10 Liver Cirrhosis Nursing Care Plans

Use this nursing care plan and management guide to provide care for patients with liver cirrhosis. Enhance your understanding of nursing assessment, interventions, goals, and nursing diagnosis, all specifically tailored to address the unique needs of individuals facing liver cirrhosis. This guide equips you with the necessary information to provide effective and specialized care to patients dealing with liver cirrhosis.

What is Liver Cirrhosis?

Liver cirrhosis, also known as hepatic cirrhosis, is a chronic hepatic disease characterized by diffuse destruction and fibrotic regeneration of hepatic cells. Various insults can injure the liver, including viral infections, toxins, hereditary conditions, or autoimmune processes. With each injury, the liver forms scar tissue or fibrosis, initially without losing its function, After a long-standing injury, most of the liver tissue gets fibrosed, leading to loss of function and the development of cirrhosis (Farci, 2022). As necrotic tissues yield to fibrosis, the disease alters the liver structure and normal vasculature, impairs blood and lymph flow, and ultimately causes hepatic insufficiency. 

Chronic liver disease usually progresses to cirrhosis. The most common causes of cirrhosis in the United States include hepatitis C, alcoholic liver disease, cryptogenic causes, hepatitis B, and other miscellaneous causes (autoimmune hepatitis,  primary biliary cholangitis, Wilson disease, etc.). Cirrhosis is the ninth leading cause of death in the United States and represents a serious threat to long-term health. Worldwide, cirrhosis is the 14th most common cause of death, but in Europe, it is the 4th most common cause of death (Wolf & Anand, 2020).

These are the clinical types of cirrhosis:

• Laennec’s cirrhosis is the most common type and occurs in 30% to 50% of cirrhotic clients. Up to 90% of them have a history of alcoholism. Liver damage results from malnutrition, especially of dietary protein, and chronic alcohol ingestion. Fibrous tissue forms in portal areas and around central veins.
• Biliary cirrhosis occurs in 15% to 20% of clients and results from injury or prolonged obstruction.
• Postnecrotic cirrhosis stems from various types of hepatitis.
• Pigment cirrhosis results from disorders such as hemochromatosis.
• Idiopathic cirrhosis has no known cause.
• Noncirrhotic fibrosis may result from schistosomiasis, congenital hepatic fibrosis, or idiopathic.

Some clients with cirrhosis are completely asymptomatic and have a reasonably normal life expectancy. Other individuals have a multitude of the most severe symptoms of end-stage liver disease and a limited chance of survival. Common signs and symptoms may include hepatomegaly, abdominal pain, ascites, abdominal distention, bulging flanks, shifting dullness, anorexia, weight loss, fatigue, and muscle wasting. Cutaneous manifestations include jaundice, spider angiomata, skin telangiectasia (“paper money skin”), palmar erythema, white nails, the disappearance of lunulae, and finger clubbing (Wolf & Anand, 2020).

Nursing Care Plans and Management

The nursing care planning goals for patients with liver cirrhosis include managing symptoms such as ascites, jaundice, and encephalopathy, reducing risk for injury, preventing and treating complications such as portal hypertension and variceal bleeding; and promoting self-care management and education to improve overall health outcomes. Moreover, nursing interventions may focus on monitoring and promoting adequate nutrition and fluid balance, as well as addressing the psychological and emotional needs of patients and families.

Nursing Problem Priorities

The following are the nursing priorities for patients with liver cirrhosis:

• Manage and monitor liver function in patients with cirrhosis.
• Address complications associated with cirrhosis, such as portal hypertension or ascites.
• Provide supportive care to manage symptoms and improve quality of life.
• Educate patients on dietary modifications and fluid restriction, if necessary.
• Administer medications to manage symptoms and slow disease progression, if applicable.
• Monitor for and manage complications like hepatic encephalopathy or variceal bleeding.
• Offer counseling and support for lifestyle modifications, including alcohol cessation and weight management.

Nursing Assessment

Assess for the following subjective and objective data:

• Complaints of fatigue and weakness
• Reports of abdominal pain or discomfort
• Presence of ascites (abdominal fluid accumulation) evidenced by distension and shifting dullness on percussion
• Nausea, vomiting, or changes in appetite
• History of alcohol abuse or excessive alcohol consumption
• Complaints of jaundice (yellowing of the skin and eyes)
• Presence of pruritus
• Reports of weight loss or changes in body weight
• History of coagulation disorders or easy bruising
• Signs of hepatic encephalopathy, such as altered mental status, confusion, or asterixis (flapping tremor)
• Presence of spider angiomas (dilated blood vessels) or palmar erythema (reddening of the palms)
• Elevated liver enzymes (ALT, AST), bilirubin, and INR (international normalized ratio)

Nursing Diagnosis

Following a thorough assessment, a nursing diagnosis is formulated to specifically address the challenges associated with liver cirrhosis based on the nurse’s clinical judgement and understanding of the patient’s unique health condition. While nursing diagnoses serve as a framework for organizing care, their usefulness may vary in different clinical situations. In real-life clinical settings, it is important to note that the use of specific nursing diagnostic labels may not be as prominent or commonly utilized as other components of the care plan. It is ultimately the nurse’s clinical expertise and judgment that shape the care plan to meet the unique needs of each patient, prioritizing their health concerns and priorities.

Nursing Goals

Goals and expected outcomes may include:

• The client will demonstrate progressive weight gain toward a goal with the client-appropriate normalization of laboratory values.
• The client will experience no further signs of malnutrition.
• The client will demonstrate stabilized fluid volume, with balanced I&O, stable weight, vital signs within the client’s normal range, and absence of edema.
• The client will maintain skin integrity.
• The client will verbalize reduced itching or the ability to tolerate itching without scratching.
• The client will identify individual risk factors and demonstrate behaviors/techniques to prevent skin breakdown.
• The client will maintain an effective respiratory pattern; be free of dyspnea and cyanosis, with ABGs and vital capacity within the acceptable range.
• The client will maintain homeostasis in absence of bleeding
• The client will demonstrate behaviors to reduce the risk of bleeding.
• The client will maintain the usual level of mentation/reality orientation.
• The client will initiate behaviors/lifestyle changes to prevent or minimize the recurrence of the problem.
• The client will verbalize understanding of changes and acceptance of self in the present situation.
• The client will identify feelings and methods for coping with a negative perception of self.
• The client will verbalize understanding of the disease process/prognosis, and potential complications.
• The client will identify/initiate necessary lifestyle changes and participate in care.

Nursing Interventions and Actions

Therapeutic interventions and nursing actions for patients with liver cirrhosis may include:

1. Enhancing Nutritional Balance

A key aspect of managing clients with liver disease, from the stages of compensated cirrhosis through liver failure, is early recognition and treatment of malnutrition. Given the increasing prevalence of obesity, diabetes, and their association with non-alcoholic fatty liver disease (NAFLD), an imbalance of nutritional intake is becoming increasingly observed in clients with cirrhosis. The resultant combination of adiposity and sarcopenia, termed sarcopenic obesity poses unique nutritional challenges, with regard to optimizing metabolic risk factors and muscle function (Dhaliwal et al., 2020).

Evaluate the client for malnutrition.
80 to 90% of the blood that leaves the stomach and intestines carries nutrients to the liver where they are converted into substances the body can use. The client with liver dysfunction often has malnutrition because of inadequate dietary intake due to poor food choices or preference for alcohol rather than food and may currently have malabsorption syndrome due to the inability to process or digest nutrients, anorexia, nausea or vomiting, indigestion, or early satiety associated with ascites. Additionally, because of the decreased secretion of bile into the gut, the client may have difficulty absorbing fat and fat-soluble vitamins A, D, E, and K.

Determine interest in eating and ability to chew, swallow, and taste.
These are factors that affect the ingestion and digestion of nutrients. Clients with massive ascites may experience abdominal discomfort, depressed appetite, and decreased oral intake. Many clients complain of anorexia, which may be compounded by the direct compression of ascites on the GI tract (Wolf & Anand, 2020).

Utilize nutritional screening tools to assess the client’s nutritional status.
All clients with liver cirrhosis, irrespective of BMI, should be screened and assessed for malnutrition. This can be performed using validated screening tools. Nutritional screening tools available to identify those at risk of malnutrition include the standard Malnutrition Universal Screening Tool (MUST) and the Nutritional Screening Risk-2002 (Dhaliwal et al., 2020). 

Assess the client’s functional status.
Functional status can be assessed immediately as the client arrives for a consultation. Do they walk unaided? What is the strength of the client’s handshake? Are they able to rise from a chair? Assess how well a person performs their activities of daily living and their perceived exercise tolerance. Directed, validated measures of functional ability in cirrhosis include short physical performance battery testing, incremental shuttle walk tests, and most recently, the liver frailty index, which incorporates hand grip strength, timed chair stands, and balance (Dhaliwal et al., 2020).

Measure dietary intake by calorie count.
This provides important information about intake, needs, and deficiencies. A client with cirrhosis requires a balanced protein diet providing 2,000 to 3,000 calories per day to permit liver cell regeneration. Understanding a client’s energy expenditure is key to accurately calculating their nutritional energy requirements to protect and optimize muscle function. For compensated cirrhosis, recommended energy intake is 25 to 35 kcal/kg/day, while recommended protein intake is 1,2 to 1,5 g/kg/day to maintain muscle mass. For clients with decompensated cirrhosis with sarcopenia recommended energy intake is  30 to 35 kcal/kg/day and recommended protein intake is 1.5 to 2.0 g/kg/day to prevent further loss and reverse sarcopenia (Dhaliwal et al., 2020).

Weigh as indicated. Compare changes in fluid status, recent weight history, and skinfold measurements.
It may be difficult to use weight as a direct indicator of nutritional status in view of edema and/or ascites. Skinfold measurements are useful in assessing changes in muscle mass and subcutaneous fat reserves. Dry body weight and BMI should be recorded, using weight following paracentesis or via estimation by subtracting a percentage of body weight based on ascites (mild 5%; moderate 10%, and severe 15%) and peripheral edema (5% if bilateral) (Dhaliwal et al., 2020).

Perform anthropometry measurements as indicated.
Anthropometry can be carried out to obtain measures of muscle mass (MAMC) and contractile function (hand grip strength), both of which predict mortality. Hand grip strength should be performed three times in the non-dominant hand and compared with historical ‘normal’ values for women (29 kg) and men (40 kg). MAMC is obtained by measuring the mid-arm circumference (MAC) which incorporates muscle and adipose and tricep skin fold, an estimate of the adipose thickness (Dhaliwal et al., 2020).

Assess the severity of cirrhosis.
For many years, the most common prognostic tool used in clients with cirrhosis was the Child-Turcotte-Pugh (CTP) system. Epidemiologic work shows that the CTP score may predict life expectancy in clients with advanced cirrhosis. A CTP score of 10 or greater is associated with a 50% chance of death within 1 year. Since 2002, liver transplant programs in the United States have used the Model for End-stage Liver Disease (MELD) scoring system to assess the relative severity of clients’ liver disease (Wolf & Anand, 2020).

Monitor laboratory studies: serum glucose, prealbumin, albumin, total protein, prothrombin time (PT), and ammonia.
See Laboratory and Diagnostic Procedures

Review the client’s glycemic control.
It is important to review the client’s glycemic control, particularly in the presence of diabetes and subsequent anti-diabetic medications. Hemoglobin (HbA1c) as a direct marker of glycemic control should be used in the clinical context, as it can be falsely reassuring in the context of anemia (Dhaliwal et al., 2020).

Encourage the client to eat; explain reasons for the types of diet. Feed the client if tiring easily, or have a family caregiver assist the client. Include the client in meal planning to consider his/her preferences in food choices.
Improved nutrition and diet are vital to recovery. The client may eat better if the family is involved and preferred foods are included as much as possible. A regular eating pattern of 2 to 3 hourly meals and snacks, including a bedtime snack, should be encouraged with the aim of reducing starvation time and minimizing the breakdown of muscle and fat stores for use as a metabolic fuel (Dhaliwal et al., 2020).

Encourage the client to eat all meals including supplementary feedings.
The client may pick at food or eat only a few bites because of a loss of interest in food or because of nausea, generalized weakness, or malaise. The 2010 practice guidelines for alcoholic liver disease published by the American Association for the Study of Liver Disease and the American College of Gastroenterology recommend aggressive treatment of protein-calorie malnutrition in clients with alcoholic cirrhosis. Multiple feedings per day, including breakfast and a snack at night, are specified (Wolf & Anand, 2020).

Give small, frequent meals.
Poor tolerance to larger meals may be due to increased intra-abdominal pressure and ascites (if present). For energy malnutrition, divided meals and late evening snacks, such as rice balls, liquid nutrients, and branch chain amino acids (BCAA) enriched supplementation are recommended. Approximately 200 kcal is divided from the target total daily calories and taken as a snack or energy before going to bed to improve nighttime starvation. These divided meals or late-evening snacks should be easy to prepare and ingest (Dhaliwal et al., 2020).

Provide salt substitutes, if allowed; avoid those containing ammonium.
Salt substitutes enhance the flavor of food and aid in increasing appetite; ammonia potentiates the risk of encephalopathy. Salt restriction is the first line of therapy. In general, clients begin with a diet containing less than 2000 mg of sodium daily. Some clients with refractory ascites require a diet containing less than 500 mg of sodium daily. However, ensuring that clients do not construct diets that might place them at risk for calorie-protein malnutrition is important (Wolf & Anand, 2020).

Restrict intake of alcohol, raw or uncooked food, and excessively fatty foods.
Any amount of alcohol is considered unsafe for anyone with cirrhosis because it is a potential cause of more liver damage and liver failure. Drinking alcoholic substances can also contribute to malnutrition, as some people addicted to alcohol may prefer drinking than eating and choosing nutritious foods. When the liver is damaged, the production and supply of bile may be affected, leading to an inability to process a high-fat meal effectively. Clients with liver cirrhosis also have impaired immune function, resulting in bacteria and viruses being harbored through raw or uncooked foods (Daniel, 2022).

Encourage frequent mouth care, especially before meals.
The client is prone to sore and/or bleeding gums and a bad taste in the mouth, which contributes to anorexia. Fetor hepaticus, also known as ‘breath of the dead’ is a condition in which the breath of the client is sweet, musty, and occasionally fecal in nature. It is associated with portal hypertension with portosystemic shunts (Thomas, 2021).

Promote undisturbed rest periods, especially before meals.
Conserving energy reduces metabolic demands on the liver and promotes cellular regeneration. The energy supply must balance total energy expenditure (TEE) to maintain nutritional equilibrium. TEE includes a combination of resting energy expenditure, physical activity expenditure, and food-related thermogenesis. Even though physical activity is reduced in many clients with cirrhosis, the TEE ranges from 28 to 37.5 kcal/kg body weight per day (Dhaliwal et al., 2020).

Recommend cessation of smoking. Provide teaching on the possible negative effects of smoking.
This reduces excessive gastric stimulation and the risk of irritation and may lead to bleeding. Smoking appears to have adverse effects on the liver via three separate mechanisms: toxic (both direct and indirect), immunologic, and oncogenic. Cigarette smoking has an important negative effect on a multitude of liver diseases via various mechanisms, therefore, smoking cessation must be prioritized (Rutledge & Asgharpour, 2020).

Maintain NPO status when indicated.
Initially, GI rest may be required in acutely ill clients to reduce demands on the liver and the production of ammonia and urea in the GI tract. When this is the case, nutrition must be supplied by another method- enteral or parenteral feedings. Individuals with cirrhosis are commonly kept NPO in the hospital for a variety of reasons and frequently fail to meet caloric goals. Practitioners should prioritize advancing their diet as early as possible, avoiding prolonged fasting, and placing an NG tube for enteral nutrition at the time of intubation (Martin & Stotts, 2020).

Refer to a dietitian to provide a diet high in calories and simple carbohydrates, low in fat, and moderate to high in protein; limit sodium and fluid as necessary. Provide liquid supplements as indicated.
High-calorie foods are desired inasmuch as client intake is usually limited. Carbohydrates supply readily available energy. Fats are poorly absorbed because of liver dysfunction and may contribute to abdominal discomfort. Proteins are needed to improve serum protein levels to reduce edema and promote liver cell regeneration. Protein and foods high in ammonia (gelatin) are restricted if the ammonia level is elevated or if the client has clinical signs of hepatic encephalopathy. In addition, these individuals may tolerate vegetable protein better than meat protein.

Provide tube feedings, TPN, and lipids if indicated.
This may be required to supplement diet or to provide nutrients when the client is too nauseated or anorexic to eat or when esophageal varices interfere with oral intake. For clients who do not have evidence of gastrointestinal (GI) bleeding, naso- or orogastric tube placement should occur immediately after intubation and can be considered safe regardless of variceal history. Parenteral feeding should only be used when enteral feeding cannot meet the client’s energy demands or is contraindicated (Martin & Stotts, 2020).

Optimize protein intake as indicated.
Optimizing protein intake is also essential due to an increased total body protein breakdown and reduced muscle protein synthesis. A minimum of 3 to 4 sources of high-protein foods a day should be recommended including eggs and lean meat (Dhaliwal et al., 2020).

Provide nutritional oral supplements as prescribed.
An adequate calorie and protein intake can be difficult to achieve, particularly for clients who have sarcopenia, and nutritional supplements are often required. This typically involves the use of low-volume, high-protein sip feeds, tailored to each client’s individual needs (Dhaliwal et al., 2020). It is reasonable to recommend a daily multivitamin (without manganese, as elevated levels observed in clients with cirrhosis may be associated with hepatic encephalopathy), and to consider individual vitamin and mineral deficiencies in the presence of malnourishment or decompensation (Martin & Stotts, 2020).

Encourage physical activities as tolerated.
Physical activity and exercise should be encouraged to support weight management and to improve muscle mass and strength; it should be individually tailored. A structured exercise program including a warm-up, a mixture of both aerobic and resistance exercises followed by a cool down for balance and flexibility training is beneficial at a moderate intensity, in which the client can still speak a two-word or three-word sentence (Dhaliwal et al., 2020).

Provide oral branch chain amino acids (BCAA) preparations as indicated.
See Pharmacologic Management

2. Managing Ascites and Fluid Volume

Ascites, which are an accumulation of excessive fluid within the peritoneal cavity, can be a complication of the either hepatic or nonhepatic disease. Clients with cirrhosis experience sodium and water retention, impaired free-water excretion, and intravascular volume overload. These abnormalities may occur even in the setting of a normal glomerular filtration rate. They are, to some extent, due to increased levels of renin and aldosterone (Wolf & Anand, 2020).

Assess respiratory status, noting increased respiratory rate, and dyspnea.
These signs can be indicative of pulmonary congestion. Manifestations of cirrhosis also include hepatopulmonary syndrome, portopulmonary hypertension, hepatic hydrothorax, decreased oxygen saturation, ventilation-perfusion mismatch, reduced pulmonary diffusion capacity, and hyperventilation (Farci, 2022).

Auscultate lungs, noting diminished breath sounds and developing adventitious sounds.
Increasing pulmonary congestion may result in consolidation, impaired gas exchange, and complications. Most clients with hepatopulmonary syndrome (HPS) present with dyspnea, orthopnea, platypnea, and cyanosis. Platypnea or orthodeoxia is defined as the presence of shortness of breath that worsens while sitting or standing and is relieved by lying down (Amer & Elsiesy, 2017).

Monitor BP (and CVP if available). Note JVD and abdominal vein distension.
BP elevations are usually associated with fluid volume excess but may not occur because of fluid shifts out of the vascular space. Distension of external jugular and abdominal veins is associated with vascular congestion. Portal hypertension results from a combination of increased portal venous inflow and increased resistance to portal blood flow. Clients with cirrhosis demonstrate increased splanchnic arterial flow and, accordingly, increased splanchnic venous inflow into the liver, which can be caused by decreased peripheral vascular resistance and increased cardiac output in the client (Wolf & Anand, 2020).

Monitor for cardiac dysrhythmias. Auscultate heart sounds, noting the development of S₃/S₄ gallop rhythm.
This may be caused by heart failure, decreased coronary arterial perfusion, and electrolyte imbalance. Upon physical examination, an accentuated and split-second heart sound, right ventricular heave, right-sided S3 gallop, jugular vein distention, and leg edema may hint at portopulmonary hypertension (Benz et al., 2020).

Assess for signs that indicate the presence of ascites.
Accordingly, the client must have approximately 1500 ml of fluid for ascites to be detected reliably by physical examination and the presence of obesity greatly reduces its diagnostic accuracy. Several signs support the presence of ascites such as the shifting dullness, fluid wave, and puddle signs. The former has 83% sensitivity and 56% specificity in detecting ascites.

Assess the degree of peripheral edema.
Fluids shift into tissues as a result of sodium and water retention, decreased albumin, and increased antidiuretic hormone (ADH). Bilateral edema can be caused by portal vein congestion leading to an increase in capillary permeability and a decrease in plasma oncotic pressure due to a decrease in the synthesis of albumin by the liver. (Goyal et al., 2022)

Measure I&O, weigh daily, and note gain of more than 0.5 kg/day.
This assesses circulating volume status, developing or the resolution of fluid shifts, and response to the therapeutic regimen. Positive balance/weight gain often reflects continuing fluid retention. Decreased circulating volume (fluid shifts) may directly affect renal function and urine output, resulting in hepatorenal syndrome. In clients with alcohol dependency, fluid retention with ascites is often observed. Severe whole-body edema can cause significant weight gain for the client (Tanaka et al., 2021).

Measure the client’s abdominal girth.
This reflects the accumulation of fluid (ascites) resulting from the loss of plasma proteins/fluid into peritoneal space. Excessive fluid accumulation can reduce circulating volume, creating a deficit (signs of dehydration). A relationship between pre-paracentesis girth and ascitic weight was found and this has the potential to aid ascitic weight estimation and, consequently, dry weight calculation, particularly for those unable to undergo paracentesis or when nutritional assessment is required when dry weight is not available (Lamarti & Hickson, 2019).

Monitor serum albumin and electrolytes (particularly potassium and sodium).
Decreased serum albumin affects plasma colloid osmotic pressure, resulting in edema formation. Reduced renal blood flow accompanied by elevated ADH and aldosterone levels and the use of diuretics (to reduce total body water) may cause various electrolyte shifts/imbalances. Ascites fluid protein and albumin are measured simultaneously with the serum albumin level to calculate the scrum-ascites albumin gradient. The presence of a gradient greater or equal to 1.1 g/dL predicts that the client has portal hypertension with 97% accuracy (JI, 2022).

Monitor serial chest x-rays and other imaging studies.
Vascular congestion, pulmonary edema, and pleural effusions frequently occur. A chest x-ray may also reveal an elevated diaphragm. Computed tomography of the thorax should be performed in order to rule out mediastinal, pulmonary, or pleural malignancies. Complementary abdominal imaging including Doppler sonography is recommendable (Benz et al., 2020).

Encourage bed rest when ascites are present.
This may promote recumbency-induced diuresis. Bed rest was previously recommended based on the assumption that an upright position further increases plasma renin levels. There is currently insufficient published evidence to routinely recommend bed rest to all clients, however (Gallo et al., 2020).

Restrict sodium and fluids as indicated. Provide adequate calories and protein.
Sodium may be restricted to minimize fluid retention in extravascular spaces. Fluid restriction may be necessary to correct dilutional hyponatremia. Current guidelines suggest a moderate restriction of dietary salt (2 g per day). Guidelines suggest examining all clients with advanced chronic liver disease with a rapid nutritional screen and to ensure an optimal daily energy and protein intake of 35 kcal/kg actual body weight per day and 1.2 to 1.5 g/kg actual body weight per day in order to avoid malnutrition (Gallo et al., 2020).

Administer salt-free albumin/plasma expanders as indicated.
Albumin may be used to increase the colloid osmotic pressure in the vascular compartment (pulling fluid into vascular space), thereby increasing effective circulating volume and decreasing the formation of ascites. Long-term administration of human albumin improves effective blood volume by attenuating peripheral arterial vasodilation, prevents renal dysfunction, enhances cardiac inotropism, and reduces systemic inflammation and endothelial dysfunction by acting as an antioxidant agent (Gallo et al., 2020).

Administer diuretics, inotropics, and V2 receptor antagonists as indicated.
See Pharmacologic Management

Prepare the client for large-volume paracentesis as indicated.
Clients with massive ascites may need to undergo large-volume paracentesis to obtain relief from symptoms of abdominal discomfort, anorexia, or dyspnea. The procedure may also help reduce the risk of umbilical hernia rupture. Large-volume paracentesis is thought to be safe in clients with peripheral edema and in clients not currently treated with diuretics (Wolf & Anand, 2020).

Assist in the insertion of peritoneovenous shunts.
LeVeen shunts and Denver shunts are devices that permit the return of ascites fluid and proteins to the intravascular space. Plastic tubing inserted subcutaneously under local anesthesia connects the peritoneal cavity to the internal jugular vein or subclavian vein via a pumping chamber. These devices are successful at relieving ascites and reversing protein loss in some clients (Wolf & Anand, 2020).

Prepare the client for insertion of the transjugular intrahepatic portosystemic shunt (TIPS) as indicated.
A TIPS is an effective tool in managing massive ascites in some clients. Ideally, TIPS placement produces a decrease in sinusoidal pressure and in plasma renin and aldosterone levels, with subsequent improved urinary sodium excretion. Multiple studies have demonstrated that TIPS is superior to large-volume paracentesis when it comes to controlling ascites (Wolf & Anand, 2020).

Educate the client about medications that should be avoided or used with caution.
Some drugs must be avoided or used with caution in clients with ascites such as NSAIDs due to the high risk of developing further sodium retention, hyponatremia, and renal failure. Metamizol use was more common in clients with persistent acute kidney injury, therefore, this drug should also be used with caution. Likewise, angiotensin-converting enzyme inhibitors, angiotensin II antagonists, or a1-adrenergic receptor blockers should generally not be used in clients with ascites because of the increased risk of renal impairment.

3. Providing Skin Care and Promoting Skin Integrity

Skin manifestations of systemic disorders give a clue to the organ involved and help identify the possible disease-causing injury. Skin changes of liver cirrhosis are not specific, as they may be seen in disorders not involving the liver. Thus, a constellation of skin changes along with systemic features may help identify the disease-causing liver cirrhosis. Early recognition of cutaneous features can help prevent or delay the development of complications and end-stage disease, decreasing morbidity and mortality (Bhandari & Mahajan, 2022).

Inspect pressure points and skin surfaces closely and routinely.
Edematous tissues are more prone to breakdown and the formation of decubitus. Ascites may stretch the skin to the point of tearing in severe cirrhosis. Edema due to a decrease in plasma oncotic pressure, like liver failure and malabsorption, does not change much with the position. Edema should also be assessed for pitting, tenderness, and skin changes (Goyal et al., 2022).

Assess for jaundice, itchiness, and scratching.
In hepatic failure, bilirubin cannot be excreted and accumulates in the skin and other tissues such as the sclera of the eye. Unexcreted bilirubin moves by diffusion into subcutaneous and cutaneous structures and irritates the tissue, causing histamine release and itching. Excessive scratching can lead to skin breakdown.

Gently massage bony prominences or areas of continued stress. The use of emollient lotions and limiting the use of soap for bathing may help.
Providing careful skin care is important because of subcutaneous edema, the client’s immobility, jaundice, and increased susceptibility to skin breakdown and infection. Lotion may be soothing to irritated skin; the nurse takes measures to minimize scratching by the client. Irritating soaps and the use of adhesive tape are avoided to prevent trauma to the skin.

Encourage and assist the client with repositioning on a regular schedule. Assist with active and passive ROM exercises as appropriate.
Repositioning reduces pressure on edematous tissues to improve circulation. Exercises enhance circulation and improve and/or maintains joint mobility. Debilitated clients frequently benefit from a formal exercise program supervised by a physical therapist (Wolf & Anand, 2020).

Recommend elevating lower extremities and the use of compression stockings.
This enhances venous return and reduces edema formation in extremities. Leg, ankle, and foot edema can be improved by elevating the legs above heart level for 30 minutes three or four times per day. However, it may not be practical for those who work to elevate their legs several times per day.  People with moderate to severe edema, those on their feet a lot, and those with ulcers require prescription compression stockings. Effective compression stockings apply the greatest amount of pressure at the ankle and gradually decrease the pressure up the leg (Sterns, 2023).

Keep linens dry and free of wrinkles.
Moisture aggravates pruritus and increases the risk of skin breakdown. Keeping the linens wrinkle-free creates a smoother surface and less prone to roughness or friction. This can reduce irritation of the client’s skin. Dry linens absorb moisture present in the environment, but it does not trap moisture against the skin, which leads to irritation and discomfort. 

Suggest clipping fingernails short; provide mittens/gloves if indicated.
This prevents the client from inadvertently injuring the skin, especially while sleeping. Pruritus is an unpleasant sensation that prompts a response to scratch. If the client has long nails, it can injure the skin during vigorous scratching (Patel et al., 2020).

Provide perineal care following urination and bowel movement.
This prevents skin excoriation breakdown from bile salts. Regular perineal care, which involves cleaning the area with mild soap and water and applying barrier cream or ointment, can help reduce the risk of skin irritation and excoriation. This can also help prevent infections, which can further damage the skin and increase the risk of complications.

Use alternating pressure mattresses, egg-crate mattresses, waterbeds, and sheepskins, as indicated.
This reduces dermal pressure, increases circulation, and diminishes the risk of tissue ischemia. The silicone mattress is a mattress made of a new type of semisolid material, whose outer layer is wrapped with a silicone layer and the inner layer is silicone gel. This kind of mattress has no fluidity, good flexibility, and pressure resistance, which can be naturally shaped according to the contour of the human body. In pressure injury-prone areas, such as bone protuberances, the use of a silicone mattress can evenly distribute the client’s mass and increase the area of force, which can effectively reduce the pressure, shear, and friction per unit area of the body surface to avoid skin damage and the formation of pressure ulcers (Chen et al., 2022).

Administer cholestyramine, ursodeoxycholic acid, rifampicin, and selective serotonin reuptake inhibitors (SSRIs) as indicated.
See Pharmacologic Management

Apply topical antipruritic agents such as ammonium lactate skin cream as indicated.
See Pharmacologic Management

Assist in preparing the client for narrowband ultraviolet B therapy (nbUVB).
nbUVB is commonly used in the dermatologic setting to treat itch and inflammatory disorders of the skin. The antipruritic effect of phototherapy may be due to an alteration of cytokine release, depletion of Langerhans cells, chemical modification of pruritogens in the skin, and the reduction of skin sensitivity to pruritogens (Patel et al., 2020).

4. Improving Breathing Pattern and Preventing Respiratory Complications

Pulmonary complications may occur in clients either with or without decompensation of liver disease. These specific disorders need to be distinguished from primary lung diseases, such as COPD, which may occur in clients with liver disease as well but are not pathogenically related to liver cirrhosis. The most frequent and clinically specific relevant pulmonary complications are hepatic hydrothorax, spontaneous pulmonary empyema, hepatopulmonary syndrome, and portopulmonary hypertension (Benz et al., 2020).

Monitor respiratory rate, depth, and effort.
Rapid shallow respiration or the presence of dyspnea may appear because of hypoxia and/or fluid accumulation in the abdomen. Classic hepatopulmonary syndrome (HPS) is marked by the symptom of platypnea (shortness of breath relieved when lying down and worsened when sitting or standing), and the finding of orthodeoxia (decrease in the arterial oxygen tension when the client moves from a supine to an upright position) (Wolf & Anand, 2020).

Auscultate breath sounds, noting crackles, wheezes, and rhonchi.
This may indicate developing complications. The presence of adventitious breath sounds may reflect the accumulation of fluids or secretions. Absent or diminished sounds suggest atelectasis. An isolated occurrence of hepatic hydrothorax without ascites may be conditioned by the negative intrathoracic pressure generated during inspiration, promoting fluid accumulation in the pleural space rather than in the abdominal cavity. Respiratory failure and tension hydrothorax with consecutive cardiac failure have also been described (Benz et al., 2020).

Investigate changes in the level of consciousness.
Changes in mentation may reflect hypoxemia and respiratory failure, which often accompany hepatic coma. Hepatic encephalopathy, a syndrome observed in some clients with cirrhosis, is marked by personality changes, intellectual impairment, and a depressed level of consciousness. Clients with mild and moderate hepatic encephalopathy demonstrate decreased short-term memory and concentration on mental status testing (Wolf & Anand, 2020).

Monitor temperature. Note the presence of chills, increased coughing, and changes in the color, and character of sputum.
These are indicative of the onset of infection, especially pneumonia. Spontaneous bacterial empyema is a specific complication of hepatic hydrothorax, analogous to spontaneous bacterial peritonitis in the context of ascites. Clinical symptoms are specific, a cardinal symptom is a fever with the clinical picture of decompensated liver cirrhosis (Benz et al., 2020).

Monitor serial ABGs, pulse oximetry, vital capacity measurements, and chest x-rays.
See Laboratory and Diagnostic Procedures

Monitor laboratory results for renal function.
See Laboratory and Diagnostic Procedures

Keep the head of the bed elevated. Position on sides.
This facilitates breathing by reducing pressure on the diaphragm and minimizes the risk of aspiration of secretions. During complaints of dyspnea or orthopnea, assist the client into a semi-Fowler or high-Fowler position. These positions promote gas exchange, which is likely to be altered by the pressure of the ascitic fluid on the diaphragm.

Encourage frequent repositioning and deep-breathing exercises and coughing exercises.
These measures aid in lung expansion and mobilizing secretions. Deep breathing expands the alveoli and aids in mobilizing secretions to the airway. Position changes help by shifting mucus and other fluids from the lungs and airways, making it easier to cough them up and expel them from the body. This helps prevent the pooling of fluids in one area of the lungs, which can lead to infections and other respiratory complications.

Provide supplemental O₂ as indicated.
This helps treat or prevent hypoxia and if respirations and oxygenation are inadequate, mechanical ventilation may be required. All clients with mild to moderate HPS should be evaluated every 3 to 6 months with ABG. All clients with oxygen saturation of less than 89% or partial pressure of oxygen less than 55 mm Hg at rest, exercise, and while asleep should be provided supplemental oxygen (Surani, 2021).

Demonstrate and assist with the incentive spirometer or pulmonary function tests.
This reduces the incidence of atelectasis and enhances the mobilization of secretions. A pulmonary function test should be performed to rule out other associated intrinsic pulmonary disorders. Pulmonary function tests may show decreased diffusion capacity for carbon monoxide (Bansal et al., 2022).

Prepare the client for contrast-enhanced echocardiography.
See Laboratory and Diagnostic Procedures

Prepare for/assist with acute care procedures.

• Paracentesis
  This is occasionally done to remove ascites fluid to relieve abdominal pressure when respiratory embarrassment is not corrected by other measures. Large-volume paracentesis is thought to be safe in clients with peripheral edema and in clients not currently treated with diuretics. A study demonstrated that large-volume paracentesis could be performed with minimal or no impact on renal function. This and other studies showed that 5 to 15 liters of ascites could be removed safely at one time (Wolf & Anand, 2020).
• Peritoneovenous shunt
  This is a surgical implant of a catheter to return accumulated fluid in the abdominal cavity to the systemic circulation via the vena cava; this also provides long-term relief of ascites and improvement in respiratory function. However, this should be the last resort for clients with refractory ascites who are not candidates for TIPS or liver transplantation. The safety of repeat large-volume paracentesis procedures may actually outweigh the safety of peritoneovenous shunt placement (Wolf & Anand, 2020).
• Transjugular intrahepatic portosystemic shunts (TIPS)
  A TIPS is an effective tool in managing massive ascites in some clients. Ideally, TIPS placement produces a decrease in sinusoidal pressure and in plasma renin and aldosterone levels, with subsequent improved urinary sodium excretion. However, the creation of a TIPS has the potential to worsen pre-existing hepatic encephalopathy and exacerbate liver dysfunction in clients with severe, underlying liver failure (Wolf & Anand, 2020).
• Liver transplantation
  Clients with massive ascites have a 1-year survival rate of less than 50%. Liver transplantation should be considered as a potential means of salvaging the client prior to the onset of intractable liver failure or hepatorenal syndrome (Wolf & Anand, 2020).

Educate the client regarding the benefits of including garlic in the diet.
Garlic has allicin which is a potent vasodilator and anti-angiogenesis. It shows significant improvement in gas exchange in small studies, which include one randomized controlled trial. Large trials are still required to prove its benefit (Surani, 2021).

5. Promoting Safety and Preventing Injury

The obstruction to blood flow through the liver caused by fibrotic changes also results in the formation of collateral blood vessels in the GI system and the shunting of blood from the portal vessels into blood vessels with lower pressures. As a result, the client with cirrhosis often has prominent distended abdominal vessels, which are visible on abdominal inspection, and distended blood vessels throughout the GI tract. The esophagus, stomach, and lower rectum are common sites of collateral blood vessels. These distended blood vessels form varices or hemorrhoids, depending on their location.

Closely assess for signs and symptoms of GI bleeding: check all secretions for frank or occult blood. Observe the color and consistency of stools, NG drainage, or vomitus.
The esophagus and rectum are the most usual sources of bleeding because of their mucosal fragility and alterations in hemostasis associated with cirrhosis. Because these vessels were not intended to carry the high pressure and volume of blood imposed by cirrhosis, they may rupture and bleed. Therefore, assessment must include observation for occult and frank bleeding from the GI tract.

Observe the presence of petechiae, ecchymosis, and bleeding from one or more sites.
Subacute disseminated intravascular coagulation (DIC) may develop secondary to altered clotting factors. Bruising, melena, and hematemesis are signs of bleeding. Altered vital signs, irritability, air hunger, pallor, and weakness are signs of significant bleeding and necessitate prompt intervention.

Monitor pulse, BP (and CVP if available).
An increased pulse with decreased BP and CVP can indicate a loss of circulating blood volume, requiring further evaluation. In a study, signs of vital instability were present in 43% of the participants, with hypotension and tachycardia upon admission. Portal hypertension causes varices or mucosal changes in the lower gastrointestinal tract that lead to lower GI bleeding (Khalifa & Rockey, 2020).

Note changes in mentation and LOC.
Changes may indicate decreased cerebral perfusion secondary to hypovolemia, and hypoxemia. Variceal bleeding can cause hypovolemia and hypotension, which can lead to reduced oxygen delivery to the brain. This can result in hypoxia, which can lead to confusion, disorientation, and altered mental status.

Monitor hemoglobin and hematocrit and clotting factors.
These are indicators of anemia, active bleeding, or impending complications. There can be pancytopenia due to hypersplenism in portal hypertension, impaired coagulation, disseminated intravascular coagulation, and hemosiderosis in cirrhosis clients due to different causes (Farci, 2022).

Avoid rectal temperature; be gentle with GI tube insertions.
Rectal and esophageal vessels are most vulnerable to rupture. Avoid invasive procedures such as giving injections. If clotting is altered, invasive procedures could result in prolonged bleeding. Thrombocytopenia occurs in cirrhosis as a result of increased splenic consumption and decreased platelet production. Thrombocytopenia has been related to increased bleeding risk, particularly with counts below 50,000 and in the setting of varices (Flores et al., 2017).

Encourage the use of a soft toothbrush, and electric razor, avoiding straining for stool, vigorous nose blowing, and so forth.
In the presence of clotting factor disturbances, minimal trauma can cause mucosal bleeding. Sneezing, lifting, or vomiting increases intra abdominothoracic pressure, which can result in bleeding. The liver synthesizes coagulation factors, anticoagulants, proteins involved in fibrinolysis, and the platelet production regulator. Importantly, hepatic dysfunction perturbs the clotting process (Flores et al., 2017).

Use small needles for injections. Apply pressure to small bleeding and venipuncture sites for longer than usual.
This minimizes damage to tissues, reducing the risk of bleeding and hematoma. Clients with cirrhosis are at increased risk of bleeding due to impaired clotting function. A smaller gauge needle can help minimize trauma to the tissue and minimize bleeding. After withdrawing the needle, apply pressure to the injection site for a few minutes to minimize bleeding. If the client has bruising or bleeding at the intended injection site, the nurse may select an alternative injection site to minimize the risk of further bleeding.

Advice to avoid aspirin-containing products.
Aspirin prolongs coagulation, potentiating the risk of hemorrhage. Aspirin also increases overall GI bleeding risk by 60%. Aspirin is widely used for the prevention of vascular events but is associated with a sustained increase in the risk of significant bleeding. Many guidelines now caution against its use among those at increased bleeding risk (Mahady et al., 2020).

Administer vitamins, stool softeners, vasoconstrictors, vasodilators, antifibrinolytics, and thrombopoietin agonists as indicated.
See Pharmacologic Management

Provide gastric lavage at room temperature and cool saline solution or water as indicated.
In presence of acute bleeding, evacuation of blood from the GI tract reduces ammonia production and the risk of hepatic encephalopathy. Clients who underwent NGT lavage were matched with clients with similar characteristics who did not undergo NGT lavage and NGT lavage were associated with a shorter time to endoscopy (Saltzman, 2023).

Assist with insertion and maintenance of GI tube.
This temporarily controls bleeding of esophageal varices when controlled by other means (e.g., lavage), and hemodynamic stability cannot be achieved. NGT lavage can remove particulate matter, fresh blood, and clots from the stomach to facilitate endoscopy. It can also be used when it is unclear that the client has ongoing bleeding and might benefit from an early endoscopy.

Prepare for surgical procedures: direct ligation (banding) or varices, esophagogastric resection, splenorenal-portocaval anastomosis.
These may be needed to control active bleeding or to decrease portal and collateral blood vessel pressure to minimize the risk of recurrence of bleeding. The decision to obtain surgical and interventional radiology consultations prior to endoscopy should be based on the likelihood of persistent or recurrent bleeding, or risks/complications stemming from endoscopic therapy (Sterns, 2023).

Educate the client to avoid swallowing foods that are chemically or mechanically irritating.
Rough or spicy foods, hot foods, hot liquids, and alcohol may be injurious to the esophagus and result in bleeding. A soft diet eliminates foods that are difficult to chew or swallow, and in the case of esophageal varices and foods that may further irritate the esophagus. The client should also avoid foods that may tear the veins in the esophagus, such as taco shells, tortilla chips, hard vegetables such as carrot sticks, and large pieces of raw fruit. To limit the irritation, the client may eat five to six small meals a day (Kent, 2017).

Encourage intake of foods rich in vitamin K, such as spinach, cabbage, cauliflower, and liver.
These foods may help decrease prothrombin time. They can help reduce the risk of bleeding by ensuring that the body has sufficient clotting factors to form clots when needed. Vitamin K is a nutrient that is essential for blood clotting, which is the process by which the body forms clots to stop bleeding. Vitamin K also counteracts the effects of certain medications, such as warfarin. By consuming adequate amounts of vitamin K, clients taking these medications can help maintain a healthy balance between clotting and bleeding.

Administer blood and blood products as prescribed.
When there is severe anemia and uremia, raising the hematocrit by more than 25% may improve the margination of platelets and hemostasis by transfusing red blood cells. The total volume infused is approximately 250 mL/unit. Platelets pooled from five or six single donors or that derive from apheresis of a single donor when infused can be expected to increase the platelet count by 5,000 to 10,000. Prothrombin complex off-label use has been reported in cirrhosis and has the advantage of correcting vitamin K-dependent clotting factor deficiencies (O’Leary et al., 2019).

6. Preventing Hepatic Encephalopathy

Hepatic encephalopathy, a syndrome observed in some clients with cirrhosis, is marked by personality changes, intellectual impairment, and a depressed level of consciousness. The diversion of portal blood into the systemic circulation appears to be a prerequisite for the syndrome. Clients may have altered brain energy metabolism and increased permeability of the blood-brain barrier. The latter may facilitate the passage of neurotoxins into the brain (Wolf & Anand, 2020).

Observe for signs and symptoms of behavioral change and mentation: lethargy, confusion, drowsiness, slurring of speech, and irritability.
Ongoing assessment of behavior and mental status is important because of fluctuating nature of the impending hepatic coma. Clients with mild and moderate hepatic encephalopathy demonstrate decreased short-term memory and concentration on mental status testing (Wolf & Anand, 2020).

Review the current medication regimen. Note adverse drug reactions and the effects of medication on the client.
Adverse drug reactions or interactions (e.g., cimetidine plus antacids) may potentiate and/or exacerbate confusion. Cimetidine-associated mental confusion is described in older adults, clients with renal or hepatic failure, or clients given high doses of the drug. Additionally, cimetidine can delay the clearance of benzodiazepines that are administered to reduce mental confusion (Pino & Azer, 2022).

Evaluate sleep and rest schedule.
Difficulty falling or staying asleep leads to sleep deprivation, resulting in diminished cognition and lethargy. Sleep disturbances are more common in clients with cirrhosis. Sleep efficiency and the client’s subjective quality of sleep improved with medications such as hydroxyzine, but caution must be used when taking this drug because it may worsen encephalopathy in some clients (Wolf & Anand, 2020).

Note the development or presence of asterixis, fetor hepaticus, and seizure activity.
This suggests elevating serum ammonia levels; increased the risk of progression to encephalopathy. In terms of the physical examination finding of asterixis, it must be emphasized that the flapping tremor of the extremities is also observed in uremia, pulmonary insufficiency, and barbiturate toxicity. Extrapyramidal symptoms including tremor, bradykinesia, cog-wheel rigidity, and shuffling gait, have been described in clients with portosystemic shunting (Wolf & Anand, 2020).

Consult with family caregivers about the client’s usual behavior and mentation. Perform a baseline assessment of the client’s personality characteristics, LOC, and orientation.
This provides a baseline for comparison of current status. Enlist the aid of the client’s significant others to help determine slight changes in personality or behavior. Having a baseline assessment will help determine subsequent changes in personality or behavior, which could progress to hepatic coma if left unchecked.

Investigate temperature elevations. Monitor for signs of infection.
Infection may precipitate hepatic encephalopathy caused by tissue catabolism and the release of nitrogen. Infection may predispose to impaired renal function and increased tissue catabolism, both of which increase blood ammonia levels. Inflammation in conjunction with ammonia also appears to play a role in hepatic encephalopathy in clients with cirrhosis, which may indicate that different types of anti-inflammatory therapy may be a potential therapeutic approach (Wolf & Anand, 2020).

Utilize testing strategies to identify hepatic encephalopathy.
Testing for minimal and covert hepatic encephalopathy is important because it may indicate poor quality of life and reduced socio-economic potential, and help counsel clients and caregivers about the disease. The Portosystemic Encephalopathy (PSE) Syndrome Test consists of five paper-pencil tests that evaluate cognitive and psychomotor processing speed and visual-motor coordination. The Continuous Reaction Times test (CRT) relies on repeated registration of motor reaction time to auditory stimuli. The test can differentiate between organic and metabolic brain impairment and is not influenced by the client’s age or gender, and there is no learning or tiring effect (Ferenci, 2017). 

Have the client write their name periodically and keep this record for comparison. Report deterioration of ability. Have the client do simple arithmetic computations.
An easy test of neurological status and muscle coordination. If writing deteriorates, hepatic encephalopathy may be worsening. The presence of disorientation and asterixis are characteristics of grade 2 hepatic encephalopathy (Wolf & Anand, 2020).

Reorient to time, place, and person as needed.
This assists in maintaining reality orientation, reducing confusion and anxiety. Reorientation to reality is a technique often used in the healthcare setting to help clients who are experiencing confusion or disorientation. This technique involves helping the client to become aware of their surroundings and the current situation, and to reestablish their connection to reality.

Maintain a pleasant, quiet environment and approach in a slow, calm manner. Encourage uninterrupted rest periods.
This reduces excessive stimulation and sensory overload, promotes relaxation, and may enhance coping. Rest also reduces the demands on the liver and increases the liver’s blood supply. After nutritional status improves and strength is increased, the nurse may encourage the client to increase activity gradually. Activity and mild exercises, as well as rest, are also planned.

Provide continuity of care. If possible, assign the same nurse over a period of time.
Familiarity provides reassurance, aids in reducing anxiety, and provides more accurate documentation of subtle changes. When the client is familiar with the surroundings and people around them, they may feel more comfortable and less vulnerable to potential dangers or threats, therefore increasing the sense of safety and security.

Reduce provocative stimuli and confrontation. Refrain from forcing activities.
This avoids triggering agitated, violent responses and promotes client safety. With minimal hepatic encephalopathy, clients may have normal abilities in the areas of memory, language, construction, and pure motor skills. However, clients with hepatic encephalopathy demonstrate impaired complex and sustained attention. They may have a delay in the choice reaction time (Wolf & Anand, 2020).

Discuss the current situation and future expectations.
The client or family caregivers may be reassured that intellectual (as well as emotional) function may improve as liver involvement resolves. By providing them with clear and accurate information about their situation, they may feel more in control and less overwhelmed. This will help decrease the level of anxiety or fear that the client may be experiencing as a result of their confusion.

Maintain bedrest, and assist with self-care activities.
This reduces metabolic demands on the liver, prevents fatigue, and promotes healing, lowering the risk of ammonia buildup. Successful treatment depends on convincing the client of the need to adhere completely to the therapeutic plan. This includes rest, lifestyle changes, adequate dietary intake, and elimination of alcohol.

Identify and provide safety needs. Assist when ambulation is needed, put the bed in a low position, and raise the side rails and pad if necessary.
This reduces the risk of injury when confusion, seizures, or violent behavior occurs. The side rails should be in place and pads used in case the client becomes agitated or restless. Because of the client’s encephalopathy and resulting neurosensory changes, reminders and reorientation are necessary to help ensure the client’s safety. Additionally, the client experiencing alcohol withdrawal would place the client at risk for seizures.

Recommend avoidance of narcotics or sedatives, anti-anxiety agents, and limiting or restricting the use of medications metabolized by the liver.
Certain drugs are toxic to the liver, whereas other drugs may not be metabolized because of cirrhosis, causing cumulative effects that affect mentation, mask signs of developing encephalopathy, or precipitate coma. Avoid medications that depress the central nervous system function, especially benzodiazepines. Clients with severe agitation and hepatic encephalopathy may receive haloperidol as a sedative (Wolf & Anand, 2020).

Eliminate or restrict protein in the diet. Provide glucose supplements and adequate hydration.
Ammonia (the product of the breakdown of protein in the GI tract) is responsible for mental changes in hepatic encephalopathy. Dietary changes may result in constipation, which also increases bacterial action and the formation of ammonia. Glucose provides a source of energy, reducing the need for protein catabolism. Protein restriction may be appropriate in some clients immediately following a severe flare of symptoms. However, protein restriction is rarely justified in clients with cirrhosis and persistent hepatic encephalopathy. Clients with mild chronic hepatic encephalopathy tolerate more than 60 to 80 g of protein per day (Wolf & Anand, 2020).

Promote the use of vegetable proteins rather than meat proteins.
Diets containing vegetable proteins appear to be better tolerated than diets rich in animal proteins, especially proteins derived from red meats. This may be because of the increased content of dietary fiber, a natural cathartic, and decreased levels of aromatic amino acids. Aromatic amino acids, as precursors of the false neurotransmitter tyramine and octopamine, are thought to inhibit dopaminergic neurotransmission and worsen hepatic encephalopathy (Wolf & Anand, 2020).

Administer cathartics, antibiotics, zinc, and L-ornithine L-aspartate (LOLA) as indicated.
See Pharmacologic Management

7. Promoting Positive Self Body Image

Living with cirrhosis has a marked impact on the quality of life of the individual. Health-related quality of life (HRQOL) is the individual’s perception of their physical, cognitive, emotional, and social functioning. Studies report that physical and psychological factors affect the quality of life of clients with cirrhosis which can be problematic and debilitating. There is strong evidence that indicates that disease severity is associated with an impairment of the client’s HRQOL. For example, gross ascites cause abdominal discomfort, breathlessness, increased stress, and anxiety related to body image, immobility, and an increased likelihood of falls (Polis & Fernandez, 2015).

Discuss the situation and encourage the verbalization of fears and concerns. Explain the relationship between the nature of disease and symptoms.
The client is very sensitive to body changes and may also experience feelings of guilt when the cause is related to alcohol or other drug use. The management of ascites involves frequent invasive procedures, an increase in pill burden, and the implementation of dietary restrictions, all of which impact HRQOL (Polis & Fernandez, 2015).

Assess changes in appearance and the meaning these changes have for the client and family.
This provides information for assessing the impact of changes in appearance, sexual function, and role on the client and family.
Clients with cirrhosis experience anxiety, reduced social interaction, delayed treatment, regret, need for awareness, reduced sexual relationships, and financial problems. As derived from the study participant’s experiences, it was found that most of the clients with cirrhosis had a low quality of life (Abdi et al., 2015).

Assess the client’s and family’s previous coping strategies.
This permits encouragement of those coping strategies that are familiar to the client and have been effective in the past. Active coping styles such as active problem-solving are predominantly used. Sociodemographic factors like gender, family status/partnership background, and employment do not seem to influence emotional state or coping style, according to a study (Kraus et al., 2000).

Support and encourage the client; provide care with a positive, friendly attitude.
A few participants in a study recounted stories in which clients experienced prejudice and discrimination from healthcare professionals when they received a diagnosis of cirrhosis. This was expressed particularly by participants with cirrhosis due to alcohol misuse or chronic hepatitis (Brown et al., 2022). Caregivers sometimes allow judgmental feelings to affect the care of the client and need to make every effort to help the client feel valued as a person.

Encourage family and caregivers to verbalize feelings, visit freely and participate in care.
Family members may feel guilty about the client’s condition and may be fearful of impending death. They need nonjudgmental emotional support and free access to the client. Participation in care helps them feel useful and promotes trust between staff, the client, and caregivers. Support persons were reported by clients to play an important role across a wide range of practical support, as well as a key role in encouraging clients to seek medical care (Brown et al., 2022).

Assist the client and family caregivers to cope with change in appearance; suggest clothing that does not emphasize altered appearance (color of clothes, etc).
The client may present an unattractive appearance as a result of jaundice, ascites, and ecchymotic areas. Providing support can enhance self-esteem and promote the client’s sense of control. This also encourages the client to continue safe roles and functions while encouraging the exploration of alternatives.

Refer to support services, counselors, and psychiatric resources, social services, clergy, and alcohol treatment program may help.
Increased vulnerability and concerns associated with this illness may require the services of additional professional resources. Patient transport services designed to assist clients with chronic illnesses to access healthcare on a regular basis are an important aspect of health service delivery. For many, the support received from health professionals, and in particular liver specialist nurses, was instrumental in their engagement with cirrhosis self-management and care (Brown et al., 2022).

Assist the client in identifying short-term goals and include them in planning care.
Accomplishing these goals serves as positive reinforcement and increases self-esteem. Some participants in a study made suggestions around improved information flow and strategies that could be used to provide more client education such as the provision of information in waiting rooms (Brown et al., 2022).

Provide the client with accurate and up-to-date information regarding their condition.
Many participants in a study highlighted the importance of knowledge and the need for use of tailored resources to overcome issues with health literacy. The use of visual resources was seen to be beneficial in the provision of cirrhosis information and care. This provides the client with a sense of control by learning about their disease condition (Brown et al., 2022).

Establish rapport with the client and family through effective and therapeutic communication.
Communication between clients and health professionals can become a potential impediment to good health outcomes in chronic disease settings. Potential solutions to effective client-health professional communication include recruiting more indigenous staff, providing appropriate cultural training for health professionals, including a client support person who can assist with communication during the clinical appointment, creating a safe environment, and allowing time in which to build rapport (Brown et al., 2022).

Assist the client in identifying previous practices that may have been harmful to self, such as alcohol and drug abuse.
Recognition and acknowledgment of the harmful effects of these practices are necessary for identifying a healthier lifestyle. Some participants in a study with a long history of alcohol misuse were aware that alcohol was a risk factor for cirrhosis, and acknowledged that the diagnosis was not unexpected. Although the experience of receiving a diagnosis was variable, some participants found that identification of cirrhosis was a source of relief or even reassurance and recognition of their concerns. Some accounts were also given about how inner strength facilitated the process of alcohol abstinence (Brown et al., 2022).

8. Initiating Patient Education and Health Teachings

Cirrhosis can change many aspects of clients’ lives and affect their families and society as a whole. When a family member becomes ill, all members are consequently affected. Educating these clients is necessary to control their disease, reduce its complications, and continue to enjoy their life (Abdi et al., 2015). Optimal management of cirrhosis can be complex. Chronic disease management is more effective if clients have the knowledge to manage their health (Brown et al., 2022).

Review disease process and prognosis and future expectations.
This provides a knowledge base from which the client can make informed choices. Health literacy refers to the degree to which individuals have the capacity to obtain, process, and understand basic health-related information needed to make appropriate health decisions. (Brown et al., 2022)

Identify environmental dangers such as exposure to hepatitis.
This can precipitate recurrence. Alcoholic liver disease once was considered to be the predominant source of cirrhosis in the United States, but hepatitis C has emerged as the nation’s leading cause of chronic hepatitis and cirrhosis (Wolf & Anand, 2020).

Assess the client’s awareness and knowledge about their disease and the treatment procedures.
The amount of knowledge and awareness clients have about their disease is a possible determining factor in how they experience their treatment course. A study reported that clients with hepatocellular carcinoma were also in search of information about their disease (Abdi et al., 2015).

Assess the client’s degree of anxiety.
From the healthcare provider’s point of view, the client’s initial experience of stress at the time of diagnosis is a good opportunity for stimulating a change in their behavior and triggering motivation. A study believed that when clients have the highest anxiety about their disease, they will possibly be more eager to absorb information and change their lifestyle. Thus, initial educational interventions for clients will yield better results  (Abdi et al., 2015).

Refer to a dietitian or nutritionist.
The client with cirrhosis needs close observation and sound nutritional counseling. During the hospital stay the nurse and other healthcare providers prepare the client with cirrhosis for discharge, focusing on dietary education. Of greatest importance is the exclusion of alcohol from the diet. The client may benefit from referral to Alcoholics Anonymous, psychiatric care, or counseling or support from a spiritual advisor.

Stress the importance of avoiding alcohol. Give information about community services available to aid in alcohol rehabilitation if indicated.
Alcohol is the leading cause of the development of cirrhosis. Many participants in a study recounted stories about alcohol cessation and counseling. Some accounts were given about how inner strength facilitated the process of alcohol abstinence. However, alcohol cessation counseling was viewed by some participants as a ‘little bit overwhelming’ as they were expected to talk about alcohol misuse in front of a group of people, while others expressed interest in counseling but said it was not offered to them or was not available where they lived (Brown et al., 2022).

Inform the client of the altered effects of medications with cirrhosis and the importance of using only drugs prescribed or cleared by a healthcare provider who is familiar with the client’s history.
Some drugs are hepatotoxic (especially narcotics, sedatives, and hypnotics). In addition, the damaged liver has a decreased ability to metabolize all drugs, potentiating cumulative effects and/or aggravation of bleeding tendencies. The institution of any new medical therapy warrants the performance of more frequent liver chemistries; clients with liver disease can ill-afford to have drug-induced liver disease superimposed on their condition (Wolf & Anand, 2020).

Review procedure for maintaining the function of peritoneovenous shunt when present.
Insertion of a Denver shunt requires the client to periodically pump the chamber to maintain the patency of the device. Clients with a LeVeen shunt may wear an abdominal binder and/or engage in a Valsalva maneuver to maintain shunt function. LeVeen shunts and Denver shunts are devices that permit the return of ascites fluid and proteins to the intravascular space. Plastic tubing inserted subcutaneously under local anesthesia connects the peritoneal cavity to the internal jugular vein or subclavian vein via a pumping chamber (Wolf & Anand, 2020).

Assist the client in identifying support person(s).
Because of the length of recovery, the potential for relapses, and slow convalescence, support systems are extremely important in maintaining behavior modifications. Support persons were reported by clients to play an important role across a wide range of practical support, as well as a key role in encouraging clients to seek medical care (Brown et al., 2022).

Emphasize the importance of good nutrition. Recommend avoidance of high-protein/salty foods, onions, and strong cheeses. Provide written dietary instructions.
Proper dietary maintenance and avoidance of foods high in sodium and protein aid in the remission of symptoms and help prevent ammonia buildup and further liver damage. Written instructions are helpful for the client to refer to at home. The client with cirrhosis without ascites, edema, or signs of impending hepatic coma should receive a nutritious, high-protein diet, if tolerated, supplemented by vitamins of the B complex, as well as A, C, and K. Sodium restriction is also indicated to prevent ascites.

Stress the necessity of follow-up care and adherence to the therapeutic regimen.
The chronic nature of the disease has the potential for life-threatening complications. This provides an opportunity for evaluation of the effectiveness of the regimen, including patency of shunt if used. Successful treatment depends on convincing the client of the need to adhere completely to the therapeutic plan. This includes rest, lifestyle changes, adequate dietary intake, and the elimination of alcohol.

Discuss sodium and salt substitute restrictions and the necessity of reading labels on food and OTC drugs.
This minimizes ascites and edema formation. Overuse of substitutes may result in other electrolyte imbalances. Food, OTC, and/or personal care products (antacids, some mouthwashes) may contain sodium or alcohol. The benefit of commercially available liquid nutritional supplements (which often contain moderate amounts of sodium) often exceeds the risk of slightly increasing the client’s salt intake (Wolf & Anand, 2020).

Encourage scheduling activities with adequate rest periods.
Adequate rest decreases metabolic demands on the body and increases the energy available for tissue regeneration. Rest reduces the demands on the liver and increases the liver’s blood supply. Because the client is susceptible to the hazards of immobility, efforts to prevent respiratory, circulatory, and vascular disturbances are initiated. These measures may help prevent such problems as atelectasis, pneumonia, venous thromboembolism, and pressure injuries.

Promote diversional activities that are enjoyable to the client.
This prevents boredom and minimizes anxiety and depression. Anxiety and depression may affect many aspects of cirrhosis care, from adherence to medications and self-care tasks to engagement with health services and with social risk behaviors such as alcohol misuse. Psychological needs such as diversional activities and psychosocial counseling may address the client’s need for more mental health care services (Brown et al., 2022).

Recommend avoidance of persons with infections, especially URI.
Decreased resistance, altered nutritional status, and immune response (leukopenia may occur with splenomegaly) potentiate the risk of infection. The client’s anemia, poor nutritional status, and poor state of health result in severe fatigue, which interferes with the ability to carry out routine activities of daily living. Clients with cirrhosis have a two- to three-fold higher risk of having bacterial infections and sepsis than other clients admitted to the hospital. Approximately 32 to 40% of hospitalized clients with cirrhosis develop bacterial infections either at admission or during hospitalization (Tonon et al., 2021).

Instruct the client or family caregivers of signs and symptoms that warrant notification of health care provider: increased abdominal girth; rapid weight loss/gain; increased peripheral edema; increased dyspnea, fever; blood in stool or urine; excess bleeding of any kind; jaundice.
Prompt reporting of symptoms reduces the risk of further hepatic damage and provides an opportunity to treat complications before they become life-threatening. The client is at increased risk for bleeding and hemorrhage because of decreased production of prothrombin and decreased ability of the diseased liver to synthesize the necessary substances for blood coagulation.

Instruct caregivers to notify health care providers of any confusion, untidiness, night wandering, tremors, or personality changes.
Changes (reflecting deterioration) may be more apparent to the family caregiver, although insidious changes may be noted by others with less frequent contact with the client. Monitoring is essential to identify early deterioration in mental status. An extensive baseline and ongoing neurologic evaluation are key to identifying progression through the four stages of encephalopathy.

Prepare the client and caregiver for transitional care.
Referral for transitional or home care may assist the client in dealing with the transition from hospital to home. The nurse should reinforce previous education and answer questions that may not have occurred to the client or family until the client is back home and trying to establish new patterns of eating, drinking, and lifestyle.

Support and encourage the client and the family in their recovery.
Recovery is neither rapid nor easy; there are frequent setbacks and an apparent lack of improvement. Many clients find it difficult to refrain from using alcohol for comfort or escape. The nurse has a significant role in offering support and encouragement to the client and in providing positive feedback when the client experiences success.

Institute effective communication with the client and the family.
The positive client-caregiver relationship is one of the determinants of a desirable commitment to treatment. Studies have shown that the client’s satisfaction with the treatment team relationship considerably increased the client’s commitment to treatment. When client-oriented care is given, the client’s participation in treatment increases (Abdi et al., 2015).

Provide information about religious services that the client and the family can utilize.
A study found that religious beliefs could help clients with cirrhosis confront their illness and deal with its complications. Worship, prayer, and visiting holy places can create hope in clients and enable them to better tolerate their condition. A number of studies have found that religion could be a major source of hope and support for clients coping with life-threatening diseases (Abdi et al., 2015).

9. Administer Medications and Provide Pharmacologic Support

Medications used for patients with liver cirrhosis aim to manage the underlying liver disease, prevent complications, and alleviate symptoms. They may include diuretics like spironolactone or furosemide to manage ascites and edema, lactulose or rifaximin to treat or prevent hepatic encephalopathy, beta-blockers like propranolol or nadolol to reduce the risk of variceal bleeding, and ursodeoxycholic acid to improve bile flow and protect liver cells.

Oral branch chain amino acids (BCAA) preparations
To improve hypoalbuminemia and amino acid imbalance, oral BCAA preparations are useful. Although oral BCAA preparations include BCAA granules and enteral nutrients for liver failure, they need to be properly used depending on the energy malnutrition state or the presence of hepatic encephalopathy. While supplemental administration of BCAA granular preparation maintains or increases the serum albumin concentration in decompensated liver cirrhosis clients, it prevents adverse events of liver cirrhosis and improves vital prognosis as well as the quality of life (Yoshiji & Kaji, 2019).

Diuretics such as spironolactone and furosemide
These should be used with caution to control edema and ascites, block the effect of aldosterone, and increase water excretion while sparing potassium when conservative therapy with bed rest and sodium restriction does not alleviate the problem. Aggressive diuretic therapy in hospitalized clients with massive ascites can safely induce a weight loss of 0.5 to 1 kg daily, provided that clients undergo careful monitoring of renal function. Diuretic therapy should be held in the event of electrolyte disturbances, azotemia, or induction of hepatic encephalopathy (Wolf & Anand, 2020).

Positive inotropic drugs and arterial vasodilators
These are given to increase cardiac output/improve renal blood flow and function, thereby reducing excess fluid. Nonselective beta-blockers (NSBBs) reduce portal pressure and are currently used for primary and secondary prophylaxis of variceal hemorrhage. Some reports suggested the protective effects of NSBBs in clients with decompensated cirrhosis are probably mediated by the reduction of intestinal permeability and inflammation, particularly in this advanced stage (Gallo et al., 2020).

V2 receptor antagonists
Vasopressin receptor antagonists are a class of agents with the potential to increase free-water excretion, improve diuresis, and decrease the need for paracentesis. However, no such agent has received US Food and Drug Administration (FDA) approval for this indication. Tolvaptan is an oral V2 receptor antagonist; it received FDA approval in 2009 only for the management of hyponatremia (Wolf & Anand, 2020).

Cholestyramine
The anion exchange resin cholestyramine currently remains the guideline-recommended first choice for the treatment of pruritus in liver diseases. The bile sequestrant can be applied in a dosage of a 4-g sachet, one hour before and after breakfast. Clients should be instructed to take cholestyramine with a minimum time interval of 4 hours to any medication due to possible interference with their intestinal absorption (Düll & Kremer, 2019).

Ursodeoxycholic acid
The bile acid ursodeoxycholic acid (UDCA)  is used as beneficial baseline therapy in several cholestatic conditions. UDCA treatment positively affects overall survival. However, UDCA at dosages of 13 to 15 mg/kg/day convincingly attenuated itch intensity solely in women. Pruritus improved in 73% of women as recently summarized in a meta-analysis of 11 randomized controlled trials (Düll & Kremer, 2019).

Rifampicin
Rifampicin is recommended as a second-line treatment for pruritus secondary to liver disease. Additionally, being an antibiotic drug, the intestinal and skin microbiome could also be modified by rifampicin. If well tolerated, rifampicin has the strongest antipruritic effect on hepatic itch and can be administered for a long period of time, up to many years. Monitoring of the laboratory results is recommended after 6 and 12 weeks of therapy as hepatotoxicity has to be considered a serious side effect (Düll & Kremer, 2019).

Selective serotonin reuptake inhibitors (SSRIs)
SSRIs may be considered the fifth-line option. A moderate itch-reducing effect was reported in a single placebo-controlled, cross-over trial using sertraline. Dosages for sertraline should be chosen at 75 to 100 mg/day (Düll & Kremer, 2019).

Topical antipruritic agents such as ammonium lactate skin cream
Mild itching complaints may respond to the treatment of topical ammonium lactate. Ammonium lactate lotion of 12% is indicated for the temporary relief of itching-associated liver cirrhosis.

Supplemental vitamins such as vitamins K, D, and C; use caution with vitamin A and iron supplements
This promotes prothrombin synthesis and coagulation if the liver is functioning. Vitamin C deficiencies increase the susceptibility of the GI system to irritation and/or bleeding. Vitamin K promotes clotting by providing fat-soluble vitamins necessary for clotting. Supplements or multivitamins that contain vitamin A can be toxic to the liver. Iron can be hard to process in high doses (Daniel, 2022).

Stool softeners
This prevents straining for stool with the resultant increase in intra-abdominal pressure and risk of vascular rupture and hemorrhage. Additionally, lactulose is administered to clients with hepatic encephalopathy, and this can also be helpful in stimulating the passage of ammonia from the tissues into the gut (Wolf & Anand, 2020).

Vasodilators
The main advantages of using vasoactive agents include the ability of these drugs to treat variceal bleeding in the emergency department, lower portal pressure, and offer the endoscopist a clearer view of varices because of less active bleeding (Carale & Anand, 2017).

Antifibrinolytics
Aminocaproic acid and tranexamic acid are administered by oral or IV routes for a short duration to reduce hyperfibrinolysis. Aminocaproic acid can be administered by mouth at a dose of 3 g four times daily until bleeding is controlled. Tranexamic acid is recommended at a dose of 1 g IV every 6 hours. These are rarely used prophylactically, but more commonly used as a rescue measure if bleeding occurs after procedures (O’Leary et al., 2019).

Vasoconstrictors
The vasoconstrictors somatostatin and octreotide are used to treat acute bleeding in clients with portal hypertension before performing an endoscopy. Intravenous infusions of octreotide will lower portal blood pressure and can prevent rebleeding during the client’s initial hospitalization (Carale & Anand, 2017).

Thrombopoietin agonists
Avatrombopag and lusutrombopag are both oral TPO agonists that have completed phase 3 trials and are now US FDA-approved for use in clients with liver disease. These agents can be used for a short duration in chronic liver disease to increase the platelet count before invasive procedures (O’Leary et al., 2019).

Cathartics
Lactulose and lactitol are non-absorbable disaccharides that have been in common clinical use since the early 1970s. They are degraded by intestinal bacteria to lactic acid and other organic acids. Lactulose appears to inhibit intestinal ammonia production and reduce colonic bacterial load (Wolf & Anand, 2020).

Antibiotics
Neomycin and other antibiotics, such as metronidazole, oral vancomycin, paromomycin, and oral quinolones, are administered in an effort to decrease the colonic concentration of ammoniagenic bacteria. Neomycin is usually reserved as a second-line treatment after the initiation of lactulose. Rifaximin, a nonabsorbable derivative of rifampin, was shown to be as effective as lactulose or lactitol at improving hepatic encephalopathy symptoms.

L-ornithine L-aspartate (LOLA)
LOLA  is available in Europe, but not in the United States. LOLA is a stable salt of the two constituent amino acids. L-ornithine stimulates the urea cycle, resulting in the loss of ammonia. LOLA was found to be effective in treating hepatic encephalopathy in a number of European trials (Wolf & Anand, 2020).

Zinc
Zinc administration has the potential to improve hyperammonemia by increasing the activity of ornithine transcarbamylase, an enzyme in the urea cycle. The subsequent increase in ureagenesis results in the loss of ammonia ions. Zinc sulfate and zinc acetate have been used at a dose of 600 mg orally every day in clinical trials (Wolf & Anand, 2020).

10. Monitoring Results of Diagnostic and Laboratory Procedures

Laboratory tests used for patients with liver cirrhosis include liver function tests (ALT, AST, bilirubin, albumin, and INR) to assess liver function and evaluate the severity of liver damage. Other tests such as complete blood count, renal function tests, viral hepatitis serology, and imaging studies like ultrasound or CT scan may be performed to further evaluate the liver and identify any underlying causes or complications associated with cirrhosis.

Serum glucose, prealbumin, albumin, total protein, prothrombin time (PT), and ammonia.
Glucose may be decreased because of impaired gluconeogenesis, depleted glycogen stores, or inadequate intake. Protein may be low because of impaired metabolism, decreased hepatic synthesis, or loss of the peritoneal cavity (ascites). Elevation of ammonia level may require a restriction of protein intake to prevent serious complications. PT is elevated due to coagulation factor defects and bilirubin, while albumin is low as it is synthesized by the liver and the liver’s functional capacity goes down. Thus, serum albumin and PT are true indicators of synthetic hepatic function (Farci, 2022).

ABGs, pulse oximetry, vital capacity measurements, and chest x-rays.
This reveals changes in respiratory status, therefore developing pulmonary complications. As an initial screening test, pulse oximetry with a cut-off of 96% saturation at room air can be used. SpO2 <96% was found to be highly sensitive and specific for detecting HPS in clients with a PaP2 <70 mm Hg. Clients with HPS generally present normal findings in spirometry and lung volume measurements. In ABG analysis, HPS is categorized by the degree of hypoxemia into mild (PaO2 >80 mm Hg, moderate (PaO2 60 to 79 mm Hg), severe (PaO2 50 to 59 mm Hg), and very severe (PaP2 <50 mm Hg) (Benz et al., 2020).

Renal function test
Hepatorenal syndrome is diagnosed when a creatinine clearance rate of less than 40 mL/minute is present or when a serum creatinine level of greater than 1.5 mg/dL, a urine volume of less than 500 mL/day, and a urine sodium level of less than 10 mEq/L are present. Urine osmolality is greater than plasma osmolality (Wolf & Anand, 2020).

Contrast-enhanced echocardiography.
Contrast-enhanced echocardiography with agitated saline is the gold standard for diagnosing pulmonary vascular dilatation. Normal saline is agitated to generate microbubbles > 10 micrometers in diameter. Normal saline is injected into a peripheral vein in the arm, and simultaneous transthoracic echocardiography (TTE) is performed. The appearance of microbubbles in the left atria between the 4th and 6th cardiac cycle indicates pulmonary vasodilatation (Bansal et al., 2022).

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See also

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References and Sources

Here are the references and sources for this Liver Cirrhosis Nursing Care Plan:

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