Which phase of hepatitis would the nurse incur strict precautionary measures at?

Liver cirrhosis is the scarring of the liver from liver diseases. The advancement of liver disease to cirrhosis is irreversible. The most common causes include: 

• Alcoholic liver disease. Years of alcohol abuse damage the liver over time. 
• Fatty liver disease. A buildup of fat in the liver caused by obesity and diabetes. Excessive alcohol intake can also be a factor. 
• Hepatitis. Inflammation to the liver. 

The liver plays vital roles in the body including metabolism, detoxification, digestion, storage of vitamins and minerals, production of clotting factors, and more.  

Complications include edema and ascites, enlargement of the spleen, bleeding from pressure in the veins, infections, malnutrition, and the buildup of toxins causing hepatic encephalopathy.  

The Nursing Process  

The treatment of liver cirrhosis is serious and complex. Nurses will be involved in the symptom management of patients with cirrhosis including paracentesis procedures, controlling cognitive manifestations of hepatic encephalopathy, promoting proper nutrition, and preparing for liver transplantation. Patients with liver cirrhosis often require education and emotional support in managing the complications of their disease. 

Nursing Care Plans Related to Liver Cirrhosis 

Dysfunctional Family Processes: Alcoholism Care Plan 

Alcoholic liver disease is a common cause of liver cirrhosis that occurs from years of heavy drinking. 

Related to: 

• Heavy alcohol use 

As evidenced by: 

Physical effects of long-term alcohol use on the liver: 

• Portal hypertension 
• Ascites 
• Jaundice 
• Splenomegaly 
• Poor nutrition 

Emotional/psychological symptoms: 

• Denial of addiction 
• Anxiety/depression 
• Guilt 
• Social Isolation/loneliness 
• Marital problems 
• Financial issues 
• Disrupted family roles 
• Unresolved grief 
• Ineffective coping 
• Knowledge deficit 

Expected Outcomes: 

• Patient will verbalize an understanding of the long-term effects of alcohol use on the liver 
• Patient will agree to rehabilitation or Alcoholics Anonymous for support with addiction 
• Patient will verbalize the consequences of alcohol use and identify necessary steps for change 

Dysfunctional Family Processes: Alcoholism Assessment

1. Assess for withdrawal.
Withdrawal symptoms must be closely monitored and treated. Delirium tremens (DTs) can result in seizures and is life-threatening. The nurse can administer benzodiazepines to manage these symptoms with caution so as not to worsen hepatic encephalopathy if present.

2. Monitor lab work.
Assess for alcohol abuse through specific liver enzymes such as AST, ALT, and GGT. GGT levels are most sensitive in detecting excessive alcohol consumption.

3. Assess support system involvement.
Assess for the effect of alcoholism and liver cirrhosis on family dynamics. Inquire about support from a spouse, family members, or friends or a lack thereof.

Dysfunctional Family Processes: Alcoholism Interventions

1. Reduce alcohol cravings.
Medications are available to assist with alcohol addiction. Disulfiram is FDA-approved to treat alcoholism. Topiramate is effective in decreasing cravings and withdrawal symptoms. Baclofen is effective in promoting alcohol abstinence in patients with cirrhosis.

2. Refer to rehabilitation or AA.
Addressing the underlying addiction is necessary to manage the disease. Patients should be provided resources for addiction counseling, Alcoholics Anonymous, as well as inpatient or outpatient rehab programs.

3. Coordinate with a dietician.
Cirrhosis and alcoholism result in malnutrition. Patients are often deficient in folate, vitamin B6, vitamin A, thiamine, and zinc. Treating malnutrition depends on the severity of the disease and can be difficult. Assessment and treatment by a dietician may be necessary.

4. Prepare for liver transplantation.
Cirrhosis cannot be cured and a liver transplant is the only treatment for end-stage liver disease. To qualify for a liver transplant, the patient must be committed to abstaining from alcohol.

Acute Confusion Care Plan 

When the liver is damaged and isn’t able to detoxify substances, those toxins build up in the blood and affect brain function.  

Nursing Diagnosis: Acute Confusion

Related to: 

• Hepatic encephalopathy (HE) 
• Accumulation of ammonia in the blood 

As evidenced by: 

• Confusion 
• Agitation 
• Slurred speech 
• Lethargy 
• Impaired decision making 
• Lack of coordination 
• Difficulty concentrating 

Expected Outcomes: 

• Patient will remain alert and oriented to person, place, and time 
• Patient will initiate lifestyle behaviors to prevent recurrence (abstaining from alcohol use) 

Acute Confusion Assessment

1. Monitor serum ammonia levels.
While ammonia levels may not always prove HE, they can be monitored for improvement or worsening.

2. Review EEG, MRI, or CT scans.
Ruling out of the possibilities of other causes such as tumors can lead to proper diagnosis and treatment.

Acute Confusion Interventions

1. Administer lactulose.
Lactulose is a laxative that rids the body of ammonia and toxins through frequent bowel movements.

2. Prevent falls and injury.
Due to the cognitive effects of HE, patients are at risk for falls and other injuries. Ensure the bed alarm is on at all times and the patient is supervised and assisted with ambulating and other ADLs.

3. Reorient as needed.
Provide reorientation to person, place, time, and situation frequently to reduce confusion and maintain a sense of reality.

4. Educate on lifestyle changes.
Managing cirrhosis can prevent HE. Patients should be advised to avoid alcohol, take prescribed medications to treat their liver disease, and maintain a healthy diet.

5. Decrease stimuli.
Prevent increasing confusion and agitation by providing a calm, quiet environment and promoting relaxation.

Risk For Impaired Skin Integrity Care Plan 

Liver cirrhosis compromises skin integrity from fluid build-up, accumulation of bile salts, and bleeding.

Nursing Diagnosis: Risk For Impaired Skin Integrity

Related to: 

• Accumulation of bile salts causing jaundice 
• Fluid build up causing edema and ascites 
• Bleeding leading to spider angiomas 
• Poor nutrition 

Note: A risk diagnosis is not evidenced by signs and symptoms as the problem has not occurred. Nursing interventions are directed at prevention. 

Expected Outcomes: 

• Patient will remain free from skin breakdown 
• Patient will monitor for worsening edema and ascites and alert their provider 
• Patient will implement two strategies to prevent skin breakdown 

Risk for Impaired Skin Integrity Assessment

1. Perform a skin assessment.
Perform a thorough skin assessment and reassess regularly. Monitor for bruising, papules, nodules, and edema that are common with liver cirrhosis. Note the color of skin and eyes which signals jaundice.

2. Assess nutritional status.
Assess the patient’s nutritional and fluid intake. Patients with cirrhosis often have a lack of appetite and are malnourished, lacking vitamins and nutrients.

Risk For Impaired Skin Integrity Interventions

1. Prevent skin tearing or shearing.
The skin may be susceptible to tearing due to edema and poor elasticity. Take care in moving, turning, and performing hygiene care.

2. Prevent edema.
Preventing edema in cirrhosis may be difficult as it is a symptom of the problem. The patient can decrease fluid buildup by restricting salt, avoiding alcohol, and taking diuretics.

3. Monitor post paracentesis.
The fluid build-up that occurs in the abdomen is due to portal hypertension; high pressure in the portal vein causing fluid to leak into the peritoneum. A paracentesis removes the fluid by drawing it out with a needle. This usually only results in temporary relief of symptoms and is a recurring problem. The nurse should monitor the puncture site for any signs of infection.

4. Control itching.
A buildup of bile salts that causes jaundice also causes itching. The patient needs to avoid scratching to prevent skin breakdown. Avoid the use of hot water and harsh soaps when bathing. Calamine lotion may help ease itchiness. Administer Benadryl or hydroxyzine to relieve the histamine response.

5. Treat malnutrition.
Improve nutrition to prevent weight loss and cachexia that increases the risk of skin breakdown. Increase protein and nutrient intake. Provide a nighttime snack to prevent fasting/catabolism. Enteral nutrition may be necessary.

References and Sources

1. Addolorato, G. (2016, August 10). Management of Alcohol Dependence in Patients with Liver Disease. NCBI. Retrieved March 24, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC4979989/
2. Alcoholic Liver Disease. (n.d.). Johns Hopkins Medicine. Retrieved March 24, 2022, from https://www.hopkinsmedicine.org/health/conditions-and-diseases/alcoholinduced-liver-disease
3. Ascites: Fluid Buildup, Causes, Symptoms & Treatment. (2021, May 28). Cleveland Clinic. Retrieved March 24, 2022, from https://my.clevelandclinic.org/health/diseases/14792-ascites
4. Baton Rouge General. (2021, July 8). Itching: An Unknown but Not Uncommon Sign of Liver Disease. Baton Rouge General. Retrieved March 24, 2022, from https://www.brgeneral.org/news-blog/2021/july/itching-an-unknown-but-not-uncommon-sign-of-live/
5. Butterworth, R. F. (2011). Hepatic Encephalopathy – NORD. National Organization for Rare Disorders. Retrieved March 24, 2022, from https://rarediseases.org/rare-diseases/hepatic-encephalopathy/
6. Cirrhosis – Symptoms and causes. (2021, February 6). Mayo Clinic. Retrieved March 24, 2022, from https://www.mayoclinic.org/diseases-conditions/cirrhosis/symptoms-causes/syc-20351487
7. Doenges, M. E., Moorhouse, M. F., & Murr, A. C. (2008). Nurse’s Pocket Guide Diagnoses, Prioritized Interventions, and Rationales (11th ed.). F. A. Davis Company.
8. Frazier, T. H., Stocker, A. M., Kershner, N. A., Marsano, L. S., & McClain, C. J. (2011). Treatment of alcoholic liver disease. Therapeutic advances in gastroenterology, 4(1), 63–81. https://doi.org/10.1177/1756283X10378925
9. Hepatic Encephalopathy: Types, Causes, Symptoms, Treatment. (2020, April 16). Cleveland Clinic. Retrieved March 24, 2022, from https://my.clevelandclinic.org/health/diseases/21220-hepatic-encephalopathy
10. Koulaouzidis, A., Bhat, S., & Moschos, J. (2007). Skin manifestations of liver diseases. Elsevier. https://www.elsevier.es/en-revista-annals-hepatology-16-articulo-skin-manifestations-liver-diseases-S166526811931926X
11. McClain, C. J. (2016, August 12). Nutrition in Patients With Cirrhosis – PMC. NCBI. Retrieved March 24, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5114497/
12. Miller, L. (2022, January 7). Delirium Tremens: Symptoms, Timeline & Treatment. American Addiction Centers. Retrieved March 24, 2022, from https://americanaddictioncenters.org/alcoholism-treatment/delirium-tremens-symptoms-and-treatment
13. Moore, K., & Aithal, G. (2006, October). Guidelines on the management of ascites in cirrhosis. NCBI. Retrieved March 24, 2022, from https://www.ncbi.nlm.nih.gov/pmc/articles/PMC1860002/
14. Phillips, M. M., & Zieve, D. (2020, January 12). Cirrhosis Information. Mount Sinai. Retrieved March 24, 2022, from https://www.mountsinai.org/health-library/diseases-conditions/cirrhosis

What is stage 2 liver disease?

What is stage 3 cirrhosis of the liver?

What precaution should a nurse initiate when caring for a patient with hepatitis B?

What are the 4 stages of cirrhosis of the liver?