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Cirrhosis Case Study
Nursing Concepts and Interventions - Care for the Older Adult 1 (N3700)
Marquette University
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Cirrhosis is a chronic progressive disease of the liver characterized by extensive degeneration and destruction of the liver cells. The liver cells attempt to regenerate, but the regenerative process is disorganized, resulting in abnormal blood vessel and bile duct architecture. The overgrowth of new and fibrous connective tissue distorts the liver's normal lobular structure. Eventually, irregular and disorganized regeneration, poor cellular nutrition, and hypoxia (from inadequate blood flow and scar tissue) result in decreased functioning of the liver. Any chronic liver disease, including excessive alcohol intake and nonalcoholic fatty liver disease (NAFLD), can cause cirrhosis. The specific cause of cirrhosis may not be determined in all patients. The most common causes of cirrhosis in the United States are chronic hepatitis C infection and alcohol- induced liver disease.
The onset of cirrhosis is usually insidious and the course is prolonged. There is no specific treatment, and interprofessional care is directed at promoting liver cell regeneration and preventing and treating complications. Major complications of cirrhosis are portal hypertension with resultant esophageal and/or gastric varices, peripheral edema and ascites, hepatic encephalopathy (mental status changes, including coma), and hepatorenal syndrome.
Objectives
Identify relevant assessment data for a patient admitted with alcohol abuse and cirrhosis of the liver. Evaluate the results of diagnostic studies for a patient with cirrhosis. Prioritize nursing diagnoses and interventions for a patient with cirrhosis. Describe interprofessional care of a patient with ascites and esophageal varices. Prioritize nursing care of a patient with acute complications related to cirrhosis. Appropriately delegate nursing care of a patient with an acute complication of cirrhosis. Develop an individualized teaching plan for a patient with chronic complications of cirrhosis.
Case Study
P. is a 55-year-old white male who was admitted to the medical-surgical unit just after
midnight with acute shortness of breath related to an increase in ascites. He has had a long-standing history of cirrhosis and alcohol abuse. He typically drinks two six packs of
beer and a couple shots of whiskey every day.
Question 1: Based on P.'s report of his drinking habits, you recognize the importance of monitoring the patient for withdrawal symptoms. Circle the statements that accurately reflect alcohol withdrawal symptoms. There are 5 correct answers.
The symptoms of alcohol withdrawal do not always progress in a predictable manner. Anxiety, agitation, weakness, nausea and/or vomiting are symptoms of alcohol withdrawal. Withdrawal symptoms will not begin until at least 12 hours after the last drink. Alcohol withdrawal delirium can usually be prevented or controlled by administration of benzodiazepines such as lorazepam (Ativan). Withdrawal symptoms may last up to 14 days
Seizure activity typically occurs 72 hours or more after the last drink. Alcohol withdrawal delirium may occur 30 to 120 hours after the last drink.
Visual or auditory hallucinations are not typically present with alcohol withdrawal delirium.
Question 2: As a result of his liver disease, P. manifests the signs and symptoms listed below. Match these clinical manifestations with the pathophysiologic changes that occur in cirrhosis. Instructions: Match each item in the first column to the correct item in the second
Clinical Manifestations Pathophysiologic Changes Anemia, leukopenia, thrombocytopenia 2
1 aldosterone metabolism
Hypokalemia 3 2 congestion of the spleen Jaundice 4 3 B deficiencies Peripheral neuropathy 1 4 bilirubin conjugation and excretion Petechiae and purpura 6 5 estrogen levels Testicular atrophy 5 6 vitamin K absorption
Question 5: You review P.'s diagnostic test results while planning appropriate nursing care. Indicate whether the following laboratory tests would be increased or decreased with liver damage with a up or down arrow.
Lab Tests
Aspartate aminotransferase (AST) HIGH
Alanine aminotransferase (ALT) HIGH
Serum albumin LOW
Serum unconjugated bilirubin HIGH
Gamma globulin LOW
Gamma glutamyl transpeptidase (GGT) HIGH
Prothrombin time HIGH
Total protein LOW
Alkaline phosphatase HIGH
Urine urobilinogen HIGH
Question 6: P. has a nursing diagnosis of ineffective breathing pattern related to reduced lung capacity. Circle the most appropriate nursing intervention for him is to
Place him in Fowler's position.
Promote deep breathing and coughing. Ensure that he is maintaining a low-protein diet.
Perform oral and pharyngeal suctioning to reduce the risk of aspiration.
Question 7: You plan care for P. based on knowledge of interprofessional treatment of his ascites. Circle the 6 correct appropriate statements related to management of ascites
Patients with severe ascites may need to restrict their sodium intake to 2 g/day.
The patient is usually not on restricted fluids unless severe ascites develops. It is important to assess and control fluid and electrolyte balance in a patient with ascites. Tolvaptan (Samsca), a vasopressin-receptor antagonist used to correct hyponatremia in patients with cirrhosis. The medication corrects dilutional hyponatremia by stimulating an increase in water excretion. Albumin may be used to maintain intravascular volume and adequate urinary output. Loop diuretics alone provide the best control of fluid balance. A paracentesis is reserved for patients with impaired respiration or abdominal pain caused by severe ascites. A peritoneovenous shunt is part of first-line therapy for patients with ascites.
A transjugular intrahepatic portosystemic shunt (TIPS) procedure may be used to
alleviate ascites that does not respond to diuretics.
Question 10: P.'s bleeding is controlled with sclerotherapy and ligation of the varices. His admission ammonia level was 60 mg/dL (35 mmol/L), but it is 90 mg/dL (52. mmol/L) 18 hours after his bleed. Circle the most likely cause in this elevation in ammonia level.
Cerebral ischemia during the hemorrhage. Blood in the intestine as a source of increased protein. Redistribution of blood away from the kidneys as an effect of vasopressin.
Impaired metabolism of vasopressin and nitroglycerin used for treatment of the
hemorrhage.
Question 11: While P.'s ammonia level is elevated, you recognize that a priority assessment would focus on which of the following? Circle the 5 correct answers.
Level of consciousness Sensory abnormalities Motor abnormalities Psychosocial integrity Fluid and electrolyte imbalance Patient knowledge of disease process Acid-base balance
Skin integrity
Question 12: P. has signs of advanced cirrhosis with marked ascites, peripheral edema, mild hepatic encephalopathy, and esophageal varices. Interprofessional care involves interventions to treat his complications and increase his comfort. Instructions: Match each intervention with its correct rationale.
Interventions Rationales
Pantoprazole Protonix) 2 1 effect of hyperaldosteronism, reducing ascites and elevating serum potassium Furosemide (Lasix) 1 2 gastric acidity High carbohydrate diet 5 3 bowel bacteria, reducing ammonia production Lactulose 3 4 plasma colloid osmotic pressure to maintain intravascular volume Rifaximin (Xifanxan) 8 5 hypoglycemia and catabolism Paracentesis 6 6 temporary relief of abdominal pain and respiratory distress Propranolol (Inderal) 7 7 portal venous pressure, preventing variceal bleeding Albumin 4 8 ammonia in the intestines, preventing absorption into blood Spironolactone (Aldactone) 9 9 in combination with potassium-sparing diuretic to mobilize ascetic fluid
Question 13: P.'s family asks the nurse if a liver transplant is possible for him. Circle the appropriate response.
"Cirrhosis is a major indication for liver transplants in adults, and you should discuss this possibility with his doctor." "Liver transplants are possible but their use is limited because patients experience a high rejection rate of this organ." "A liver transplant is an accepted treatment for patients with end-stage liver disease and offers a return to a normal life."
"I'm sorry, but liver transplants are not indicated for patients with cirrhosis because so
much damage has occurred to other body systems."
Cirrhosis Case Study
Course: Nursing Concepts and Interventions - Care for the Older Adult 1 (N3700)
University: Marquette University
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