Critical Analysis on Liver Cirrhosis Nursing Care

This essay provides a detailed insight into the nursing care plan and interventions for liver cirrhosis. It includes a critical analysis of different nursing care strategies and their effectiveness. The patient's case description, diagnosis, assessment tools used, and nursing care plan are discussed.

Running head: CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
Name of the Student:
Name of the University:
Author note:

1CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
Table of Contents
Introduction................................................................................................................................2
Discussion..................................................................................................................................2
 Case description:.............................................................................................................2
 Diagnosis of the patient:..................................................................................................3
 Assessment tool used for Diagnosis:...............................................................................5
 Nursing Care plan:..........................................................................................................7
 Pharmacological interventions:.......................................................................................8
 Critical analysis of nursing strategies:............................................................................9
Conclusion................................................................................................................................11
References................................................................................................................................13
Appendix..................................................................................................................................17

2CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
Introduction
In this essay, a detail insight on the nursing care plan and its interventions on liver
cirrhosis is conducted. Critical analysis is done on liver cirrhosis with different approaches of
the nursing care strategies. The patient was suffering from liver cirrhosis as examined from
the symptoms obtained from his medical report. Liver cirrhosis also identified as hepatic
cirrhosis (British Liver Trust 2019). It is an enduring hepatic sickness specified by diffuse
demolition and fibrotic renewal of various hepatic cells which leads to two major health
problem of acute anxiety and chronic pain due to change in liver structure. Fibrosis is caused
due to necrotic tissues, the diseases changes the structure of liver and standard vasculature,
weakens body fluid and lymph movement, and eventually leads to hepatic insufficiency. In
United States, cirrhosis is considered as the fourth principal reason of demise between people
aged 35 to 55, and signifies a severe danger to long-standing health (Beck, Tornquist and
Edberg 2014). The case description of the patient was analysed, thoroughly and the diagnosis
method was listed down according to the sign and symptoms of the patient health, and for the
nursing care Activities of Daily Life (ADL) framework, is used as compared to other
framework because in ADLs the duty and routines are performed on a regular basis to help
the patient with proper care and to live independently. Different assessment tool such as
anxiety assessment tool, VIP score or waterloo score was used to test patient’s health and
according to the patient health report nursing care plan strategies was made and critical
analysis was performed on that nursing strategy (Gimenes et al. 2016).
Discussion
 Case description:
Ravi was already diagnosed with liver related disease (alcoholic liver disease) six
months ago. He had medical history of hypertension and was on a strict diet controlled type 2

3CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
diabetes. Though Ravi had stopped consuming alcohol from last few months, his health was
still declining and he was getting exhausted and weak after a small task and used to spend his
time in resting and sleeping. He was suffering from itchy skin and was looking jaundiced.
Ravi could not sleep properly on bed because of his swollen abdomen. His skin was
becoming fragile and because of his diabetes, his wounds would take more time to heal. The
liver consultant met Ravi and informed him regarding his declining liver function and the fact
that no medical or surgical treatment could help him (Borras et al. 2014). From Ravi’s above
condition, it was clear that he had liver cirrhosis as he was continuously suffering from
tremendous pain and his skin was still fragile and itchy with jaundiced appearance. Nurse
was appointed to take proper care of him by using her nursing care plan. Proper care and
medication was done. As a palliative measure, Ravi could open his bowel twice a day by
passing small amounts of urine. After the assessment of his condition, he was medicated with
certain medicines and diagnosis was performed.
 Diagnosis of the patient:
As the patient was already diagnosed with alcoholic liver disease, it was
comparatively easy to relate his symptoms with the condition of liver cirrhosis. According to
British Liver Trust 2019, the early and late symptoms of liver cirrhosis was elaborated. Early
symptoms included usually feeling sick and drained all the time, loss of hunger, weight loss
and muscle deterioration, nausea and vomiting, frequent aching in the liver zone, blemished
red palms, and distressed sleep pattern (Jensen et al. 2018). Late symptoms of liver cirrhosis
included itchy skin, yellowing of eyes and skin resulting in jaundiced appearance, white nails,
hair loss, swelling in leg, feet, abdomen, and ankles, dark discharge of urine and continuous
muscle pain.
Hence, from the above symptoms it was clear that Ravi was suffering from liver
cirrhosis as he had itchy skin with jaundiced appearance, he used to get tired easily and spend

4CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
his most time in resting and sleeping, he was suffering from constant pain with swollen
abdomen. After complete analysis of his symptoms, he was diagnosed accordingly for acute
anxiety and chronic pain (Kimbell et al. 2018). A Liver consultant physically examined Ravi
and different test was performed to be sure about his disease, which included Liver function
test (LFTs), liver biopsy, endoscopy and imaging test for scanning liver function such as CT
scan, ultrasound and MRI as mentioned in NICE guidelines for diagnosis of liver cirrhosis
(Nice.org.uk 2019). Certain assessment tools were also used for his complete analysis. From
the above information, it was concluded that Ravi had two major health problem, which
included acute anxiety and chronic pain. The pathophysiology of these problems was
researched in details.
a) Acute anxiety- In liver cirrhosis patients, leading life turn out to be meaningless due to
physical complications and psychological complications like anxiety and misery, regular
rehospitalisation due to difficulties and deteriorating symptoms, and succeeding monetary
difficulty. Neurochemicals like Serotonin, GABA, Dopamine, and Neuroepinephrin are
linked with acute anxiety. The major neurotransmitter involved are serotonin, norepinephrine
and gamma-amino butyric acid (Louvet and Mathurin 2015). Since Ravi had an anxiety issue,
decreased norepinephrine level was the main cause of this problem. The acute anxiety issue
in the patient was due to the dysfunction of these neurotransmitter and its receptors. As the
patient used to drink excessive alcohol it lead to decline in the level of these neurotransmitter,
which in turn caused these symptoms like acute anxiety and restlessness. Ravi was diagnosed
with medicines in order to increase the level of these neurotransmitter and their receptors.
b) Chronic pain- Pain is referred to have a biologically significant protective purpose.
Chronic pain is a consequence of standard functional procedures contained by the nociceptive
scheme. As the patient used to drink heavily, his abdomen was swollen which in turn led to
the onset of chronic pain as it hampered the nociceptive pain receptors leading to liver

5CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
dysfunction (Mirecc.va.gov 2019). Other than acute pain, nociceptive receptors also
contribute to the persistent neurotic pain syndrome, which is due to the injury caused to this
receptor due to liver cirrhosis. Under normal situations, when healing takes place the
nociceptive sensory system returns back to the usual practical state. In this case, the structure
of liver was altered of the patient due to excessive drinking which in turn injured the nervous
system leading to chronic neuropathic pain. Nociceptive pain receptors was working
abnormally in the patient due to altered structure of his liver or swollen abdomen, hence,
medicines were prescribed to Ravi to overcome this problem (Morrison, Sgrillo and Daniels
2014).
 Assessment tool used for Diagnosis:
Different assessment tools were used for the diagnosis of liver cirrhosis such as Water
low score, NEWS2, VIP score, anxiety measurement tool and pain score. These tools were
used for detailed analysis of liver cirrhosis:
a) Water low score- Water low score offers an assessed threat for the enlargement of a stress
sore in a patient. The principal purpose of this tool was to assist the doctors with patient’s risk
of increasing pressure ulcer (Judy-waterlow.co.uk 2019). The Waterlow comprises of seven
criteria for assessing the patients: weight, height, and visual valuation of the skin, sex or age,
continence, flexibility, and appetite, and distinct risk elements, distributed into tissue
undernourishment, neurological discrepancy, major surgery, and medication. The score
obtained from the above tool determined the risk zone of the patient like a score between 10-
14 shows 'at risk'; a score between 15-19 shows 'high risk', and; a score above 20 shows “very
high risk” (Judy-waterlow.co.uk 2019).
b) NEWS 2- NEWS 2 is the newest version of National Early Warning Score (NEWS), which
was first established in 2012 and was updated in the year 2017. This tool was constructed on

6CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
a concept of simple combined scoring scheme, where score was allotted on physiological
measurements after the patient was monitored and examined in the hospital (RCP London
2019). Six parameters were considered for scoring the patient health, which includes
respiration rate, oxygen saturation, temperature, pulse rate, systolic blood pressure and level
of consciousness. The aggregated score of the patient will help in determining the risk zone
of the patient.
c) VIP score- Visual Infusion Phlebitis (VIP) score is a standard tool used for observing or
monitoring the infusion sites. RCN recommended VIP score tool for infusion sites
monitoring. The patient using intravenous (IV) devices are required to check their IV sites
after every round to confirm there is no sign of Infusion phlebitis (Icid.salisbury.nhs.uk
2019). VIP score is then noted and documented in the care plan document sheet. The
complexity in the stage (early stage, medium stage and advanced stage) of phlebitis will
suggest the risk zone of the patient.
d) Anxiety measurement tool- Hamilton anxiety Rating Scale (HAM-A) is the most widely
used tool for assessing the rigorousness of patient’s anxiety level (Gl-assessment.co.uk 2019).
The main significance of this tool is to evaluate the patient's reaction to a particular sequence
of treatment. HAM-A is guileless to interpret and easy to use.
Hospital Anxiety and Depression Scale (HADS) is a self-rating scale used for
measuring the anxiety as well depression level of the patient (Gl-assessment.co.uk 2019).
This tool enables the early documentation of anxiety level and depression level. Separate
score is generate for both conditions and from that score the patient’s health risk was
identified and documented on paper. From the above assessment tool, it was clear that Ravi
was at a “higher risk” as his health was deteriorating day-by-day and the symptom level of
his health was in a higher risk zone.

7CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
e) Pain score- Pain score is a standard tool or instrument used for measuring pain in numeric
form. There are three different ways of measuring pain, which includes self-report,
physiological and behavioural (Yopp et al. 2014). Pain intensity using pain score is measured
on the scale 1 to 10 where, the number obtained on the pain score will specify the intensity of
pain suffered by the patient.
f) MUST score- Malnutrition Universal Screening tool (MUST) is used for malnourished
patient. It is a five step-screening tool, which includes guidelines for developing a care plan.
In liver cirrhosis patient, an abnormal weight loss takes place, which is an indication for
damaged liver condition. According to the condition of Ravi, he was at a high risk of threat
and required immediate action (Bapen.org.uk 2019).
 Nursing Care plan:
Nurses from every areas must be capable to propose health evidence and instruction
to patients in order to raise alertness of liver related disease and to endorse healthy-living
approaches. As the Liver consultant had already informed Ravi that any medical treatment or
surgical treatment would not help him, he had to undergo symptom management with the
help of proper nursing care plan. Nursing care plan (NCP) is distributed into six different
phases namely: Assessment, Nursing diagnosis, Healthcare plan, nursing prescription,
Nursing evaluation, and prognosis (Greenslade and Clayton 2018). NCP for patients suffering
from liver cirrhosis comprises rest, adequate nutrition, skin care, decreased risk of injury, and
managing the complications. From the case report, it was identified that the patient was
suffering from weight loss and change in bowel system and function which lead to an
improper absorption system hence, to combat this complication the care plan included a
dietary nutritional plan. The skin integrity of the patient was a major symptom of liver
cirrhosis as his skin was more becoming more fragile and itchy with jaundiced appearance

8CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
hence; to reduce this complication a proper skin integrity plan must be included in the NCP.
Ravi used to get tired very easily and spend his most time in sleeping or resting which made
him loss of activity and enthusiasm in life hence, to combat this problem an effective
breathing and working activity must be include in the care plan. From the patient report it
was observed that Ravi had a fear of dying, he was losing hope in his life, which in turn made
him depressed, and sad hence, the NCP must include a method of reducing this Psychological
problem of the patient, which in turn will motivate him to get well soon (Lubbe and Roets
2014). The main role of nurses was to perform towards the decrease of harmful clinical
impression of the illness in such patients in order to decrease frequent hospitalizations and to
enhance the quality of life. The nursing diagnosis used for such patient were Bathing
personal-care insufficiency, Dressing personal-care insufficiency, Threat for bleeding,
Danger for weakened skin integrity, Risk for severe confusion, Possibility for falls,
Imbalanced nourishment: lower than body necessities, and Superfluous fluid volume.
 Pharmacological interventions:
Pharmacological intervention is the method of drug therapy for treating alcohol-related
liver disease. Different drugs was given to the patient such as lactulose, Senna, oromorph and
amlodipine. Lactulose is the drug given to the patient for reducing the level of ammonia in
the blood that pull out the water from patient body and into colon to soften patient stool.
Senna is an herb, which is made up of many chemicals known as sennosides, which infuriate
the linings of bowel thereby loosing stool and bowel movement of the patient (Shah and
Mudassar 2019). As the patient was an alcoholic to reduce or relieve him from severe pain,
he was medicated with oromorph. Liver process amlodipine, and in case of alcohol-related
liver problem, liver is unable to process amlodipine naturally hence medication is given due
to which invasion of calcium ions takes place in smooth muscle and cardiac muscle cells

9CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
hence resulting in vasodilation of arteries and oxygen consumption. Hence, these
pharmacological interventions are taken in case of Ravi.
 Critical analysis of nursing strategies:
A lone nurture action, treatment, method, movement, or facility planned to
accomplish a consequence of different nursing diagnosis is defined as Nursing Intervention.
The critical analysis on different used nursing interventions are as follows:
a) Imbalanced nutrition- Nursing intervention should be followed when the amount of
nutrition uptake is not sufficient for the patient’s body.
Intervention- Mellinger and Volk 2013 explained in their study that managing liver cirrhosis
is multidisciplinary approach. They proposed that proper care and coordination between the
nurse and the patient should take place relate to their dietary intake or to any other
interventions. Dietary intake should be measured by using calorie count, encouraging the
patient to eat sufficient required meals, which also include supplementary diets, suggest the
patient to eat soft food and construct a proper meal plan, which exclude consumption of
caffeine.
Rationale- Meal plan helps the patient to have an important information regarding his intake
of meal, needs and the deficiencies. Due to continuous weakness and nausea, the patient loses
interest in proper meal and take consume small amount of food, hence this nursing
intervention will help the patient to overcome this complication.
b) Risk of skin fragility- The nursing care plan generated for this problem helps the patient
to maintain their skin integrity and skin breakdown.
Intervention- A close and routine inspection of the patient’s skin should be conducted, the
patient should take bath-using baking soda and body lotion should be applied on a daily basis,
the use of soap should be exempted, the area of stress in patient skin should be messaged

10CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
gently on a regular basis, proper medication should be taken. Saberifiroozi 2017 in his article
has also mentioned some care indicators, quality of care and certain guidelines for improving
the care of patient in more holistic way.
Rationale- Applying lotion helps in smoothing of patient’s skin and provide relief from
itching due to jaundice; Oedematous tissues are highly prone to breakdown and hence proper
massage will help the patient skin to improve circulation and in maintaining the joint’s
morbidity. Hence, this nursing intervention will help the patient to overcome skin related
problem like fragile skin.
c) Ineffective breathing pattern- The nursing care plan generated for this problem helps the
patient to have a longer stamina during any activity as the people who suffer from liver
cirrhosis get tired easily and do not have enough stamina to work (Gimenes et al. 2016). They
tend to relax more either by sleeping or by resting constantly which in turn makes them weak.
Intervention- Monitoring the patient’s respiratory rate, depth and effort, all the changes in
patient’s consciousness should be closely monitored and recorded, the head of bed should be
elevated if the patient is resting or sleeping, supplementary oxygen should be provided when
required by the patient, and the breath sounds of the patient should ne auscultated routinely
(Mellinger and Volk 2013).
Rationale- In case of fluid accumulation in the abdomen certain fluctuations in the respiratory
rate or depth is monitored; the elevated bed head helps the patient to accelerate breathing by
decreasing force on the diaphragm and by lowering the risk of secretions. When the oxygen
level is inadequate, the patient is given supplementary oxygen to treat hypoxia.
d) Deficient knowledge- This nursing plan includes the information, which is required to be
addressed to the patient in order to have a proper knowledge about the disease and its future
scope.

11CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
Intervention- The disease onset process, prognosis and the future scope should be clearly
explained to the patient, proper diet plan should be maintained, the patient should be assisted
with a support person who can help him to recover with moral support, and the patient should
be motivated to leave alcohol for better health result and if the patient is incapable to do so
then he or she is sent to rehabilitation centres. Naugler et al. 2015 in their study also
explained about the knowledge expansion of the disease. The accessibility of novel
communication equipment, like teleconferencing, bids the opportunity of MDT development
into rural zones, including zones like correctional facilities.
Rationale- Patient suffering with cirrhosis requires a nutritional knowledge and a base
knowledge regarding the causes of liver cirrhosis and over consumption of alcohol. The
patient should engulf a deep knowledge regarding the drugs with are hepatotoxic and if their
body can metabolize such drugs (Jensen et al. 2018). Proper dietary check-up with written
instruction should be provided to the patient. The patient should continuously take rest to
increase the energy of tissue regeneration and thus decreasing the metabolic effect of drugs.
Conclusion
The number of people suffering with liver cirrhosis are increasing worldwide with
more number of patients being diagnosed and admitted to the hospitals. In this essay, a proper
nursing care plan was constructed which was important to evaluate the patient and their
requirements for better approach and treatment stating that nurses are focused to work in the
multidisciplinary group to adapt their methodology for respective patient’s unique requests.
The achievement of the nursing goals or nursing care plan was because of the fact that nurses
understood the communal sources and difficulties of liver disease suffered by the patient by
managing patient complexities. In this study, Ravi also appointed nurse for his treatment and care
where the doctor himself told him that any medical or surgical treatment would not help him.
Nurses appointed by the patient had a crucial role in increasing and encouraging high value care

12CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
to the patient with advanced liver cirrhosis. Patient suffering with liver cirrhosis go through
intrusive procedures, which are painful for cure and diagnosis of disease in hospitals hence,
nursing care plan and treatment are much more effective and easy for patients to understand
and cope up, as nurses improve the skills and competencies for diagnoses and thus identify
suitable interventions to deliver the best possible care. Precise and effective nursing
diagnoses monitor the choice of interventions, which will enhance patient results, with more
care that is effective and help in escaping rehospitalisation. Hence, this essay gave a detail
insight on the best nursing care strategies for best care of patients suffering with advanced
liver cirrhosis.

13CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
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17CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
Appendix
Nursing Care Plan:
Identify
problems/ Issue
Take action MDT members
approach on problems
Monitoring of vital
signs
Chronic pain Following interventions can
be considered for chronic
pain:
a) Provide relaxation methods
like back rubbing and shifting
location to relieve pain.
(Ucuzal and Dogan 2015)
b) Educating the patient with
relaxation procedures such as
deep breathing. (Ucuzal and
dogan 2015)
c) Provide the patient with
analgesic to relieve him from
pain and fever. (Shah and
Mudassar 2019).
d) Patient should be
encouraged to take complete
bed rest. No abdominal
discomfort. (Owens et al.
2017).
e) Maintaining low level of
sodium and fat in the diet of
the patient. (Beck, Tornquist
and Edberg 2014)
f) Motivating the patient to
leave alcohol for no further
damage. (Greenslade and
Clayton 2018)
g) Opioid analgesics is
prescribed to the patient to
reduce pain and to monitor it.
(Shah and Mudassar 2019)
h) Neuropathic pain is treated
with using tricyclic
antidepressants, antiepileptic
medicines, and GABA
analogues. (Shah and
Mudassar 2019)
Multidisciplinary
pain treatment
facilities (MPTF) are
clinics of MDT that
promoted focused
multidisciplinary
facilities for the
treatment and
management of
chronic pain (Owens
et al. 2017). They
had supervisors from
three different health
care disciplines
including one
specialist.
Pain is observed and
measured using pain
assessment tools like
FLACC, visual
analogue scale and
Wong-baker faces
pain scale, which
provides the pain
score of the patient.

18CRITICAL ANALYSIS ON LIVER CIRRHOSIS NURSING CARE
Acute anxiety Following interventions can
be considered for acute
anxiety:
a) Provide quiet and calm
environment to the patient.
(Saberifiroozi 2017)
b) Keep the head of the bed
elevated. (Owens et al. 2017)
c) In case of acute anxiety,
provide the patient with
supplemental O2. (Yopp et
al. 2014)
d) Support the patient while
conducting Activities of daily
life (ADL). (Naugler et al.
2015)
e) Encourage the family
members to verbalize with
the patient. (Greenslade and
Clayton 2018)
f) Assess the level of stress
and anxiety. (Jensen et al.
2018)
g) Provide the patient with
soft and calm music to relax.
(Owens et al. 2017)
h) Effective breathing pattern
should be explained to the
patient to reduce anxiety
issue. (Mellinger and Volk
2013)
A multidisciplinary
team (MDT) case
management strategy
was developed to
facilitate effective and
beneficial care
strategies and methods
to reduce anxiety issue
in the patient
(Naugler et al.
2015).
Anxiety is observed
and measured by using
Anxiety measurement
tools such as Hamilton
anxiety Rating Scale
(HAM-A) and
Hospital Anxiety and
Depression Scale
(HADS) which,
evaluate the anxiety
level of the patient by
providing anxiety
scores.