as her student nurse. RESTORATIVE MEASURES USED To maintain the therapeutic communication to my client, I address every question ask to the client in a polite manner, and explain every procedure prior to doing it to the client. Through doing these things will reduced the anxiety of my client and irritability during the implementation of care. I also ask the consent of my client every time I want to ask some questions that is about her family data and lifestyle in order to take the approval of my client for my care study.

EVALUATION The Patient tolerated every procedure performed onto her and was cooperative and responsive to every care given. Vital signs of the patient were stabilized upon monitoring it every four hours, and Intake and Output was within the normal range. PATIENT TEACHING M: Encourage the client to urinate if feeling of voiding is present and to take the medication as prescribed. To attain the desired effect of the drug and for the completion of the medication therapy. E: Encourage patient to have a clean and safe environment for faster recovery. Clean and safe environment promotes comfort and relaxation for faster recovery of the patient. Encourage the patient to be calm and maintain a comfort position. Counsel patient about diet and exercise because losing weight and exercising can decrease the risk of developing hypertension. Encourage also the patient the importance of blood pressure monitoring. Educate the patient the importance of proper medication administration and timing. T: Emphasize to the patient the importance of right timing and right dosing during insulin administration. To avoid the undesired effect of medications. H: Encourage the client to inhale and exhale exercise. To improve air gas exchange in the body. O: Encourage the patient to visit the physician for condition monitoring. D: Encourage the patient to have a low cholesterol, low sodium and low carbohydrate diet. For the blood volume not to increase resulting to hypertension. S: Encourage the patient to continue praying and seek guidance from God. Strong faith to God helps the patient spiritually to alleviate the condition with God's will. Medical Treatment Most treatment for cirrhosis is directed toward relief of complications. Some underlying causes of cirrhosis, such as Wilson's disease, can be treated with medication.

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Many medicines have been studied, such as steroids, penicillamine (Cuprimine, Depen), and an anti-inflammatory agent (colchicine), but they have not been shown to prolong survival or improve survival rate. Researchers are studying various experimental treatments for cirrhosis.