8 Liver Cirrhosis Nursing Care Plans

Imbalanced Nutrition: Less Than Body Requirements

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).

Nursing Diagnosis

• Imbalanced Nutrition: Less Than Body Requirements

May be related to

• Inadequate diet; inability to process/digest nutrients
• Anorexia, nausea/vomiting, indigestion, early satiety (ascites)
• Abnormal bowel function

Possibly evidenced by

• Weight loss
• Changes in bowel sounds and function
• Poor muscle tone/wasting
• Imbalances in nutritional studies

Desired Outcomes

• 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.

Nursing Assessment and Rationales

1. 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.

2. 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).

3. 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). 

4. 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).

5. 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).

6. 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).

7. 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).

8. 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).

9. Monitor laboratory studies: 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).

10. 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).

Nursing Interventions and Rationales

1. 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).

2. 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).

3. 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).

4. 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).

5. 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).

6. 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).

7. 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).

8. 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).

9. 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).

10. 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.

11. 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).

12. 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).

13. 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).

14. 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).

15. Provide oral branch chain amino acids (BCAA) preparations as indicated.
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).