An Integrative Review of the Literature and Evidence

This document is an integrative review of the literature and evidence on nursing care management for alcohol-related liver diseases cirrhosis in the UK. It discusses the background and rationale, research aim and objectives, search strategy process, and evaluation and integration of evidence. The document aims to enhance knowledge and understanding of learners and provide insights into advanced alcohol-related liver diseases and nursing care management.

An Integrative Review
of the Literature and
Evidence

Contents
Assignment Summary and Overview of the study..........................................................................3
1. Introduction, Background and Rational.......................................................................................3
Research Aim:.......................................................................................................................5
Research Objectives:............................................................................................................5
2. Search Strategy Process...............................................................................................................6
3. Evaluation as well as Integration of the Evidence.......................................................................6
3.1 Evaluating how nurses can empower and support patients with alcohol related liver
diseases cirrhosis in the UK to understand their condition through patient education and health
promotion...............................................................................................................................6
3.2 Evaluating the stages of cirrhosis of the liver and related nursing care for end-stage liver
disease.....................................................................................................................................8
3.3 Evaluation of the role of alcohol specialist nurse and liver nurse in adult nursing........10
3.4 Integration of key findings of studies and multi professional clinical implications.......12
4. Conclusion.................................................................................................................................13
References......................................................................................................................................14

Assignment Summary and Overview of the study
Cirrhosis disease is the late phase of scarring (fibrosis) of the liver which is caused by
various types of liver issues, diseases as well as situation which are hepatitis & chronic
alcoholism (Good and Lazar, 2016). It is said that each and every time a person’s liver get
injured whether it is by any kind of disease, due to excessive alcohol consumption and by any
other cause, it will try to repair by itself. For such procedure there are the formation of scar
tissues. This is the sort of diseases which is considered as one of the most harmful and dangerous
disease which can create death of patient if not taking precautions properly. As the cirrhosis
progresses, it is said that more & more such tissue develops which as a result makes it quite
difficult for liver to perform its function in an effective way (Gardiner, Geldenhuys and Gott,
2018). It has also been identified that the advanced cirrhosis treatment is quite difficult and life
threatening which requires lot of advanced nursing management. It has been said that integrative
literature review help in order to gain an understanding related to the nursing care management.
Further more, it will also help in evaluating advanced alcohol related liver diseases within UK
and how it can be implemented on the patient. Along with this, will provide an evaluation of
benefits gain by patients with the help of advanced medical treatment given to those who have
liver disease due to consumption of Alcohol. In addition to this, analysis of the methodological
strengths as well as weaknesses of each and every study are going to be discussed with the
comparison & contrast the overall outcome along with the analysis of reliability and validity of
advanced care management and its on impact on the nursing practice.
Key words: Alcohol Related Liver Disease, Liver Disease, Cirrhosis, Specialist Nurse
Education, UK, Nursing Management, Liver Nurse, Alcohol Nurse, Support, end stage liver
disease.
1. Introduction, Background and Rational
Cirrhosis refers to a chronic degenerative disease which is usually distinguished by the
changes or replacement of operational liver tissues by fibrosis. It is said that Cirrhosis is one of
the major public health concern and is considered as second major reason of death among
gastrointestinal diseases (Delgado& Foster, 2017). Liver diseases is one of the most harmful

disease which highly influence the overall health of a person as compare to any other type of
organ failure. In addition to this, it has also been identified that with the increment of liver
related diseases patients experience negative issues such as jaundice, gastric, nutritional
deficiency and many more. Furthermore, patient who have end stage liver cirrhosis issues face
lack of protein and calories which affect their overall body functions in an adverse manner.
There are different sort of standardized nursing terminology within medical professionals and
practices which as a result contributes to take effective decisions in an effective manner which as
a result produce positive outcome (Ryan, 2016). Furthermore, it is said that accurate and
required nursing diagnosis help in guiding the selection of proper and advance treatment to
patient as per their condition of liver arise due to consumption of alcohol. NHS which is one of
the biggest healthcare organizations are the base organization in this research as it includes
patients suffering from various diseases. Also the treatment provided by NHS healthcare
professionals are quite different and advanced which as a result increase the overall potential of
the patients within limited time frame. NHS uses high range of services or medical tools which
help them to treat liver related diseases in an effective manner which is usually arise due to more
consumption of alcohol. In the current research, an evaluation of nursing care management in
advanced alcohol related liver diseases are going to be done (Jun, Kovner and Stimpfel, 2016).
This research help in enhancing the knowledge and understanding of learners. Also various
journals and articles are going to be examined in this research which help in drawing valid
conclusion. Also the articles and journals chosen in this research for evaluation are taken from
last 20 years which assist in gathering sufficient amount of information and knowledge related to
the topic.
A liver related diseases named as Cirrhosis is one of the most dangerous diseases apart
from any other organ related diseases. Cirrhosis is a disease which is also known as liver
cirrhosis aswell as hepatic cirrhosis, whichis a condition where the liver is unable to perform all
the function properly becauseof the long-term damage (Palmer and Alfano, 2017). This is a
damage which is usually identified by the changes of normal tissues within liver by the scar
tissue. Usually, this is the type of disease which is commonly develops slowly and took over a
months aswell as years to form. Whenthe disease worsens, individual may feel tired, weakness,
itchy, might have swelling in their lower legs, which are the common symptoms of liver diseases
which affect the full body of a person. It is said that consuming or usage of problematic drugs

and alcohol is highly damaging the lives of people as it leads towards liver related diseases
(Kranzbühler and Teerling, 2018). NHS is the organization which provides services and
treatment to the people who are suffering from liver disease cirrhosis within UK. There are some
sources according to which prognosis of patients who have advanced cirrhosis is quite poor as
only less than 10% of the individual person who are having such diseases lives more than five
years. In addition to this, it has also been identified that each year there are approximately 3.3
million death occurs due to harmful consumption of alcohol and is moved from eight to fifth
most harmful disease which causes death as well as illness under the age of 50. This is one of the
harmful diseases which leads towards the death of patient if proper medical treatment and
nursing care is not provided to them (Weaver and Hinds, 2016).
The need or purpose behind conducting the research on such topic is to increase the
awareness about liver related diseases cirrhosis among the people. Along with this, the
investigation help in analyzing various issues which cause such diseases apart from consumption
of alcohol. Also this help in identifying the factors as well as different nursing care management
which is provided by medical professionals to the patients suffering from cirrhosis within UK.
The investigation is mainly done by researchers for two main purpose one is to gain knowledge
and understanding related to the topic so that they will be able to get opportunity in near future
(Schulenkorf, Sherry and Rowe, 2016). On the other hand, another purpose is the personal
interest of investigator as well as it is one of the emerging topic currently which as a result assist
in improving personal knowledge and skills related to the selected topic. Therefore there are two
main purpose of conducting this research.
Research Aim:
Aim of the present research is “An integrative review of the literature and evidence exploring
nursing care management advanced alcohol related liver diseases cirrhosis patients in the UK.”
Research Objectives:
Objective 1: Investigate how nurses can empower and support patients with alcohol related
liver diseases cirrhosis in the UK to understand their condition through patient education and
health promotion.
Objective 2: Identify the stage of Cirrhosis of the liver and the related nursing care for end
stage liver disease.
Objective 3: Explore Alcohol Specialist nurses and liver nurse role in adult nursing.

2. Search Strategy Process
The search strategy process includes the databases PubMed, Research gate.
PubMed is adopted in order to examine various topics and issues and the main reason
behind choosing this is that it contain huge number of journal literature which assist in collecting
or gathering data and information related to the selected topic. In addition to this, the search
terms which is used is in the combination as well as is guided by Boolean Operators which
consist of the words,‘cirrhosis and/or advance nursing care’; ‘‘Advanced and effective nursing
care of cirrhosis; Cirrhosis and/or last stage of liver diseases. In addition to this, it is said that
search inclusion/exclusion criteria for the present research is from 2000-2020 which means from
last 20 years old articles and journals can be used. Apart from this, the main focus is the
population of UK as the topic is based on UK patients and their issues. Furthermore it has also
been identified that with the help of these sources sufficient information will be gathered by
reviewing various journals published from last 20 years (Hoppmann and Massoud, 2020). If
talking about quantitative and qualitative approach, for concluding the present research in an
appropriate manner, both qualitative as well as quantitative approach is used which is known as
mixed method approach. Also it has been said that most evidence reviewed are mainly in the
form of quantitative along with qualitative primary research in this field. All these methods or
key areas help in reviewing the journals which are mainly 5 in number which leads towards the
attainment of success in order to conclude the whole research in an effective manner (Shoss,
2017).
3. Evaluation as well as Integration of the Evidence
This is the section where mainly three primary themes are developed with the help of which
in depth analysis and knowledge can be earned with the help of journals and articles. All these
three objectives are going to be discussed in detail manner where main sources are journals
related to the topic and help in gathering information and data and conclude it in a fruitful way
(Pauli, Starkweather & Robins, 2019).
3.1 Evaluating how nurses can empower and support patients with alcohol related liver diseases
cirrhosis in the UK to understand their condition through patient education and health
promotion
Theresa Hydes and et. al., (2019)

According to Rev Lat Am Enfermagem. (2017), alcohol is one of the commodities apart
from tobacco and high salt food products which increase the disease such as liver problem
cirrhosis. There are people around UK who have less knowledge and understanding about liver
disease which commonly develops due to consumption of alcohol. There must be proper
treatment and care given to the patient who are suffering from liver disease by medical
professionals and healthcare nurses. It has also been identified that there are huge cases come at
the healthcare institution who have disease related to livers which are mainly arise due to
consumption of alcohol (Boling & Hardin-Pierce,2016). Global Burden of Disease project it has
been estimated that over 1.25 million deaths arise in the year 2016 because of liver related
diseases(Theresa Hydes and et. al., 2019). Main reason behind this is people are not aware about
such diseases and because of lack knowledge and understanding they are unable to get proper
treatment at time. In such issues it has been identified that nurses plays very essential role as they
are the one who perform comprehensive as well as continuous care and treatment to the patients.
According to Clayton, (2016), for meeting the comprehensive and the complex needs of patients
it is very essential for the nurses to have proper knowledge about the problems faced by patients
and the treatment given them to the patient. In addition to this, it has also been said that patients
who have liver cirrhosis issues need to be taken extra care by the nurses who consist of some
complications, proper guidance and knowledge about the medication (Kumar and et. al., 2017).
It has been identified that liver disease is one of the biggest killer diseasein the UK.
These data affect large number of healthcare professionals as this is becoming one of the most
common diseases across UK where lifestyle is one of the most common factor which raises such
problems and issues. Lifestyle-related element have contributed to increase in prevalence of the
liver disease. In addition to this, it has also been identified that promoting such liver diseaseneed
to be one of the integral element of the role for a healthcare as well as medical professionals.
Along with this, it is said that nurses are specifically well placed inorder to make each and every
contact with the patients effective, and have positive relationship with the patients so they will be
able to share their issues with them and give them treatment accordingly (Foronda, MacWilliams
and McArthur, 2016). It is said that there is a huge potential within the nursing staffin order to
empower as well as encourage patient them by providing data and information, the treatment
given to them alongwith the support to assistindividuals so that they can live their life healthier.

With reference to liver health, nurses are the one who could be themost powerful force in order
to identifying therisk arise due to liver disease (Dixon and Christoff, 2017).
In addition to this, it has been identified by examining various journal and articles that
good practice consistof encouraging aswell as educating individuals on healthy eating, increasing
exercise, and weight managementor reduce obesity which is associatedwith liver disease.
Therefore, it is required by the higher authorities of the medical organization that the nurses
provide complete guidance and information to the patient and their family members so they can
consider each and every point at the time to taking treatment (Le Pelley and Wills, 2016). Along
with this, nurses are the one who empower and support patients in order to fight with the disease
related to liver which usually arise of consuming problematic alcohol. This help in educating
people towards such disease which can help them to take every precaution in an effective and
appropriate manner.
3.2 Evaluating the stages of cirrhosis of the liver and related nursing care for end-stage liver
disease
Frontline Gastroenterol. (2016)
According to J Am Coll Surg, (2017), investigation was performed to gather the
knowledge about practice patterns that are basically followed by healthcare professionals of
United Kingdom in order to deliver palliative care in cirrhosis. This has resulted into
approximately 6181 potential contacts that was specifically being identified where approximately
517 healthcare professionals responded towards the investigation which was conducted. the
answers which were given by most of the HCPs was that rule exist for SPC in caring for people
with cirrhosis. Although many of SPC HCPs, stated that they specifically feel ill at the time of
delivering good care to patients of cirrhosis who are already leading towards death.In present
context, it can be said that training is something that is required to manage symptom control,
liver related symptoms, end of life issues and so on. With the help of this, all HCP groups would
effectively start increasing community provisions of palliative care support. Including this, if it is
critically analysed then many of the general practitioners had unablefeeling for themselves
towards managing advanced cirrhosis in the community (Crookes, Else and Lewis, 2020). Away
with this, some of the differences that also came in front towards optimal trigger for SPC referral
with liver HCPs less likely to refer at symptom deterioration.It is also critically analyse that it is
not only important for HCPs to effectively take into consideration of training but it will be also

required for them to enable themselves towards working with SPC, liver teams and general
practitioners which will help them in improvising their own confidence level and deliver low
response rates towards making the general findings for further validation (Frontline
Gastroenterol, 2016). It has also been critically analysed that liver disease is considered to be the
largest cause of premature death within United Kingdom and it consists of approximately 2% of
the death rate within England. The reason that came in front was the increase in consumption of
alcohol which results into to rise in obesity cases and viral hepatitis (Shields and Yonelinas,
2017). This is something which can be taken as a concerned that has not only reached the public
health problems but it has also impacted negatively on overall health standards of citizens that
belongs to United Kingdom. On the other side, based on the investigations it can be said that
individuals dealing with cirrhosis and are at end stage of the liver disease requires proper
supportive and palliative care from the HCPs. Based on the lancet commission report which
show that liver care is something which is important within primary care and Hospital services
where high quality care is necessary for the individuals dealing with cirrhosis (Koch and Kiesel,
2018).
Away with this, in the year of 2013 there was an investigation performed by liver team of
royal free Hospital London and Marie Curie palliative care Research development, where
recommendation was presented that it is required to conduct National survey of tertiary care
secondary and primary which will help in analysing the current situations and attitude towards
different range of practices that has already been performed by HCPs. In present context there is
a need of training is something that is identified (OBE and et. al., 2016).
According to Mazzarelli, (2018), Patient withcriticalcirrhosis needs liver transplant, but
this is considered to be something that me increase the risk of perioperative mortality. There are
a range of models which has been presented within healthcare industry like model for end stage
liver disease (MELD) score has given the information that serum sodium, estimation of Survival
probability in patients dealing with cirrhosis. Away with this, it is also needed to consider
additional evaluation as well at the time of an individual dealing with critical illness.The result
has showed that approximately 276 patients that met with inclusion criteria within the
investigation approximately 153 for the individuals who survived and approximately 123 were
the individuals who did not survived. In present context, if it is analysed then both non survivors
and survivors are said to be cohorts and had similar type of characteristics in relation to

demographics (Tait and et. al., 2017). Apart from this, non survivors had increased infection,
gastrointestinal bleeding coma mechanical ventilation, dialysis, renal replacement therapy,
vasopressors and MELD. The score that has been identified considering the low predictive power
was (c-statistic 0.73), which was considered to be the independent directors of mortality. On the
other hand multivariate analysis has showed the results of MELD (adjusted odds ratio = 1.05),
mechanical ventilation (4.55), vasopressors (3.87) and including continuous renal replacement
therapy where score was (2.43). these are said to be some of the calculations that showed the
independent predictors of mortality and it is also considered to be the strongest predictive
accuracy (Zacune and Hensman, 2017).
Key findings has clearly showed that MELD score has demonstrated poor predictive
accuracy in relation to critically ill patients with cirrhosis and cannot be considered as a best
predictor or indicator for prognosis for the individuals that are at higher risk of death (Cirrhosis
patients). On the other hand, prognostic accuracy is also low at the time of indicating different
variable based organ support (Chiu and et. al., 2018). However, National health service has
already developed a range of plans to address high mortality rate due to liver disease. Economic
cost and benefits is something that is required by NHS to effectively improve the understanding
of the disease and it needs of the patients dealing with process including their families as well
(Sira and et. al., 2019). This effectively improve the efficiency level of liver team across care
boundaries and also improve communication with those at risk of death. It is also much needed
to deliver training sessions to all the professionals in relation with treatments and care because
then only the mortality rate easily be reduced to minimal.If it is critically analysed then SPC
professionals (60%; 147/246) including general practitioners (54%; 22/41) are said to be the
individuals who are already confident with their skills and managing individuals who are dealing
with cirrhosis. The particular need that came in front of training is issues specific to liver disease
where it was identified that training in EoL issues is something that are required to be addressed
(Hudson and et. al., 2017).
3.3 Evaluation of the role of alcohol specialist nurse and liver nurse in adult nursing
Tammy, (2018)
According to Tammy, (2018), there are ample number of investigations performed on liver
disease, where most of them has considered the information that palliative care is something
which is essential for heavy drinkers. It has been analysed that liver disease (cirrhosis) needs

proper palliative care and this is where alcohol specialist nurse and liver nurse are said to be the
two main nurses who plays an important role. As mentioned in the investigation performed by
Dolores, 2019), where feasibility trial has showed that complex intervention which has been
delivered by different nurse specialist which will effectively improve the care coordination
quality-of-life and anticipatory care planning which willlead towards advanced liver disease care
system that will not only support the health conditions but it will also give enhancement towards
different range of programs like palliative care (ClinNurs, 2019).
This could be understood with good example of patients who are dealing with cirrhosis,
who have received 6 month of intervention including usual care from the nurses who have
trained with different range of training like how liver works and so on. In present context, the
nurse has specifically supported patients to live with the particular condition with the help of
different resources like facilitating care taking help of different community professionals. If it is
critically analysed then in present context mixed method evaluation was utilised results that has
been carried out has showed that intervention was specifically being accepted by 47 patients for
27 individuals who were delivering care to the patients and 13 other individuals who were linked
with the case. Additional expert at wise that was given by the nurses has showed Full support of
continuity of care that resulted into positive outcomes. Away with this, the intervention also
effectively improve the number of electronic summary care plans which was specifically being
shared by hospitals and primary care. If it is critically analyse and then nurse led intervention has
given acceptable, feasible and proved results where recruitment process and outcome measures
for a future randomised control trial will be effective in generalist palliative care (Skjæret and
Vereijken, 2016).
On the other hand, social different patients with alcohol related liver disease are
specifically hard to engage. This means that population who have addictive nature towards
alcohol has a higher risk of dying then less deprived (Palliat Med, 2018). Fibroscan device is
considered to be an effective tool which delivers non invasive results to world’s measuring liver
stiffness. This has given the results like > 7.1 kPa is considered to be the possible chronic liver
disease (cirrhosis). In present context role of alcohol specialist nurse and liver nurse in adult
nursingis much more crucial because individuals that are specifically identified has the habit of
consuming alcoholand the particular disease requires a lot of potential from nurses in order to
reduce its impact on human body. High engagement done by potential nurses would effectively

help in early interventions and also enhance the chances of getting much more improved
outcomes in relation to the health conditions of patients dealing with cirrhosis. Also, a nurse led
fibroscan, would effectively encourage socially deprived drinkers to engage with labour services
and this will decrease the chances of death rate that means only takes place in United Kingdom
because of unhealthy liver (Kelkar and Morisaka, 2018).
Key findings has been made considering different journals where role of alcohol specialist
nurse and liver nurse requires no conflicts of interest while delivering services to individuals
dealing with cirrhosis. Away with this, access to additional expert advice continuity of care and
support given by these nurses will effectively help patients dealing with the particular disease to
increase the intervention related chances where they can take into consideration of electronic
summary care plans that may effectively deliver promising results towards health outcomes.
3.4 Integration of key findings of studies and multi professional clinical implications
The particular themes on which the overall investigation has been performed has clearly
showed promising results towards reduction in patients dealing with cirrhosis.On the other hand
monitoring all the vital science is something which is required for all the nurses to take into
consideration of patient’s health conditions because this will effectively help in delivering care in
relation with cirrhosis (Tu and et. al., 2020). Because it has been found that identifying a
particular intervention in relation with a particular therapy that has been given to the patient it is
much needed for individuals to consider standardized language system as it will help in in
finding the best number of interventions considering the psychological domain. Including this, it
is much more required for the nurses to keep on developing their competencies and skills
because then only they can effectively recognise the accurate diagnosis in relation with cirrhosis
(Torraco, 2016). This will help in delivering the best and suitable care to the patients and also it
is pretty much needed to consider a valid nursing diagnosis guide as it will also help in avoiding
re-hospitalization because of inadequate nursing care management given by or followed by
nurses (Galvani, Dance and Wright, 2018). It is also needed for NHS to outline all the financial
challenges and try to overcome them as this will automatically help them in in gaining ample
number of benefits like economic costs which will directly put positive impact on understanding
the overall needs of patients dealing withcirrhosis and improve the communication process that
will reduce the chances of death because of the particular disease.

4. Conclusion
Considering the above mentioned exploration, it can easily be said that high mortality from
liver disease has decreased in some faces considering different range of plans. However, many of
the individuals will continue to die with high symptom of burden and because of little care
planning.On the other side, it is required for NHS to focus on its financial challenges over the
next years because it is may be possible that they might not become able to address the problems
in relation with liver organ. Away with this, MELD has effectively given the information that
poor predictive accuracy can be seen when measuring the health conditions of a critically ill
patient dealing with cirrhosis. Therefore, it cannot be considered as the best indicator for
prognosis while dealing with the patients that are already at the critical condition in ICU ward.

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