Nursing Care Plan – nCholecystectomy (Gallbladder Removal)

 

 

 

 

 

 

 

 

 

Cholecystectomy is the surgical removal of the ngallbladder. The operation is done to remove gallstones or to nremove an infected or inflamed gallbladder.

Benefits and Risk

Gallbladder removal will relieve pain, treat infection, nand in most cases stop gallstones from coming back. The risks of not having nsurgery

are the possibility of nworsening symptoms, infection, or bursting of the gallbladder.

Possible complications ninclude bleeding, bile duct injury, fever, liver injury, infection, numbness, nraised scars, hernia at the incision, anesthesia complications, puncture of the nintestine, and death.

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3. Nursing Care Plan – CholelithiasisCholelithiasis is the formatio of gallstones, which are composed of cholesterol, calcium salts, and bile pigments. When gallstones block the flow of bile, the gallbladder becomes swollen, leading to the possibility of pain, inflammation, or…

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How to Remove Gallstones from nour Body Naturally

Diseases of the gallbladder and biliary tract are common, often painful nconditions that usually require surgery and may be life threatening. They ninclude cholelithiasis, cholangitis, cholecystitis, cholesterolosis, biliary ncirrhosis, and gallstone ileus and are often associated with deposition of ncalculi and inflammation. The gallbladder stores the bile salts and the ncholesterol made in the liver. Bile salts are then discharge from the ngallbladder into the intestine to help digest fats. These bile salts are n”soapy” substances. They are produced in response to the amount of nfat in the diet requiring digestion. Sometimes, these salts can become stones nwithin the gallbladder itself; the stones often contain substantial amounts of ncholesterol. The stones cause local inflammation; if the muscular gallbladder ntries to expel them, blockage of the bile ducts by the stone may cause pain, nadditional inflammation, or jaundice (yellowing).

Two risk factors for gallbladder disease increase by sixth to eight ntimes. These are (1) heavy intake of saturated fat and cholesterol in the diet, nwhich increases bile salt production, and (2) being overweight. Obesity not nonly greatly increases the frequency of the condition, but it also makes nsurgery to correct it more difficult and more hazardous.

As a nurse, we gather more information, read, and study more about the ndisease. After surgery treatment, what we can do was to monitor patients’ vital nsigns and measure drainage daily which normally 200 to 300ml. Normally, surgery nis a treatment of choice but there are other treatments I could suggest such as nlow-fat diet; vitamin K; and during the attack, insertion of nasogastric tube nand I.V. line.

However, several months ago, I received an email from one of my friends. nShe related to me about an incredible experience of her friend named Nenette, nwho complained of frequent severe stomach pains every seven in the morning.. nSometimes, the pain also occurs at night. One evening, her husband had to rush nher to the nearest hospital because she was practically on the floor grimacing nin pain.
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nWhen they reached at the hospital, the doctors could not tell what was wrong nwith her.
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nThis event prompted the couple to seek an Internal Medicine Specialist After nseveral extensive and expensive tests, they found that she had many stones iher gallbladder. The doctor wanted to schedule an operation to remove the nstones at the soonest possible time. It was cited that the removal of the stone nwas the only remedy to relieve her from daily painful attacks.
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nSeeing his wife suffered from severe pain almost made him give in to the ndoctors’recommendation until a friend told them that there is a natural way of nremoving gall stones without cutting someone’s belly. The procedure was writteby Dr. Lai Chiu Nan.
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nThey were not optimistic about the procedure but they decided to try it. They ntold themselves they wouldn’t loose anything if they try it anyway.
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nSo they tried it and bought an apple juice, epson salt, olive oil, and fresh nlemon amounting to Php 700.00 all in all. Nenette started the procedure on a nMonday and completed it on Saturday of the same week. The next morning, they ncounted close to 100 floating green stones. They looked like gems and come idifferent sizes.
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nBut that was not the highlight of the story. From the day they saw those stone nfloating, Nenette has not experience any more pain.
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nWith that remarkable experience, they personally recommend this because they nknow it works. This process saved Nenette from her daily painful attacks and a npossible painful operation. It also saved them from spending much money from nthe operation itself.

Below is the procedure written by Dr. Lai Chiu Nan which is nentitled “Removing Gallstones Naturally.”

BACKGROUND:

Gallstones may not be everyone’s concern. nBut they should be because we all have them. Moreover, gallstones may lead to ncancer.

Cancer is never the first illness, Dr Chiu Nan points out. n”Usually, there are a lot of other problems leading up to cancer. In my ncancer research in China, nI came across some material, which says that people with cancer usually have gallstones. nWe all have gallstones; it’s a matter of big or small, many or few. One of the nsymptoms of gallstones is feeling of bloatedness after heavy meal. You feel nlike you can’t digest the food. If it gets more serious, you feel pain in the nliver area.”

So, if you think you have gallstones, Dr Chiu Nan offers the nfollowing method to remove them naturally. The treatment is also good for those nwith a weak liver, because the liver and gallbladder are closely linked.

RECOMMENDED PRACTICE:

For the first 5 days, take 4 glasses of apple juice everyday or eat 4 or n5 apples, whichever you prefer. Apple juice softens the gallstones. During the n5 days, eat normally.

On the 6th day, take no dinner. Avoid food after 2 pm. At 6 pm, take a nteaspoon of Epson Salt (magnesium sulphate) with a glass of warm water. nAt 8 pm, repeat the same. Magnesium Sulphate opens the gallbladder ducts.
n(Tip: Buy the Epson Salt before you start this program. We tried buying EpsoSalt at six (6) Mercury drug stores where we live but they don’t have nit. Finally, we found some at Mercury drug branch in Quiapo, Manila near the Quiapo Church).

At 10 pm, take ½ cup olive (or sesame) oil with ½ cup nfresh lemon juice. Mix it well and drink it. The oil lubricates the stones to nease their passage.

(Important tip: Drink slowly for better result, avoid food after 2 pm nand expect more output the next day.)

The next morning, you will find green stones in your stools. Usually nthey float.

Dr Chiu Nan’s NOTE: “You nmight want to count them. I have people who passes 40, 50 or up to 100 stones”.

The first purge will be solely your normal output, the green stones will nonly come out after that. Per those who have practiced, the stones look like ncrystal or jade”, try to arrange in such timing that the last day is a nrest day at home, reason being…. you know.

Even if you don’t have any symptoms of gallstones, you still might have nsome. It’s always good to give your gallbladder a clean up now and then. You’ll nfind that your digestion is much better nafterwards.”

RECOMMENDED PERIOD: Do it once a year

 

 

 

Although disorders of nthe biliary tract don’t garner as much attention as other conditions, they are ncommon. Today’s endoscopy team faces more and more of these disorders every nday.

“In terms of biliary nendoscopy, we’ve gone from an era a decade ago where endoscopic approaches to nthe biliary tree were primarily diagnostic — Is there or is there not a stone? nIs there or is there not a stricture? — to an era in which the radiology is so ngood that we can do all of that with either CT (computed tomography) scanning nor MRI (magnetic resonance imaging),” says Jean-Pierre Raufman, MD, head of the nDivision of Gastroenterology and Hepatology at the University of Maryland nSchool of Medicine in Baltimore. “Over 90 percent of these procedures are now ntherapeutic, with an overall excellent efficacy and very low risk to the npatient with real advances in terms of morbidity and mortality.”

Biliary Atresia

“The classic biliary tract ndiseases can be divided into those that primarily affect children and those nthat affect adults,” says John M. Vierling, MD, director of hepatology and nmedical director of multi-organ transplantation at Cedars-Sinai Medical Center nin Los Angeles, Calif. “The most common indication for liver transplantation iinfants and young children is a disease referred to as biliary atresia.”

Biliary atresia affects napproximately one in every 15,000 live births. Due to bile ducts of the liver nnot having normal openings, bile becomes trapped in the liver, causing jaundice nand cirrhosis. The diagnosis of biliary atresia occurs usually ieonates who nremain jaundiced for six weeks or more after birth and have pale stool and dark nurine. Some patients will have a jaundice-free period of several weeks before nthe onset of unremitting jaundice.¹ The condition is fatal if left nuntreated.

No curative therapy for nbiliary atresia exists. Surgical treatment, the Kasai nportoenterostomy, restores bile flow and clears jaundice, and if successful, nachieves a 10-year survival rate.² Yet even with early surgery, 60 npercent to 80 percent of patients eventually develop end-stage biliary ncirrhosis and require liver transplantation.³

Delayed recognition of the ndisease and delayed referral for specialty care remain major obstacles to noptimal timing of the initial surgical intervention.⁴ “Recognitiois key,” Vierling says. “The closer you get to [the first 90 days of life], the nworse the prospect that you will have a good outcome of the Kasai nprocedure.”

Primary Sclerosing nCholangitis

Although primary sclerosing ncholangitis (PSC) is primarily a disease of the bile ducts of the liver, ducts nof the gallbladder and pancreas may also be involved.

Inflamed bile ducts become nscarred and hardened, eventually causing liver failure. The disease may be npresent for several years before symptoms develop, such as fatigue, loss of nappetite, weight loss and jaundice.⁵ PSC is diagnosed through ncholangiography, which involves injecting dye into the bile ducts and taking aX-ray.

“About 70 percent of npatients who have PSC usually have underlying inflammatory bowel disease, nmainly ulcerative colitis,” says Hazar Michael, MD, director of GI Endoscopy nand Endoscopic Ultrasound at Winthrop University Hospital nin Minneola, N.Y.

PSC is more common among nmen than women. It usually begins between ages 30 and 60, but the disease caalso arise during childhood.⁶ Due to the difference in clinical npresentation of PSC in children, a high degree of suspicion is often required nto make the diagnosis of childhood PSC.⁷ Most children present with nnon-specific symptoms, including fatigue and weight loss and, less commonly, nitching.⁸

“When you think of the ncholestatic diseases in children or adults, technicians and people that may see nthem for endoscopic reasons should be aware that itch is a very important nsystem that may be related to the disease,” Vierling says.

For PSC, there isn’t a lot nof effective treatment, Michael says. “You can try endoscopic therapy, which ncould be attempted to make the patient feel better,” she says. “Unfortunately, nit doesn’t change the natural history of the disease. Most of the patients will nundergo cirrhosis and permanent liver damage.

The only cure for PSC will nbe liver transplantation.” Vierling adds, “This disease has a very worrisome nfeature. It should be considered a pre-malignant condition because, regardless nof how long you have had it, there is a risk for development of ncholangiocarcinoma.” Cholangiocarcinoma, a malignant tumor of the bile duct, noccurs in approximately two out of 100,000 people.

Primary Biliary nCirrhosis

Primary biliary cirrhosis n(PBC), a chronic liver disease, is more prevalent than was previously nsuspected. The disease affects females more often than males, with onset nbetween the ages of 30 and 60 years. “PBC, up to the time of a patient ndeveloping actual cirrhosis, is a misnomer.” Vierling says. “It is only the nfourth and final stage of the disease that is truly a biliary cirrhosis.”

PBC is characterized by nprogressive destruction of the bile ducts in the liver, with inflammation leading nto scarring and cirrhosis. Symptoms can include itching, jaundice, cholesterol ndeposits on the skin, fluid retention and dry eyes or mouth. Asymptomatic npatients usually survive more than 10 years, while patients with symptomatic nPBC and jaundice survive approximately seven years.9 Diagnosis is based ophysical examination, biochemical tests and liver biopsy.¹⁰

Vierling says, “The new nadvances in this disease relate to a recognition of its primary auto antibody nmarker, which is referred to as antimitochondrial antibody, or AMA.” AMAs are nfound in 96 percent of patients with PBC.¹¹ The presence of AMA is nalmost diagnostic of the disorder.

Identification of PBC is nimportant because effective treatment with ursodeoxycholic acid has been showto halt disease progression and improve survival without need for liver ntransplantation.¹²

Cholelithiasis n(Gallstones)

A discussion about diseases nof the biliary tract would not be complete without mentioning gallstones. nApproximately 16 to 22 million people have or have had gallstones in the United nStates.¹³

The management of gallstone ndisease accounts for 1 percent of annual healthcare expenditures in the United States, napproximately $6 billion.¹⁴

There are two main types of nstones. Cholesterol stones arise exclusively in the gallbladder and consist of n50 percent to 100 percent cholesterol.¹⁵ Pigment stones may arise nanywhere in the biliary tree and are classified as black or brown.¹⁶

Symptoms often include nfever, jaundice and persistent pain. Ultrasonography provides a simple, quick nmethod of diagnosis. It has a 95-percent sensitivity and specificity for stones nmore than 4 millimeter nin diameter.¹⁷

“Not everybody with ngallstone disease needs a cholecystectomy,” Michael says. “About 80 percent of npatients remain asymptomatic and only 20 percent of patients run into trouble nfrom their gallbladder disease.” Vierling concurs, “It is now recognized that nthe presence of gallstones in the absence of classic attacks of cholecystitis nleads to a recommendation that the gallstones be noted present but no ninterventions such as surgical removal or cholecystectomy be performed. Thus, nthe number of cholecystectomies that were previously performed when gallstones nwere identified — but not necessarily in the context of acute cholecystitis — nhas decreased in the United States.”

With any disease, including ngallstones, it is often difficult to foresee advances in diagnosis and ntreatment. Raufman, however, mentions that there are current attempts to try to nidentify genetic changes that are responsible for gallstone formation or the ndevelopment of biliary cancer. “Once you understand the mechanism, you can try nto develop targets for therapy.”

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DID YOU KNOW Digestive disorders caused … 37.8 million visits to office-based physicians in 2000. Approximately 3.7 million visits to hospital outpatient departments that same year. Ulcers in approximately 17.7 millio Americans in 1997. Source: National Center for Health Statistics

 

 

Cancer of the Bladder

     The bladder is a hollow organ that stores nurine as it is filtered from the kidneys. The flexible bladder wall is made up nof three layers, allowing the bladder to expand and contract as needed. 90% of nbladder cancers are found in the epithelial lining, the innermost layer nof the wall.

 
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Bladder cancer is the sixth leading ncause of new cancer cases in Canada neach year. It is diagnosed two to three times more often in men than in women, nand it is seen in Caucasians twice as often as those of African descent. It’s nthe fourth most common cancer among American men, the ninth most common iwomen.
nBecause of early diagnosis and better treatments, the nmortality rates for this disease have been falling significantly over the last n25 years.

Causes of nCancer of the Bladder

The actual cause of bladder cancer is unknown, but there are some proverisk factors. They include:

• smoking – smokers are twice as likely to develop bladder cancer thaon-smokers

• chemical exposure – certai chemicals, such as those used in the following professions, can become concentrated in the urine, creating a risk factor for cancer:

• hairdressers
• painters
• textile workers
• dye, leather, and rubber workers
• race – Caucasians have twice as high a risk of developing this cancer as people of African descent; Asians have the lowest risk

• gender – men have a two to three times higher risk than women of developing bladder cancer

• age – most cases of bladder cancer are diagnosed in people over the age of 40 years

• previous use of certai chemotherapy medications, such as cyclophosphamide* (often used in breast cancer and lymphoma treatment), can significantly increase the risk of later developing bladder cancer

• previous radiation to the pelvic area

• family or personal history of bladder cancer

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Symptoms and nComplications of Cancer of the Bladder

The symptoms of bladder cancer are easily confused with those of a nbladder or urinary tract infection, kidney stones, or prostate problems. They are:

• blood in the urine (most common)

• pain or burning sensatio while urinating

• a feeling of urgency or needing to urinate immediately

• the feeling of not having emptied the bladder completely after urinating

• pai in the lower back

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If nany of these symptoms are present, it’s important to get them checked by your ndoctor to get a diagnosis of what’s causing the symptoms.
nIt is important to catch bladder cancer early. This increases the chance that treatment will be successful. nComplications from bladder cancer occur more from the treatment (such as nsurgery) rather than the cancer itself. However, if the cancer is left nuntreated and allowed to grow, it will eventually cause even greater ncomplications. Cancer that has spread from the bladder is more difficult to ntreat.
nComplications from surgery depend on the type of nsurgery. If a partial cystectomy (removal of part of the bladder) takes nplace, the bladder can still collect urine, but will be quite a bit smaller. nThis means the person will have to urinate much more often. As well, cancer careturn, and frequent checkups are necessary so that any cancerous cells can be nfound as early as possible.
nAfter a full cystectomy (removal of the entire nbladder), there’s no bladder to hold the urine, so another way to hold and neliminate urine must be made. In some cases, a new bladder can be created by nusing a small section of bowel tissue. This new bladder has to be regularly nemptied manually, usually by using a tube or a catheter (a thin, nflexible tube inserted into the body that permits the introduction or nwithdrawal of fluids).
nOr, a urostomy may be necessary, in which a nsurgeon connects the ureters (tubes that drain the urine from the nkidneys to the bladder) to the abdominal wall to create a stoma n(opening). A plastic bag is externally attached to the stoma, acting like a nbladder to collect urine. The bag must be emptied regularly.
nOther complications from bladder cancer surgery may ninclude infertility for women (if the uterus is removed), menopause (if the novaries are removed), and possibly some sexual dysfunction if the vagina has nbeen made smaller or shorter.
nMen can also experience sexual dysfunction and ninfertility due to the removal of the prostate and the seminal vesicles n(the glands that make semen).
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Diagnosing nCancer of the Bladder

To diagnose bladder cancer, your doctor will review your medical nhistory, including information about past employment, possible exposure to nchemicals, and lifestyle habits such as smoking. Your doctor will then do a nphysical exam and will probably perform a vaginal and/or rectal examination to nrule out other possible causes of the symptoms.
nBlood tests are done to check for kidney function, nand urine is checked for blood or cancer cells. Next, a cystoscopy is nperformed. A doctor inserts a thin tube called a cystoscope through the urethra n(the tube that carries urine from the bladder to outside the body during nurination) and into the bladder.
nThe cystoscope allows the doctor to look inside the nbladder for any abnormalities, and to take a tiny sample of tissue (a biopsy), nwhich will be checked for cancer cells. If you have a cystoscopy, your doctor nmay give you either a local or general anesthetic.
nOnce a diagnosis of cancer is made, the stage of nthe cancer (how far it has advanced) is determined. Some of the nfollowing tests might be done:

• CT or CAT scans (computed tomography) show any tumours or abnormalities in the urinary tract area (this includes the bladder, kidneys, urethra, and ureters).

• MRIs (magnetic resonance imaging), more sophisticated than CT scans, show any irregularities in the bladder or urinary tract area.

• IVP (intravenous pyelogram or intravenous pyelography) involves injection of dye into the bloodstream (which becomes concentrated in the urine), at which point X-rays are taken. The X-rays follow the urinary path and show any obstructions or abnormalities.

• Bone scans determine if the cancer has spread to the bones.

• Chest X-rays show if the cancer has spread to the lungs.

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Treating and nPreventing Cancer of the Bladder

Like most cancers, bladder cancer can be treated by surgery, radiotherapy, nchemotherapy, or a combination of therapies. The choice of treatment depends othe location and the staging of the cancer.

Surgery

Whebladder cancer is caught early, a transurethral resection (TUR) can be ndone. Using a cystoscope, the doctor uses a special tool to burn away the ncancerous cells inside the bladder. The advantage of this treatment is that the nbladder stays intact and people can still urinate normally after the procedure.
nSurgery to remove the bladder is called a cystectomy. nIf the cancer has invaded through the bladder wall, or if it covers a large nportion of the bladder, surgeons generally choose this surgery over TUR.
nIn women, removing the bladder usually involves also nremoving the uterus (hysterectomy), fallopian tubes, ovaries, and part nof the vagina. If the woman is young, the ovaries might be left intact so that nshe won’t have early menopause. For men, the prostate and the seminal vesicles n(the glands that produce semen) must usually be removed along with the bladder.
nOccasionally, an operation called a segmental ncystectomy may be performed if the cancer is limited to a small part of the nbladder wall. This surgery doesn’t remove the entire bladder, so people castill urinate normally afterward.

Radiotherapy

There nare two types of radiotherapy used to treat bladder cancer: internal and nexternal.
nExternal radiotherapy aims radiation directly at the cancer cells in the nbladder. It may be done prior to surgery to shrink the size of the tumour, or nafter the surgery along with chemotherapy.
nInternal radiotherapy is done by inserting radiation implants directly into the nbladder. This treatment requires a hospital stay. Visitors might not be allowed n- this is to avoid exposing them to the radiation coming from the person being ntreated. Once the implants are removed, no more radiation is released and the nperson can return home from the hospital.
nSome people receive both internal and external nradiation.
nThe side effects of radiotherapy are usually ntemporary, and they include:

• fatigue
• red, dry skin at the radiatio site

• nausea
• decreased appetite
• diarrhea
• vaginal dryness (for women)
• difficulty having erectio (for men)

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Chemotherapy

Chemotherapy ncan be used alone or in combination with surgery and/or radiotherapy. It’s navailable as a general treatment (usually given intravenously) or a nlocal one.
nLocal chemotherapy (intravesical therapy) involves putting nchemotherapy medications directly into the bladder for several hours at a time. nThe greatest advantage to intravesical treatment is that there are fewer side neffects since the medications are not given systemically (throughout the body). nThis approach is usually reserved for superficial tumours removed during a ncystoscopy, both to treat tiny amounts of tumour left behind or to prevent recurrence nafter successful removal.
nGeneral, or systemic, chemotherapy circulates throughout the body, so more of the body nsystems are affected by the treatment. This approach is used if the cancer has nspread and can’t be reached by the local (intravesical) approach.
nSide effects from chemotherapy include:

• nausea and vomiting
• hair loss
• fatigue
• diarrhea
• mouth sores
• increased risk of infection

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Nursing Interventions: Bladder Cancer

• Encourage the patient to express feelings and concerns about the extent of the cancer.

• To relieve discomfort administer ordered analgesics for pain as necessary.

• Implement comfort measures and provide distractions that will enable the patient to relax.

• As appropriate, implement measures to prevent or alleviate complications of treatment.

• Monitor the patient’s intake and output. Question him regularly about changes in his urine elimination pattern to detect changes in his condition.

• Observe the patient’s urine for signs of hematuria (reddish tint to gross bloodiness).

• Monitor the patient’s laboratory tests, such as changes in white blood cell differential, indicating possible bone marrow suppression from chemotherapy.

• If the patient is being given intravesical chemotherapy, watch closely for myelosuppression, chemical cystitis, and ski rash.

• Instruct the patient and the family about the types of treatment that are being planned for him.

• Teach the patient and family to recognize and to manage adverse effects of chemotherapy.

• Stress the importance of notifying the doctor if the patient develops signs and symptoms of urinary tract infection or other sudden changes in his condition.

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The prognosis (outlook) for bladder cancer is good. The sooner the cancer nis discovered, the better the chances of survival. The five-year survival rate ncan be as high as 94% if the cancer is detected early. However, this drops ndramatically once the cancer has spread to other areas of the body.
nIf bladder cancer does return, it most often happens nwithin the first year or two after treatment, so good follow-up is essential. nThis involves cystoscopies and urine tests at least every three months for a ncouple of years, then less frequent ongoing monitoring.
nWhile some of the risk factors for bladder cancer ncan’t be avoided (age and gender, for example), there are some precautions that ncan be taken to help avoid developing it. nFor those who work with high-risk chemicals, it’s important to have urine tests nas part of general annual physical examinations. Any unusual bladder symptoms nshould be checked by a doctor immediately.
nSince smoking is a known risk factor for getting nbladder cancer, smokers should try to quit or ask their doctor about ways to nquit.

 

 

Cirrhosis of Liver

          nCirrhosis is a condition in which the liver slowly deteriorates and nmalfunctions due to chronic injury. Scar tissue replaces healthy liver tissue, npartially blocking the flow of blood through the liver.
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nScarring also impairs the liver’s ability to

1. -control infections
2. -remove bacteria and toxins from the blood

3. -process nutrients, hormones, and drugs
4. -make proteins that regulate blood clotting

5. -produce bile to help absorb fats—including cholesterol—and fat-soluble vitamins

6.  

7. 
        A healthy liver is able to regenerate most of its own cells when they become damaged. With end-stage cirrhosis, the liver cao longer effectively replace damaged cells. A healthy liver is necessary for survival.

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Cirrhosis nis the twelfth leading cause of death by disease, accounting for 27,000 deaths neach year.1 The condition affects men slightly more often than women.

nCauses
n  Cirrhosis has various causes. In the United States, heavy alcohol nconsumption and chronic hepatitis C have been the most common causes of ncirrhosis. Obesity is becoming a common cause of cirrhosis, either as the sole ncause or in combination with alcohol, hepatitis C, or both. Many people with ncirrhosis have more than one cause of liver damage.
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nCirrhosis is not caused by trauma to the liver or other acute, or short-term, ncauses of damage. Usually years of chronic injury are required to cause ncirrhosis.
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n  Alcohol-related liver disease. Most people who consume alcohol do not nsuffer damage to the liver. But heavy alcohol use over several years can cause nchronic injury to the liver. The amount of alcohol it takes to damage the liver nvaries greatly from person to person. For women, consuming two to three ndrinks—including beer and wine—per day and for men, three to four drinks per nday, can lead to liver damage and cirrhosis. In the past, alcohol-related ncirrhosis led to more deaths than cirrhosis due to any other cause. Deaths ncaused by obesity-related cirrhosis are increasing.
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n  Chronic hepatitis C. The hepatitis C virus is a liver infection that is nspread by contact with an infected person’s blood. Chronic hepatitis C causes ninflammation and damage to the liver over time that can lead to cirrhosis.
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n  Chronic hepatitis B and D. The hepatitis B virus is a liver infectiothat is spread by contact with an infected person’s blood, semen, or other body nfluid. Hepatitis B, like hepatitis C, causes liver inflammation and injury that ncan lead to cirrhosis. The hepatitis B vaccine is given to all infants and many nadults to prevent the virus. Hepatitis D is another virus that infects the nliver and can lead to cirrhosis, but it occurs only in people who already have nhepatitis B.
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n  Nonalcoholic fatty liver disease (NAFLD). In NAFLD, fat builds up in the nliver and eventually causes cirrhosis. This increasingly common liver disease nis associated with obesity, diabetes, protein malnutrition, coronary artery ndisease, and corticosteroid medications.
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n   Autoimmune hepatitis. This form of hepatitis is caused by the nbody’s immune system attacking liver cells and causing inflammation, damage, nand eventually cirrhosis. Researchers believe genetic factors may make some npeople more prone to autoimmune diseases. About 70 percent of those with nautoimmune hepatitis are female.
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n  Diseases that damage or destroy bile ducts. Several different diseases ncan damage or destroy the ducts that carry bile from the liver, causing bile to nback up in the liver and leading to cirrhosis. In adults, the most commocondition in this category is primary biliary cirrhosis, a disease in which the nbile ducts become inflamed and damaged and, ultimately, disappear. Secondary nbiliary cirrhosis can happen if the ducts are mistakenly tied off or injured nduring gallbladder surgery. Primary sclerosing cholangitis is another conditiothat causes damage and scarring of bile ducts. In infants, damaged bile ducts nare commonly caused by Alagille syndrome or biliary atresia, conditions iwhich the ducts are absent or injured.
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n  Inherited diseases. Cystic fibrosis, alpha-1 antitrypsin deficiency, nhemochromatosis, Wilsodisease, galactosemia, and glycogen storage diseases are inherited diseases nthat interfere with how the liver produces, processes, and stores enzymes, nproteins, metals, and other substances the body needs to function properly. nCirrhosis can result from these conditions.
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n  Drugs, toxins, and infections. Other causes of cirrhosis include drug nreactions, prolonged exposure to toxic chemicals, parasitic infections, and nrepeated bouts of heart failure with liver congestion.
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nSymptoms
nMany people with cirrhosis have no symptoms in the early stages of the disease. nHowever, as the disease progresses, a person may experience the following nsymptoms:
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nweakness
nfatigue
nloss of appetite
nnausea
nvomiting
nweight loss
nabdominal pain and bloating when fluid accumulates in the abdomen
nitching
nspiderlike blood vessels on the skin
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nComplications
nAs liver function deteriorates, one or more complications may develop. In some npeople, complications may be the first signs of the disease.
nEdema and ascites. When liver damage progresses to an advanced stage, fluid ncollects in the legs, called edema, and in the abdomen, called ascites. Ascites ncan lead to bacterial peritonitis, a serious infection.
nBruising and bleeding. When the liver slows or stops producing the proteins nneeded for blood clotting, a person will bruise or bleed easily.
nPortal hypertension. Normally, blood from the intestines and spleen is carried nto the liver through the portal vein. But cirrhosis slows the normal flow of nblood, which increases the pressure in the portal vein. This condition is ncalled portal hypertension.
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nEsophageal varices and gastropathy. When portal hypertension occurs, it may ncause enlarged blood vessels in the esophagus, called varices, or in the nstomach, called gastropathy, or both. Enlarged blood vessels are more likely to nburst due to thin walls and increased pressure. If they burst, serious bleeding ncan occur in the esophagus or upper stomach, requiring immediate medical nattention.
n
nSplenomegaly. When portal hypertension occurs, the spleen frequently enlarges nand holds white blood cells and platelets, reducing the numbers of these cells nin the blood. A low platelet count may be the first evidence that a person has ndeveloped cirrhosis.
n
nJaundice. Jaundice occurs when the diseased liver does not remove enough nbilirubin from the blood, causing yellowing of the skin and whites of the eyes nand darkening of the urine. Bilirubin is the pigment that gives bile its nreddish-yellow color.
n
nGallstones. If cirrhosis prevents bile from flowing freely to and from the ngallbladder, the bile hardens as gallstones.
n
nSensitivity to medications. Cirrhosis slows the liver’s ability to filter nmedications from the blood. When this occurs, medications act longer thaexpected and build up in the body. This causes a person to be more sensitive to nmedications and their side effects.
n
nHepatic encephalopathy. A failing liver cannot remove toxins from the blood, nand they eventually accumulate in the brain. The buildup of toxins in the nbrain—called hepatic encephalopathy—can decrease mental function and cause ncoma. Signs of decreased mental function include confusion, personality nchanges, memory loss, trouble concentrating, and a change in sleep habits.
n
nInsulin resistance and type 2 diabetes. Cirrhosis causes resistance to insulin—a nhormone produced by the pancreas that enables the body to use glucose as nenergy. With insulin resistance, the body’s muscle, fat, and liver cells do not nuse insulin properly. The pancreas tries to keep up with the demand for insuliby producing more, but excess glucose builds up in the bloodstream causing type n2 diabetes.
n
nLiver cancer. Hepatocellular carcinoma is a type of liver cancer that can occur nin people with cirrhosis. Hepatocellular carcinoma has a high mortality rate, nbut several treatment options are available.
n
nOther problems. Cirrhosis can cause immune system dysfunction, leading to the nrisk of infection. Cirrhosis can also cause kidney and lung failure, known as nhepatorenal and hepatopulmonary syndromes.
n
n
nThe diagnosis of cirrhosis is usually based on the presence of a risk factor nfor cirrhosis, such as alcohol use or obesity, and is confirmed by physical nexamination, blood tests, and imaging. The doctor will ask about the person’s nmedical history and symptoms and perform a thorough physical examination to nobserve for clinical signs of the disease. For example, on abdominal nexamination, the liver may feel hard or enlarged with signs of ascites. The ndoctor will order blood tests that may be helpful in evaluating the liver and nincreasing the suspicion of cirrhosis.
n
nTo view the liver for signs of enlargement, reduced blood flow, or ascites, the ndoctor may order a computerized tomography (CT) scan, ultrasound, magnetic nresonance imaging (MRI), or liver scan. The doctor may look at the liver ndirectly by inserting a laparoscope into the abdomen. A laparoscope is ainstrument with a camera that relays pictures to a computer screen.
n
nA liver biopsy can confirm the diagnosis of cirrhosis but is not always nnecessary. A biopsy is usually done if the result might have an impact otreatment. The biopsy is performed with a needle inserted between the ribs or ninto a vein in the neck. Precautions are taken to minimize discomfort. A tiny nsample of liver tissue is examined with a microscope for scarring or other nsigns of cirrhosis. Sometimes a cause of liver damage other than cirrhosis is nfound during biopsy.
n
n
nSeverity of cirrhosis
nThe model for end-stage liver disease (MELD) score measures the severity of ncirrhosis. The MELD score was developed to predict the 90-day survival of npeople with advanced cirrhosis. The MELD score is based on three blood tests:
n
ninternational normalized ratio (INR)—tests the clotting tendency of blood
nbilirubin—tests the amount of bile pigment in the blood
ncreatinine—tests kidney function
nMELD scores usually range between 6 and 40, with a score of 6 indicating the nbest likelihood of 90-day survival.
n
n
nTreatment
nTreatment for cirrhosis depends on the cause of the disease and whether ncomplications are present. The goals of treatment are to slow the progressioof scar tissue in the liver and prevent or treat the complications of the ndisease. Hospitalization may be necessary for cirrhosis with complications.
n
nEating a nutritious diet. Because malnutrition is common in people with ncirrhosis, a healthy diet is important in all stages of the disease. Health ncare providers recommend a meal plan that is well balanced. If ascites ndevelops, a sodium-restricted diet is recommended. A person with cirrhosis nshould not eat raw shellfish, which can contain a bacterium that causes serious ninfection. To improve nutrition, the doctor may add a liquid supplement takeby mouth or through a nasogastric tube—a tiny tube inserted through the nose nand throat that reaches into the stomach.
n
nAvoiding alcohol and other substances. People with cirrhosis are encouraged not nto consume any alcohol or illicit substances, as both will cause more liver ndamage. Because many vitamins and medications—prescription and nover-the-counter—can affect liver function, a doctor should be consulted before ntaking them.
n
nTreatment for cirrhosis also addresses specific complications. For edema and nascites, the doctor will recommend diuretics—medications that remove fluid from nthe body. Large amounts of ascitic fluid may be removed from the abdomen and nchecked for bacterial peritonitis. Oral antibiotics may be prescribed to nprevent infection. Severe infection with ascites will require intravenous (IV) nantibiotics.
n
nThe doctor may prescribe a beta-blocker or nitrate for portal hypertension. nBeta-blockers can lower the pressure in the varices and reduce the risk of nbleeding. Gastrointestinal bleeding requires an immediate upper endoscopy to nlook for esophageal varices. The doctor may perform a band-ligation using a nspecial device to compress the varices and stop the bleeding. People who have nhad varices in the past may need to take medicine to prevent future episodes.
n
nHepatic encephalopathy is treated by cleansing the bowel with lactulose—a nlaxative given orally or in enemas. Antibiotics are added to the treatment if nnecessary. Patients may be asked to reduce dietary protein intake. Hepatic nencephalopathy may improve as other complications of cirrhosis are controlled.
n
nSome people with cirrhosis who develop hepatorenal failure must undergo regular nhemodialysis treatment, which uses a machine to clean wastes from the blood. nMedications are also given to improve blood flow through the kidneys.
n
nOther treatments address the specific causes of cirrhosis. Treatment for ncirrhosis caused by hepatitis depends on the specific type of hepatitis. For nexample, interferon and other antiviral drugs are prescribed for viral nhepatitis, and autoimmune hepatitis requires corticosteroids and other drugs nthat suppress the immune system.
n
nMedications are given to treat various symptoms of cirrhosis, such as itching nand abdominal pain.
n
nLver transplant A liver transplant is considered when complications ncannot be controlled by treatment. Liver transplantation is a major operatioin which the diseased liver is removed and replaced with a healthy one from aorgan donor. A team of health professionals determines the risks and benefits nof the procedure for each patient. Survival rates have improved over the past nseveral years because of drugs that suppress the immune system and keep it from nattacking and damaging the new liver.
n
nThe number of people who need a liver transplant far exceeds the number of navailable organs. A persoeeding a transplant must go through a complicated nevaluation process before being added to a long transplant waiting list. nGenerally, organs are given to people with the best chance of living the nlongest after a transplant. Survival after a transplant requires intensive nfollow-up and cooperation on the part of the patient and caregiver.
n
n
nPoints to Remember
n
nCirrhosis is a condition in which the liver slowly deteriorates and nmalfunctions due to chronic injury. Scar tissue replaces normal, healthy liver ntissue, preventing the liver from working as it should.
nIn the United States, nheavy alcohol consumption and chronic hepatitis C have been the most commocauses of cirrhosis. Obesity is becoming a common cause of cirrhosis, either as nthe sole cause or in combination with alcohol, hepatitis C, or both. Many npeople with cirrhosis have more than one cause of liver damage.
nOther causes of cirrhosis include hepatitis B, hepatitis D, and autoimmune nhepatitis; diseases that damage or destroy bile ducts, inherited diseases, and nnonalcoholic fatty liver disease; and drugs, toxins, and infections.
nMany people with cirrhosis have no symptoms in the early stages of the disease. nAs the disease progresses, symptoms may include weakness, fatigue, loss of nappetite, nausea, vomiting, weight loss, abdominal pain and bloating, itching, nand spiderlike blood vessels on the skin.
nAs liver function deteriorates, one or more complications may develop. In some npeople, complications may be the first signs of the disease.
nThe goals of treatment are to stop the progression of scar tissue in the liver nand prevent or treat complications.
nTreatment for cirrhosis includes avoidance of alcohol and other drugs, nnutrition therapy, and other therapies that treat specific complications or ncauses of the disease.
nHospitalization may be necessary for cirrhosis with complications.
nA liver transplant is considered when complications of cirrhosis cannot be ncontrolled by treatment.
n
nNursing Priorities
n
n1. Maintain adequate nutrition.
n2. Prevent complications.
n3. Enhance self-concept, acceptance of situation.
n4. Provide information about disease process/prognosis, potential ncomplications, and treatment needs.
n
nDischarge Goals
n
n1. Nutritional intake adequate for individual needs.
n2. Complications prevented/minimized.
n3. Dealing effectively with current reality.
n4. Disease process, prognosis, potential complications, and therapeutic regimeunderstood.
n5. Plan in place to meet needs after discharge.
n
nNURSING DIAGNOSIS: imbalanced Nutrition: less than body requirements
nMay be related to

Inadequate ndiet; inability to process/digest nutrients
nAnorexia, nausea/vomiting, indigestion, early satiety (ascites)
nAbnormal bowel function

Possibly nevidenced by

Weight loss
nChanges in bowel sounds and function
nPoor muscle tone/wasting; [fatigue]
nImbalances iutritional studies

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT nWILL:
nNutritional Status (NOC)

Demonstrate nprogressive weight gain toward goal with client-appropriate normalization of nlaboratory values.
nExperience no further signs of malnutrition.

NURSING DIAGNOSIS: excess Fluid Volume
nMay be related to

Compromised nregulatory mechanism (e.g., syndrome of inappropriate antidiuretic hormone n[SIADH], decreased plasma proteins, malnutrition)
nExcess sodium/fluid intake

Possibly evidenced by

Edema, nanasarca, weight gain
nIntake greater than output, oliguria, changes in urine specific gravity
nDyspnea, adventitious breath sounds, pleural effusion
nBP changes, altered CVP
nJVD, positive hepatojugular reflex
nAltered electrolyte levels
nChange in mental status

DESIRED nOUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
nFluid Balance (NOC)

Demonstrate nstabilized fluid volume, with balanced I&O, stable weight, vital signs nwithin client’s normal range, and absence of edema.

nNURSING DIAGNOSIS: risk for impaired Skin Integrity
nRisk factors may include

Altered ncirculation/metabolic state
nAccumulation of bile salts in skin
nPoor skin turgor, skeletal prominence, presence of edema, ascites

Possibly nevidenced by

[Not napplicable; presence of signs and symptoms establishes an actual ndiagnosis.]

DESIRED OUTCOMES/EVALUATION CRITERIA—CLIENT nWILL:
nRisk Control (NOC)

Maintaiskin integrity.
nIdentify individual risk factors and demonstrate behaviors/techniques to nprevent skin breakdown.

NURSING DIAGNOSIS: risk for ineffective nBreathing Pattern
nRisk factors may include

Intra-abdominal nfluid collection (ascites)
nDecreased lung expansion, accumulated secretions
nDecreased energy, fatigue

Possibly nevidenced by

[Not napplicable; presence of signs and symptoms establishes an actual ndiagnosis.]

DESIRED nOUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
nRespiratory Status: Ventilation (NOC)

Maintaieffective respiratory pattern; be free of dyspnea and cyanosis, with ABGs and nvital capacity within acceptable range.

NURSING DIAGNOSIS: risk for Injury [hemorrhage]
nRisk factors may include

Abnormal nblood profile; altered clotting factors (decreased production of prothrombin, nfibrinogen, and factors VIII, IX, and X; impaired vitamin K absorption; and nrelease of thromboplastin)
nPortal hypertension, development of esophageal varices

Possibly nevidenced by

[Not napplicable; presence of signs and symptoms establishes an actual ndiagnosis.]

DESIRED nOUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
nCoagulation Status (NOC)

Maintaihomeostasis with absence of bleeding.
nRisk Control (NOC)
nDemonstrate behaviors to reduce risk of bleeding.

NURSING DIAGNOSIS: risk for acute Confusion
nRisk factors may include

Alcohol nabuse
nInability of liver to detoxify certain enzymes/drugs

Possibly nevidenced by

[Not napplicable; presence of signs and symptoms establishes an actual ndiagnosis.]

DESIRED nOUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
nCognition (NOC)

Maintaiusual level of mentation/reality orientation.
nInitiate behaviors/lifestyle changes to prevent or minimize recurrence of nproblem.

nNURSING DIAGNOSIS: Self-Esteem [specify]/disturbed Body Image
nMay be related to

Biophysical nchanges/altered physical appearance
nUncertainty of prognosis, changes in role function
nPersonal vulnerability
nSelf-destructive behavior (alcohol-induced disease)

Possibly nevidenced by

Verbalizatioof change/restriction in lifestyle
nFear of rejection or reaction by others
nNegative feelings about body/abilities
nFeelings of helplessness, hopelessness, or powerlessness

DESIRED nOUTCOMES/EVALUATION CRITERIA—CLIENT WILL:
nSelf-Esteem (NOC)

Verbalize nunderstanding of changes and acceptance of self in the present situation.
nIdentify feelings and methods for coping with negative perception of self.

NURSING nDIAGNOSIS: deficient Knowledge [Learning Need] regarding condition, prognosis, ntreatment, self-care, and discharge needs

May be nrelated to
nLack of exposure/recall; information misinterpretation
nUnfamiliarity with information resources

Possibly nevidenced by

Questions; nrequest for information, statement of misconception
nInaccurate follow-through of instructions/development of preventable ncomplications

DESIRED nOUTCOMES/EVALUATION CRITERIA—CLIENT WILL:

Knowledge: nIllness Care (NOC)
nVerbalize understanding of disease process/prognosis, potential complications.
nCorrelate symptoms with causative factors.
nKnowledge; Health Behaviors (NOC)
nIdentify/initiate necessary lifestyle changes and participate in care.