5. Cirrhosis: chronic inflammation and fibrosis (irreversible scarring) of the liver in which some liver cells (hepatocytes) undergo necrosis and others undergo proliferative regeneration.
   1. Pathophysiology: progressive destruction of hepatic cells-loss of normal metabolic function of the liver and formation of scar tissue. Regeneration and proliferation of fibrous tissue-obstruction of the portal vein-increased portal hypertension, ascites, liver failure, and eventual death.
   2. Risk factors:
      1. Alcohol abuse most common cause.
      2. Nutritional deficiency with decreased protein intake.
      3. Hepatotoxins.
      4. Virus.
      5. Hepatitis B and C.
   3. Assessment:
      1. Subjective data:
         1. Chronic feeling of malaise.
         2. Anorexia, nausea.
         3. Abdominal pain.
         4. Pruritus.
      2. Objective data:
         1. GI:
            1. Malnutrition, weight loss.
            2. Vomiting.
            3. Flatulence.
            4. Ascites.
            5. Enlarged liver and spleen.
            6. Glossitis.
            7. Fetid breath (sweet, musty odor).
         2. Blood-coagulation defects, possible esophageal varices, portal hypertension, bleeding from gums and injection sites.
         3. Skin and hair-edema, jaundice, spider angioma (telangiectasias); palmar erythema, decreased pubic and axillary hair.
         4. Reproductive-menstrual abnormalities, gynecomastia, testicular atrophy, impotence.
         5. Neurological deficits, including memory loss, hepatic coma, decreased level of consciousness: flapping tremor, grimacing.
         6. Lab data:
            1. Decreased: albumin, potassium, magnesium, blood urea nitrogen (BUN).
            2. Elevated: prothrombin time, globulins, ammonia, AST (SGOT), Bromsulphalein (BSP), alkaline phosphate, uric acid, blood sugar.
         7. Diagnostic tests
            1. Celiac angiography, hepatoportography
            2. Liver biopsy
            3. Paracentesis
   4. Analysis/nursing diagnosis:
      1. Altered nutrition, less than body requirements, related to decreased intake, nausea, and vomiting.
      2. Risk for injury related to decreased prothrombin production.
      3. Activity intolerance related to fatigue.
      4. Fatigue related to anorexia and nutritional deficiencies.
      5. Self-esteem disturbance related to physical body changes.
      6. Risk for impaired skin integrity related to pruritus.
   5. Nursing care plan/implementation:
      1. Goal: provide for special safety needs.
         1. Monitor vitals (including neurological) frequently for hemorrhage from esophageal varices (may have Sengstaken-Blakemore or Linton tube inserted).
         2. Prepare patient for LeVeen shunt surgery for portal hypertension as needed.
         3. Assist with paracentesis performed for ascites; monitor vitals to prevent shock during procedure.
      2. Goal: relieve discomfort caused by complications.
         1. Position: semi-Fowler's or Fowler’s to decrease pressure on diaphragm due to ascites.
         2. Deep breathing q2h to prevent respiratory complications.
         3. Skin care, topical medications to relieve pruritus; nail care to decrease possibility of further skin injury.
         4. Frequent oral hygiene related to nausea, vomiting, and fetid breath.
      3. Goal: improve fluid and electrolyte balance.
         1. IV fluids and vitamins.
         2. I&O, hourly urines during acute attacks.
         3. Daily: girths, weights to monitor fluid balance.
         4. Diuretics as ordered to decrease edema.
         5. May receive serum albumin to promote adequate vascular volume, prevent azotemia and encephalopathy, and promote diuresis (observe carefiilly, because albumin could escape quickly through cell walls and cause increase in ascites).
      4. Goal: promote optimum nutrition within dietary restrictions.
         1. NPO during acute episodes.
         2. Small, frequent meals when able to eat.
         3. Low protein (to decrease the amount of nitrogenous materials in the intestines) and sodium (to decrease fluid retention).
         4. Moderate carbohydrate (to meet energy demands) and fat (to make diet more palatable to anorexic patients).
      5. Goal: provide emotional support.
         1. Quiet environment during acute episodes to decrease external stimuli.
         2. Identify community agencies for assistance far patient, Alcoholics Anonymous; for family, Al-Anon/Alateen.
      6. Goal: health teaching.
         1. Avoid alcohol, exposure to infections.
         2. Dietary allowances, restrictions.
         3. Drugs: names, purposes.
         4. Signs, symptoms of disease; complications.
         5. Stress-management techniques.
   6. Evaluation/outcome criteria:
      1. No complications.
      2. Nutritional status improves; lists dietary restrictions.
      3. No alcohol consumption.
      4. Lists signs and symptoms of progression of disease and complications.
      5. Complies with discharge plan, becomes involved with an alcohol treatment program.