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The following questions relates to the patient within the first 24 hours:

  1. Outline the causes, incidence and risk factors of the identified condition and how it can impact on the patient and family
  2. List five (5) common signs and symptoms of the identified condition; for each provide a link to the underlying pathophysiology
  3. This can be done in the form of a table – each point needs to be appropriately referenced
  4. Describe two (2) common classes of drugs used for patients with the identified condition including physiological effect of each class on the body
  5. This does not mean specific drugs but rather the class that these drugs belong to.
  6. Identify and explain, in order of priority the nursing care strategies you, as the registered nurse, should use within the first 24 hours post admission for this patient.
Causes of Liver Cirrhosis

The liver Cirrhosis is the late stage of liver fibrosis that caused by a variety of the conditions and disease of the liver such as chronic alcoholism and hepatitis (Germani, Burroughs & Dhillon, 2010). The liver does many essential functions such as detoxification of the harmful substances, cleansing of blood and synthesis of vital nutrients. Liver cirrhosis arises due to the liver damage. Every time, when liver gets injured, it attempts to repair or regenerate itself (Germani, Burroughs & Dhillon, 2010). During this process, there is the formation of scar tissue. As the cirrhosis proceeds, there is the formation of progressively scar tissue, so, it becomes difficult to function properly by the liver.

There are wide varieties of the conditions and diseases that cause the liver damage and leads to the liver cirrhosis. Common causes of the liver cirrhosis are:

Hepatitis B and C that are chronic hepatitis caused by the virus

Alcohol abuse (Chronic)

Fat accumulation in the liver that is a nonalcoholic disease of the fatty liver

Other causes that can also cause cirrhosis are:

Hemochromatosis building up of iron in the liver (Jiménez-Romero, 2015)

Wilson’s disease that is an accumulation of the copper in the liver

 Inherited disorders that disturb the sugar metabolism

Inherited digestive disorders

 Autoimmune hepatitis immune system induced liver disease

Primary bile ducts cirrhosis

 Medication induced such as due to methotrexate (Jiménez-Romero, 2015)

Researches revealed that the hepatocellular carcinoma related to the cirrhosis is increasing in few developed countries; on the other side, the mortality rate from the non-hepatocellular carcinoma is decreased or stable (Kutsenko, Le, Trinh, Dang & Nguyen, 2017). The studies on the liver cirrhosis cleared that the cause of the death related to the liver is with the compensated liver cirrhosis. During studies, it has been examined that NAFLD- associated cirrhosis and alcoholic cirrhosis is increasing day by day. When the assessment of the etiology is done, over 25 years, the significant changes were observed and HBV associated cases are comparatively constant (X, 2017).

Use of alcohol heavily

Injection of drugs by using infected needles

Body piercings or tattoos

Before 1992, blood transfusion

Exposure to the blood and the body’s fluid of the other people

Unprotected sex

Exposure to toxins or certain chemicals

In the case of Mr. James, the liver cirrhosis is associated with the hepatitis C induced and their smoking and drinking habit is increasing the chances of the hepatocellular carcinoma and Mr. James has also been noted as the recreational use of the drugs. From the incidences study, it has been revealed that if James does not get better treatment, diet, and precaution, there are chances of the hepatic carcinoma that can lead to death.

Symptoms of Liver Cirrhosis

Individuals with the liver cirrhosis will be spotted with progressive signs and symptoms as it failed to work. Some of the symptoms are directly associated with the liver inability to waste products metabolism. Other symptoms have related the failure of the liver to synthesize proteins that are required for the functioning of the body and also due to the effect on the functioning of the blood clotting, brain function and sex characteristics that are secondary (Niederau, Lange, Frühauf & Thiel, 2008). Thus, the signs and symptoms of liver cirrhosis include:

The occurrence of bruising because of a decrease in the production of the blood clotting factors

Deposition of the bile salts in the skin caused the itching (Solà & Ginès, 2015)

 In men, enlargement of the breasts may occur due to an imbalance in the sex hormones especially related to increasing in the estradiol (gynecomestia) (Solà & Ginès, 2015)

Lethargy and confusion occur due to rise in the ammonia level as ammonia is the end product of the metabolism of the protein that needs normal liver functioning for the removal of the ammonia, Ascites is another condition that is related to decreased protein production due to the improper liver functioning (Solà & Ginès, 2015)

Impotence occurs due to the decreased functioning of the sex hormones that relate to lesser sex drive and shrinkage of the testicles.

Source ((Møller & Bendtsen, 2018)

Common symptoms of the liver cirrhosis

Symptom

Common cause

Abdominal distension

Ascites

Confusion, lethargy

Hepatic encephalopathy

Fatigue, pallor

Anaemia because of hypersplenism, bleeding, the effect of alcohol

Dyspnea, hypoxia

Due to Porto-pulmonary hypertension, Hepato-pulmonary syndrome

Fluid overload, oliguria, symptoms of renal failure

Hepato-renal failure

Fragility fracture

Osteoporosis

Symptoms of infection

leukopenia

Rectal bleeding

Rectal varices

Splenomegaly

Portal hypotension

Upper gastro-intestinal bleeding

Portal hypertension gastropathy,

Esophageal varices

Clubbing

Hepato-pulmonary syndrome

By discussing the signs and symptoms of the liver cirrhosis and the case study of James, it is cleared that James has the impression of the liver cirrhosis as the symptom of lethargy, confusion, gastrointestinal bleeding, fatigue, weight reduction, bruises on arm and legs, abdominal distension and edema all are observed (Møller & Bendtsen, 2018). So, Mr. James requires the treatment and primary care accordingly.

For the better treatment of the liver cirrhosis, the underlying cause of the disease should be cleared that either it is alcohol induced or hepatitis induced. The treatment also depends upon the condition of the disease that either it is acute or chronic liver damage (Parés, 2014). As in the second question, we have discussed the common symptoms of the liver cirrhosis and also from the case study of Mr. James, it has been stated that hepatitis B and C and lethargy and confusion symptoms.

For the treatment of the hepatitis B and C, antiviral drugs are used that helps in reducing the viral infection. There is a number of the drugs those can be administered orally for the treatment of hepatitis B and C. This treatment requires 12 to 48 weeks (Parés, 2014). If there is the early treatment of the hepatitis B and C, the disease can be stopped to being chronic and liver cirrhosis can be prevented. But in the case of Mr. James, the liver cirrhosis occurs so, the doctor has to recommend these drugs for the treatment of the hepatitis B and C that supports or delays the further liver damage (Parés, 2014).

Treatment of Liver Cirrhosis

The second class of the drugs that are used for the liver cirrhosis are the diuretics and low protein diet that is used to remove the excess salt and water concentration from the blood as it leads to oedema and portal hypertension (Roche & Samuel, 2013). Oedema causes the abdominal distension and tenderness. In the liver cirrhosis the patient is unable to metabolize the protein and due to this, there is increasing the concentration of ammonia in blood that causes the lethargy and confusion (Roche & Samuel, 2013). Hence, the patient is recommended for low protein diet and diuretics for the management of oedema, lethargy, confusion and portal hypertension (Yildirim, 2017).

In the case of Mr. James as their liver cirrhosis is due to the Hepatitis B, smoking and alcohol. For delaying or stopping the liver damage further, Mr. James has to stop drinking alcohol and smoking and should be treated with the antiviral drugs and diuretics as they have also a complaint of the lethargy, confusion, and oedema (Yildirim, 2017).

As in the case of Mr. James, he is 48 years old that was admitted to the hospital with the examination of jaundice and ascites. Mr. James is less irritable, a lethargic patient with an orientation to time, person, and place. He is moderately using their accessory muscles with slight tacypnoeic. James’s wife reported that he is spitting sputum with blood staining from the last few weeks with no shortness of breathing and no related coughing (Fenimore & Manno, 2008). James has lost about 9kg that related to lesser appetite. On diagnoses, the sclera is mildly jaundiced but no changes are diagnosed in his urine output. James has some bruises that are unexplained on legs and arms. His abdomen is distended and tight and there is pitting oedema on his ankles. Mr. James is suffering from Hepatitis C from the last ten years.  Mr. James is smoker currently and drinks 2 glasses of beer daily. In the past 15 years ago, James has a history of the recreational use of the drug (Fenimore & Manno, 2008).

From the above study and the study of causes, incidences, risk factors, signs, and symptoms, it was sure that James is patient of the liver cirrhosis that is hepatitis C induced and he has signs and symptoms of the liver cirrhosis.

According to the care strategy, the nurse has to know the condition of the patient, then past history, social history, issues and problems related to the condition. After that, the nurse makes a plan for the care priority, implement and then note the outcomes of the care strategy (Fenimore & Manno, 2008). In the above case, the condition of the patient is chronic as he is suffering from the liver cirrhosis that is hepatitis induced.

Care Approach for Liver Cirrhosis

On the priority bases, the nurse has to maintain the abdominal distention and to stop continuous bleeding that could be critical condition. For the treatment of ascites, the treatment should be given by the diuretics that help in the management of fluid balance and ammonia level that also help in the management of the lethargic condition (Yadav & Vargas, 2015). Diuretics also help in the management of the ankles oedema. For the treatment of the gastrointestinal bleeding, the drugs used are the vasodilator that reduces the pressure on the veins and helps in prevention of the gastro-intestinal bleeding (Yadav & Vargas, 2015). The nurse also gives the treatment or care that helps in reducing their smoking habit and consumption of alcohol.

 The nurse has to specially concentrate on the diet of the patient, as a patient in the liver cirrhosis condition should take low protein and sodium diet balanced diet that helps in maintenance of ammonia level in blood. The diet is the best remedy for the prevention of further liver damage. So, the priority care of the nurse is to manage the viral infection, fluid balance, ammonia balance and reduction in smoking and alcohol consumption through the medication and diet (Yadav & Vargas, 2015). After managing all these, the nurse should try to find out the outcomes, that which strategies are succeeding and which are not performed well and then again try to modify them for the patient improvement.

References

Fenimore, G., & Manno, M. (2008). Control cirrhosis complications. Nursing Critical Care, 3(1), 44-47.

Germani, G., Burroughs, A., & Dhillon, A. (2010). The relationship between liver disease stage and liver fibrosis: a tangled web. Histopathology, 57(6), 773-784.

Jiménez-Romero, C. (2015). Incidence, risk factors and outcome ofde novotumors in liver transplant recipients focusing on alcoholic cirrhosis. World Journal Of Hepatology, 7(7), 942.

Kutsenko, A., Le, A., Trinh, S., Dang, H., & Nguyen, M. (2017). Metabolic risk factors increase the risk of hepatocellular carcinoma in patients with hepatitis C cirrhosis. Journal Of Hepatology, 66(1), S125-S126.

Møller, S., & Bendtsen, F. (2018). The pathophysiology of arterial vasodilatation and hyperdynamic circulation in cirrhosis. Liver International.

Niederau, C., Lange, S., Frühauf, M., & Thiel, A. (2008). Cutaneous signs of liver disease: value for prognosis of severe fibrosis and cirrhosis. Liver International, 28(5), 659-666.

Parés, A. (2014). Treatment of primary biliary cirrhosis: Is there more to offer than ursodeoxycholic acid?. Clinical Liver Disease, 3(2), 29-33.

Roche, B., & Samuel, D. (2013). Treatment of Patients with HBV-related Decompensated Cirrhosis and Liver Transplanted Patients. Clinics In Liver Disease, 17(3), 451-473.

Solà, E., & Ginès, P. (2015). Challenges and Management of Liver Cirrhosis: Pathophysiology of Renal Dysfunction in Cirrhosis. Digestive Diseases, 33(4), 534-538.

X, L. (2017). Analysis of Risk Factors for Development of Hepatocellular Carcinoma in Chronic HBV - Infected Liver Cirrhosis Patients: A Meta-Analysis. International Journal Of Immunotherapy And Cancer Research, 034-040.

Yadav, A., & Vargas, H. (2015). Care of the patient with cirrhosis. Clinical Liver Disease, 5(4), 100-104.

Yildirim, M. (2017). Falls in Patients With Liver Cirrhosis. Gastroenterology Nursing, 40(4), 306-310.

Link underlying the pathophysiology

https://www.medicinenet.com/cirrhosis/article.htm#why_does_cirrhosis_cause_problems

https://www.mayoclinic.org/diseases-conditions/cirrhosis/symptoms-causes/syc-20351487

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