Cirrhosis

• What are the risk factors for cirrhosis?

  • alcoholism #1
  • Hepatitis #2
  • Non-alcoholic fatty liver disease (NAFLD)
  • Non-alcoholic steatohepatitis
  • Drug Toxicity ~ esp acetaminophen
• What is the dose limit and antidote for acetaminophen?

  4 grams/day

  Antidote: N-acetylcysteine within 8 hours
• What type of labs will you see increased in cirrhosis?

  • bilirubin
  • ammonia
  • coagulation times [INR, PT, PTT]
  • liver enzymes [AST, ALT]
• When do labs suggest alcoholic liver disease for cirrhosis?

  AST is 2x greater than ALT
• If ALT is higher in labs for a person in cirrhosis what does this suggest?

  non-alcoholic liver disease
• What labs are decreased in cirrhosis?

  • Potassium
  • platelets
  • H&H
  • Albumin
  • BUN
  • glucose
  • Magnesium
• What are the main symptoms presented in cirrhosis?

  • Ascites
  • Esophageal Varices
  • Hepatic Encephalopathy
  • Vitamin Deficiency
  • Jaundice
• What are the symptoms the characterize ascites?

  • large, firm, abdomen
  • generalized edema
  • possible respiratory distress
• What are esophageal varices?

  Thin-walled veins that are prone to rupture

  • risk factors to rupture = coughing, vomiting, straining, gastric reflux
• What can the rupture of esophageal varices result in?

  hemorrhage

  • Turn pt to side ---> suction & protect airway
• What are the symptoms presented in hepatic encephalopathy?

  • mental status changes
  • constructional apraxia ~ can't produce simple drawing/write legibly
  • Asterixis ~ "liver flap" twitching of extremities
  • Fector hepaticus = sweet fecal odor to breath
• How does vitamin deficiency manifest in clients with cirrhosis?

  • decreased fat-soluble vitamins especially K will manifest into bleeding Sx
  • Decreased stores of vitamin B = paresthesia
  • Anemia
• What does hepato-renal syndrome signify?

  signifies end-stage disease with death within 6 months of onset
• What are symptoms of hepato-renal syndrome?

  edema, oliguria, azotemia
• What is azotemia?

  high lvls of urea and creatinine in blood
• What are the potential complications that the nurse should manage with a client with cirrhosis?

  • Fluid volume excess
  • Risk for injury d/t bleeding
  • Disturbed thought process r/t ammonia accumulation
• How does the nurse manage fluid volume excess in a patient with cirrhosis?

  • Monitor Fluid balance: I & O, daily weights, edema, lung sounds
  • Measure abdominal girth QD
  • 2 g Na restriction & aldosterone restriction = 1st line Tx w/ or w/o lasix
  • Administer diuretics
  • Administer plasma proteins = Albumin
  • Assist with paracentesis
• What are some diuretics given with the patient experiencing fluid volume excess in cirrhosis?

  Spironolactone & Furosemide combo

  • Aldactone preferred = blocks aldosterone which liver cannot detoxify
  • Not restricted fluids unless Na < 120
  • Monitor potassium closely ! = Aldactone is K sparing --> if pt has hepato-renal syndrome, potassium could rise
• How does the nurse manage the client experiencing risk for injury r/t bleeding in a patient with cirrhosis?

  Bleeding precautions:

  • minimize high risk situations = coughing, vomiting,
  • avoid injections and invasive procedures
  • apply pressure to puncture sites for at least 5 min or draw from med lock
  • fall precautions
  • Administer prevention and treatment meds
  • Monitor INR & platelets; bodily fluids & VS for bleeding
• How does the nurse manage the client experiencing disturbed thought process r/t ammonia accumulation?

  • Monitor ammonia lvls, mental status changes, presence of asterixis
  • Safety precautions: fall risk, infection control
  • treat infection
  • decrease dietary protein = 1 - 1.5 g/day; carb load (vegetables)
  • Medications: lactulose, antibiotics, rifaximin (Xifacin)
  • Avoid sedative drugs
• A patient with cirrhosis presents with confusion, lethargy, fatigue and twitching of extremities. The nurse suspect hepatic encephalopathy d/t high ammonia lvls from morning blood draw. What type of medications should the nurse expect to see in her orders?

  • Lactulose = changes gut microbiome to decrease intestinal ammonia production
  • reduces colon pH = slows passage of ammonia to blood
  • causes pt to poop = less absoprtion
  • Antibiotics destroy intestinal bacteria which act on protein in feces to produce ammonia
  • Possible rifaximin (Xifacin) = add if not responsive to lactulose
• What can the nurse do to prepare a patient pre-operatively for a paracentesis?

  • obtain consent
  • Ask pt to void
  • position in semi/high fowler's
• What are some post-op nursing care given for the client who just finished a paracentesis?

  Monitor VS & Site

  • use site closer to mid-abdomen
  • observe color of the aspirate; should be clear light yellow
  • if cloudy consider spontaneous bacterial empyema
  • if removing > 8 L= administer albumin to reduce risk of hypovolemia shock
  • change positions slowly & check VS
  • in diuretic sensitive ascites > 5 L remove then manage by low Na
  • if diuretic refractory, take as much as possible
• What are nursing care in the complications of paracentesis?

  • Monitor site for leakage, bleeding as site is portal for infection/peritonitis
  • could insert pleur-x drain for home management of chronic ascites
• What is the nursing care for post-procedure: endoscopic banding?


  • monitor for return of swallow/gag reflex
  • neuro status
  • All Tx is temporary; varices will recur unless cirrhosis resolves
  • banding w/ beta-blockers = best Tx to reduce re-bleed
• What is TIPS - Transjugular Intrahepatic Portsystemic Shunt?

  A shunt used to treat portal hypertension
• What is some nursing care for a patient who had a TIPS procedure?

  • Monitor jugular site for bleeding
  • Monitor for encephalopathy
  • Patient Education
  • pt not good as surgical candidates d/t bleeding tendencies and poor protein stores
• How does the nurse manage VTE prevention in a patient with cirrhosis?

  • Prevention: H2RA or PPI; stool softener, non-specific beta-blockers such as propranolol
  • Tx: Vitamin K, vasoconstriction such as octreotide or vasopressin, antibiotics
• What does Octreotide (Sandostatin) do in the treatment plan of cirrhosis?

  VTE Prevention = decrease splanchnic and hepatic blood flow & portal pressure [more effective and fewer SE than pressin]
• How does pressin help in VTE prevention of cirrhosis?

  • Pressin is gen vasoconstrictor that clamps down on varices 
  • S: mesenteric and cardiac ischemia so give concurrently w/ NGT