Essay on Altered Nutrition: Case Study

Cirrhosis is one of the leading causes of death in the United States, with the majority of cases being caused by excessive alcohol consumption. In Cirrhosis the liver undergoes structural changes and eventually fails to function due to the scarring. Because of these structural changes, pathophysiological changes begin to happen, with portal hypertension being the key change associated with Cirrhosis. Other changes associated with Cirrhosis include esophageal varices, Asterixis, steatorrhea, decreased absorption of fat-soluble vitamins, medication toxicity, bleeding and bruising, jaundice, and hepatic encephalopathy.

Cirrhosis of the liver is a chronic disease that causes cell destruction and fibrosis or scarring of hepatic tissue. Medical management for Cirrhosis is based on the presenting symptoms. The provider may order antacids to decrease the irritation of esophageal varices. Vitamins and nutritional supplements are sometimes given because of the nausea and vomiting, and because of the decrease in vitamins. Because of the ascites diuretics may be administered to decrease the fluid in the abdomen. You also need to teach the patient to avoid hepatotoxic medications such as Acetaminophen because the liver is not metabolizing like it is supposed to because of the scarring. A low sodium diet is usually enforced to help decrease fluid retention with ascites and a low protein diet to decrease the ammonia levels does decrease the risk of hepatic encephalopathy. Some nursing management for Cirrhosis is weighing the patient and the same time daily as similar as possible, monitoring intake and output, measuring abdominal girth at the same location, and sodium and fluid restriction to assess if the ascites are getting any better or getting worse. Monitor electrolytes because some may be lost with diuretics or with vomiting. Liver function tests such as ALT/AST, ammonia, and bilirubin should be obtained to assess liver damage. Examine for JVD and administer diuretics to help with fluid excess. Because of the risk of bleeding associated with decreased clotting factors you should monitor for signs of bleeding such as blood in urine, melena, and hematemesis. You should use the smallest needles possible and use soft toothbrushes. Protect the patient from falls and abrasions and after giving an injection apply direct pressure. Also, you might have to administer stool softeners, so they won’t have to strain with bowel movements. Because of the altered nutrition, you should prescribe a high-carb, high-protein diet as allowed. Educate the patient to avoid alcohol and watch for signs of withdrawal such as seizures, confusion, tremors, agitation, violence, and mood changes. Provide small frequent meals and elevate the HOB during meals. AST/ALT labs will be elevated because of the liver damage. Bilirubin will be elevated because the liver can’t conjugate it, this causes jaundice. Your albumin will be decreased because the liver can not synthesize this protein anymore. Ammonia will be elevated because the liver can not break down the proteins anymore. Prothrombin time will be prolonged because the liver cannot make clotting factors anymore.

Patients with Cirrhosis are prone to gastrointestinal bleeding because of the portal hypertension. Portal hypertension is caused by the portal venous system being blocked because of the scarring of the tissue causing blood to back up causing an increase in pressure and leading to enlargement of the veins making them susceptible to rupturing causing bleeding. Another complication is ascites which is the accumulation of protein-rich fluid in the abdomen that can cause abdominal pain and girth and can also cause shortness of breath due to the pressure on the diaphragm, it also can cause an increased risk for infection and some can develop pleural effusions. Hepatic encephalopathy is caused by high ammonia levels in the body because the liver is no longer able to breakdown the proteins into urea and excrete it out of the body, this can be recognized by neuro changes such as restlessness, confusion, seizures, and coma, this can be prevented by a low protein diet, management of encephalopathy is administration of lactulose to remove ammonia from the blood and neomycin which is a nonabsorbent antibiotic, asses neuro status and vital signs frequently, reduce ammonia by NG suctioning, and get daily ammonia levels. Coagulopathy can happen because the liver can no longer synthesize clotting factors and this causes prolonged PT and bleeding. Jaundice develops because the bilirubin can not be conjugated by the liver, so it remains in the body causing yellowing of the skin and sclera. Hepatorenal syndrome is a rapid deterioration of the kidney function because of altered blood flow to the kidneys, this causes elevated BUN and creatinine and sometimes oliguria, which has a high mortality rate. Spontaneous Bacterial Peritonitis is the development of peritonitis in the abdomen, this causes fever, abdominal pain, encephalopathy, and acute hemodynamic decompensation.

Enteral nutrition is given through a transnasal tube, gastroenteric tube, or PEG tube to give nutrition to patients who are unable to eat by mouth but have at least a partially functional GI tract. Can be given intermittently or continuously. You should check the placement of the tube by pulling back residual volume and this also checks for how you are tolerating the feedings, X-rays, or lung sounds. You should have the bed at least 30 degrees with feeding to prevent aspiration. You should not administer medications while the feed is running and never push the feed in a tube, use gravity. Some complications are tolerance, aspiration, D/N/V, tube displacement or obstruction, hyperglycemia, dehydration, and azotemia. Parental nutrition is given through am port-a-Cath or a PICC line only when enteral is inadequate or contraindicated. Should be given if oral intake has been inadequate for 7-10 days. Only give to those patients who have a nonfunctional GI tract. The line is infused with heparin to reduce fibrin buildup. Can cause infections and swelling of the veins and hyperglycemia. Medications should not be given down the same tube.

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An endoscopy procedure looks at the upper GI tract and allows the doctor to visualize and biopsy. The patient should be NPO for 8 hours, Informed consent should be signed before sedation, and the patient will be placed in a left lateral position, sedation is required by midazolam, atropine, glucagon, anesthetic gargle, or spray, procedure: Monitor LOC, vital signs every 15 min for the first hour, O2 saturation, and pain. Monitor for signs of perforation such as pain, bleeding, fever, and difficulty swallowing. Evaluate gag reflexes to make sure they can have anything by mouth. The patient should be on bed rest until fully alert because of the risk of falls. Make sure they have transportation before the procedure begins because they will not be able to drive after.

Fecal diversion is indicated if the bowels need to rest or if the bowels cannot work properly. Preoperative care includes consulting with an enterostomal therapist, obtaining consent, administering bowel prep to ensure bowels are cleared, IV antibiotics before surgery, Possible NG tube placement, and instructing on cough and deep breath after surgery. Postoperative care includes stoma and wound care, Monitoring fecal drainage, early ambulation, pain medications, monitoring intake, and output, monitoring electrolytes, IV therapy, NGT placement, Skincare, and low residue diet.

Colostomy care includes ash warm water, dried thoroughly, Proper pouch fits snugly, Skin barrier, Change pouch q 5-10 days or PRN (leakage). Colostomy irrigation includes: Force should not be used with colostomy care, Position on the toilet,500 to 1000 ml warm water, 18 to 20 inches above stoma (shoulder height), Lubricate and dilate stoma, Irrigation sleeve, Instill over 5 to 10 min.

Nursing Diagnosis for Cirrhosis include Fluid Volume excess related to water and sodium retention secondary to decreased plasma protein, Fluid volume deficit related to third spacing of peritoneal fluid (ascites), coagulation abnormalities, variceal bleeding, and Risk for injury related to coagulopathy.

References:

1. Capriotti, & Frizzell. (2016). Pathophysiology Introductory Concepts and Clinical Perspectives. Philadelphia: F. A. Davis.
2. Hoffman, & Sullivan. (2017). Medical surgical nursing making connections to practice. Philadelphia: F. A. Davis.