Nursing Care Plan for Cirrhosis of Liver
A comprehensive, evidence-based guide for nursing students
Introduction to Liver Cirrhosis
Cirrhosis of Liver is a chronic, progressive disease characterized by diffuse destruction and fibrotic regeneration of hepatic cells. Various insults can lead to liver injury, including viral infections, chronic alcohol consumption, toxins, hereditary conditions, and autoimmune processes. As necrotic tissues yield to fibrosis, the disease alters liver structure and vasculature, impairs blood and lymph flow, and ultimately causes hepatic insufficiency.
Common Causes:
- Alcoholic liver disease
- Non-alcoholic fatty liver disease (NAFLD)
- Chronic hepatitis B and C
- Autoimmune hepatitis
- Genetic disorders (hemochromatosis, Wilson’s disease)
- Biliary diseases (primary biliary cholangitis, primary sclerosing cholangitis)
Common Complications:
- Portal hypertension
- Ascites
- Esophageal varices
- Hepatic encephalopathy
- Coagulopathy
- Hepatorenal syndrome
- Hepatocellular carcinoma
Table of Contents
Imbalanced Nutrition: Less Than Body Requirements
Priority: High
NANDA Domain: Nutrition
Malnutrition is prevalent in cirrhosis, affecting 20-90% of patients depending on disease severity. Protein-calorie malnutrition increases complications and mortality in these patients.
Assessment Data
Unintentional weight loss (>5% in 3 months or >10% in 6 months)
Reduced muscle mass and subcutaneous fat (sarcopenia)
Anorexia, early satiety, altered taste perception
Abnormal lab values: decreased albumin, prealbumin, transferrin
Poor dietary intake and food preferences
Nausea, vomiting, indigestion
Abdominal discomfort due to ascites
Expected Outcomes
Patient will demonstrate progressive weight gain toward goal
Patient will consume 80-100% of estimated nutritional requirements
Patient will exhibit improved serum albumin levels (>3.5 g/dL)
Patient will maintain or improve muscle strength
Patient will verbalize understanding of nutritional needs specific to liver disease
Nursing Interventions
Conduct nutritional screening using validated tools (MUST, NRS-2002)
Early identification of malnutrition allows for timely intervention
Calculate and monitor caloric needs (30-35 kcal/kg/day) and protein requirements (1.2-1.5 g/kg/day)
Higher protein/calorie requirements help combat sarcopenia and malnutrition
Provide small, frequent meals (5-6 per day) including a bedtime snack
Reduces early satiety due to ascites and prevents overnight catabolism
Monitor anthropometric measurements (triceps skinfold, mid-arm muscle circumference)
Objective measures of nutritional status that aren’t affected by ascites
Schedule meals around medication administration and procedures
Maximizes nutritional intake and medication efficacy
Consult dietitian for individualized meal planning
Specialized nutrition advice improves dietary compliance and outcomes
Provide oral nutritional supplements between meals as needed
Supplements can help meet nutritional requirements when oral intake is insufficient
Monitor for vitamin deficiencies (especially fat-soluble vitamins A, D, E, K)
Impaired bile production affects absorption of fat-soluble vitamins
Excess Fluid Volume
Priority: High
NANDA Domain: Nutrition
Ascites is the pathological accumulation of fluid within the peritoneal cavity, occurring in 50-60% of cirrhosis patients within 10 years of diagnosis. It significantly impacts quality of life and indicates poor prognosis.
Assessment Data
Abdominal distention with shifting dullness on percussion
Increased abdominal girth measurements
Peripheral edema, especially lower extremities
Weight gain unrelated to nutritional intake
Dyspnea, orthopnea, decreased breath sounds at bases
Hypoalbuminemia (serum albumin <3.5 g/dL)
Elevated portal venous pressure (>10 mmHg)
Expected Outcomes
Patient will demonstrate decreased abdominal girth measurements
Patient will maintain balanced fluid intake and output
Patient will report improved comfort and reduced dyspnea
Patient will demonstrate reduced peripheral edema
Patient will maintain stable weight without excessive fluid accumulation
Nursing Interventions
Measure abdominal girth at the umbilicus daily at the same time
Provides objective measurement of ascites accumulation or resolution
Implement sodium restriction (2,000 mg/day or less as prescribed)
Sodium restriction helps reduce fluid retention and ascites formation
Administer diuretics as prescribed (spironolactone and furosemide combination)
Combination therapy enhances natriuresis while maintaining potassium balance
Monitor daily weights, vital signs, and I&O; report weight gain >0.5 kg/day
Rapid weight changes indicate fluid shifts requiring intervention
Elevate head of bed 30-45 degrees and position patient for optimal lung expansion
Reduces pressure on the diaphragm, improving respiratory function
Monitor serum electrolytes (especially sodium, potassium) and renal function
Diuretic therapy can lead to electrolyte imbalances and renal dysfunction
Prepare patient for paracentesis when indicated
Large-volume paracentesis provides symptomatic relief for tense ascites
Administer intravenous albumin as prescribed following large-volume paracentesis
Albumin helps maintain plasma oncotic pressure and prevents post-paracentesis circulatory dysfunction
Impaired Skin Integrity
NANDA Domain: Safety/Protection
Skin manifestations are common in cirrhosis due to jaundice, pruritus, edema, and malnutrition. Recognizing these changes early can prevent complications and improve quality of life.
Assessment Data
Jaundice (yellowing of skin and sclera)
Pruritus with excoriation marks from scratching
Spider angiomas and palmar erythema
Skin thinning and poor elasticity
Edema in dependent areas with shiny, taut skin
Ecchymoses and petechiae due to coagulopathy
Poor wound healing and increased vulnerability to pressure injuries
Expected Outcomes
Patient will maintain intact skin without breakdown
Patient will verbalize relief from pruritus
Patient will demonstrate appropriate skin care techniques
Patient will show no signs of new skin lesions or infections
Patient will verbalize methods to prevent skin injuries
Nursing Interventions
Perform comprehensive skin assessment every shift
Early detection allows for prompt intervention of skin issues
Apply emollients and moisturizers to prevent dryness
Maintains skin hydration and reduces risk of breakdown
Implement turning schedule every 2 hours for bed-bound patients
Reduces pressure on bony prominences and improves circulation
Keep fingernails short and consider mittens if scratching continues
Prevents skin damage from pruritus-induced scratching
Use pressure-reducing devices (specialty mattress, heel protectors)
Redistributes pressure to prevent tissue ischemia
Administer antihistamines and bile-binding agents as prescribed
Reduces pruritus caused by bile salt accumulation
Provide meticulous perineal care after elimination
Prevents skin irritation from bile salts in excretions
Elevate edematous extremities when seated or in bed
Promotes venous return and reduces edema in dependent areas
Ineffective Breathing Pattern
NANDA Domain: Activity/Rest
Respiratory complications in cirrhosis include hepatopulmonary syndrome, portopulmonary hypertension, and respiratory compromise due to ascites and pleural effusion.
Assessment Data
Dyspnea, orthopnea, and tachypnea
Decreased breath sounds in lung bases
Abnormal arterial blood gases (hypoxemia)
Limited diaphragmatic excursion due to ascites
Platypnea (dyspnea that worsens when sitting upright)
Use of accessory muscles for breathing
Hepatic hydrothorax (pleural effusion)
Expected Outcomes
Patient will maintain respiratory rate within normal range (12-20 breaths/min)
Patient will demonstrate improved oxygen saturation (>92%)
Patient will report decreased dyspnea with activity
Patient will demonstrate effective breathing techniques
Patient will maintain clear lung sounds bilaterally
Nursing Interventions
Position patient with head elevated 30-45 degrees or in semi-Fowler’s position
Decreases abdominal pressure on the diaphragm, improving lung expansion
Monitor respiratory rate, depth, and pattern every 4 hours and as needed
Early detection of respiratory compromise allows for prompt intervention
Auscultate lung sounds every shift and after interventions
Assesses for adventitious sounds indicating fluid accumulation or consolidation
Administer oxygen therapy as prescribed to maintain SpO2 >92%
Supplemental oxygen improves tissue oxygenation in hypoxemic patients
Teach pursed-lip breathing and diaphragmatic breathing techniques
Improves ventilation, reduces air trapping, and decreases work of breathing
Coordinate care to provide rest periods between activities
Prevents excess oxygen demand and reduces respiratory fatigue
Monitor for signs of respiratory infection (fever, productive cough)
Patients with cirrhosis are at higher risk for respiratory infections
Prepare for thoracentesis if pleural effusion (hepatic hydrothorax) develops
Removal of pleural fluid improves lung expansion and relieves dyspnea
Risk for Injury (Bleeding)
Priority: High
NANDA Domain: Safety/Protection
Bleeding risk in cirrhosis results from coagulopathy, thrombocytopenia, and portal hypertension, with variceal hemorrhage being life-threatening.
Assessment Data
Prolonged prothrombin time (PT) and elevated INR
Thrombocytopenia (platelets <50,000/μL)
Esophageal or gastric varices on endoscopy
History of previous gastrointestinal bleeding
Hematemesis, melena, or hematochezia
Easy bruising, petechiae, or gingival bleeding
Splenomegaly contributing to thrombocytopenia
Expected Outcomes
Patient will remain free from signs of bleeding
Patient will maintain stable hemoglobin and hematocrit levels
Patient will verbalize understanding of bleeding precautions
Patient will demonstrate proper technique for monitoring stools for occult blood
Patient will identify and report early signs of bleeding promptly
Nursing Interventions
Monitor for signs of bleeding every shift (skin, gums, IV sites, stool, urine)
Early detection of bleeding allows for prompt intervention
Check vital signs, including orthostatic measurements, to detect early hypovolemia
Orthostatic hypotension may be the first sign of occult bleeding
Use soft toothbrush and electric razor for oral care and shaving
Reduces trauma that could lead to bleeding in patients with coagulopathy
Apply pressure to venipuncture sites for at least 5 minutes
Extended pressure ensures clotting in patients with prolonged coagulation times
Administer blood products as prescribed (platelets, fresh frozen plasma)
Replaces clotting factors and platelets to reduce bleeding risk
Monitor hemoglobin, hematocrit, platelet count, and coagulation studies
Provides objective measurement of bleeding risk and response to interventions
Administer non-selective beta-blockers as prescribed for variceal prophylaxis
Reduces portal pressure and risk of variceal bleeding
Keep emergency equipment available for acute bleeding (large-bore IV access, airway equipment)
Ensures rapid response to potentially life-threatening hemorrhage
Critical Information:
Variceal hemorrhage has a 15-30% mortality rate within 6 weeks. For active bleeding, immediately:
- Establish two large-bore IV lines
- Draw blood for CBC, coagulation studies, cross-matching
- Prepare for endoscopic intervention
- Have octreotide and vasopressin available
Risk for Hepatic Encephalopathy
Priority: High
NANDA Domain: Perception/Cognition
Hepatic encephalopathy (HE) is a neuropsychiatric complication affecting up to 70% of patients with cirrhosis, resulting from the liver’s inability to clear neurotoxins from the bloodstream.
Assessment Data
Altered mental status, ranging from subtle changes to coma
Asterixis (flapping tremor) on hand extension
Disturbances in sleep-wake cycle
Impaired attention and concentration
Elevated serum ammonia levels
Fetor hepaticus (musty, sweet breath)
Precipitating factors: GI bleeding, infection, medication non-adherence
Expected Outcomes
Patient will maintain baseline mental status
Patient will demonstrate absence of asterixis
Patient/caregiver will identify precipitating factors for HE
Patient will adhere to medication regimen to prevent encephalopathy
Patient will maintain safe behavior and environment
Nursing Interventions
Perform neurological assessment q4h or as indicated using West Haven criteria for HE
Provides objective measurement of encephalopathy stage and progression
Administer lactulose as prescribed, titrating to 2-3 soft bowel movements daily
Reduces ammonia absorption from the intestines by acidifying colonic contents
Administer rifaximin as prescribed
Non-absorbable antibiotic reduces ammonia-producing gut bacteria
Implement safety precautions based on mental status (bed alarm, assistance with ambulation)
Prevents injury in patients with altered mental status
Maintain protein intake as prescribed (typically 1.2-1.5 g/kg/day)
Protein restriction is no longer recommended except during acute episodes
Monitor for and treat constipation promptly
Constipation increases intestinal ammonia production and absorption
Provide frequent reorientation and cognitive stimulation
Helps maintain cognitive function and reduces confusion
Avoid CNS depressants (benzodiazepines, opioids) when possible
These medications can precipitate or worsen HE
West Haven Criteria for Hepatic Encephalopathy:
- Grade 0: No abnormality (minimal HE detected only by specialized testing)
- Grade 1: Trivial lack of awareness, shortened attention span, sleep disturbances
- Grade 2: Lethargy, disorientation, personality changes, inappropriate behavior
- Grade 3: Somnolence, confusion, gross disorientation, bizarre behavior
- Grade 4: Coma, unresponsive to verbal or painful stimuli
Disturbed Body Image
NANDA Domain: Self-Perception
Physical changes in cirrhosis, including ascites, jaundice, muscle wasting, and spider angiomas, can significantly impact a patient’s self-perception and social engagement.
Assessment Data
Verbalization of negative feelings about body changes
Social isolation or withdrawal from activities
Refusal to look at or touch affected body parts
Concealing body with clothing or positioning
Visible physical changes (ascites, jaundice, muscle wasting)
Gynecomastia and testicular atrophy in males
Expressed feelings of shame or embarrassment
Expected Outcomes
Patient will verbalize acceptance of changed body appearance
Patient will participate in self-care and social activities
Patient will express positive aspects of self unrelated to physical appearance
Patient will utilize effective coping strategies for managing body image concerns
Patient will verbalize understanding of the relationship between disease process and physical changes
Nursing Interventions
Establish therapeutic relationship and encourage expression of feelings
Creates safe environment for discussing sensitive body image concerns
Provide education about the temporary or manageable nature of some physical changes
Understanding that some changes (e.g., ascites) can be managed helps reduce distress
Recommend clothing adaptations for comfort and appearance
Loose-fitting clothing with elastic waistbands accommodates ascites while maintaining dignity
Refer to support groups for cirrhosis or chronic illness
Peer support from others with similar experiences normalizes feelings and provides coping strategies
Include family/significant others in discussions about physical changes
Increases understanding and support from close relationships
Recommend counseling or psychotherapy when adjustment difficulties persist
Professional mental health support may be needed for severe body image distress
Focus on abilities rather than limitations during care interactions
Emphasizes remaining strengths and functional capacity
Teach grooming and hygiene strategies to enhance appearance
Maintaining appearance can improve self-esteem and social confidence
Deficient Knowledge
NANDA Domain: Perception/Cognition
Cirrhosis management requires complex self-care behaviors including medication adherence, dietary modifications, symptom monitoring, and lifestyle changes. Patient education is essential for effective disease management.
Assessment Data
Verbalization of misconceptions about disease process
Difficulty explaining rationale for treatment regimen
Poor adherence to treatment plan
Repeated hospital readmissions for preventable complications
Asking numerous questions about condition or expressing confusion
Limited prior experience with healthcare system
Cognitive impairment affecting learning ability
Expected Outcomes
Patient will verbalize understanding of cirrhosis and its management
Patient will demonstrate medication administration correctly
Patient will identify symptoms requiring medical attention
Patient will follow recommended dietary and fluid guidelines
Patient will maintain follow-up appointments with healthcare team
Nursing Interventions
Assess current knowledge level and learning preferences
Tailors education to the individual’s needs and preferred learning style
Provide simple, clear explanations about liver function and the effects of cirrhosis
Basic understanding of disease process improves adherence to treatment
Teach medication purpose, dosage, administration, and side effects
Understanding medications improves adherence and safety
Provide written instructions to supplement verbal teaching
Written materials reinforce learning and serve as reference after discharge
Educate about dietary restrictions (sodium, protein as applicable, alcohol abstinence)
Dietary adherence helps manage ascites and prevents encephalopathy
Teach self-monitoring techniques (daily weights, abdominal measurements, signs of bleeding)
Early recognition of complications allows for timely intervention
Include family/caregivers in teaching sessions
Support persons reinforce learning and assist with complex care needs
Provide information on community resources and support groups
Connects patients with ongoing support for chronic disease management
Key Education Topics:
- Disease process and potential complications
- Medication management (diuretics, lactulose, beta blockers)
- Sodium restriction and fluid management
- Absolute alcohol abstinence
- Recognition of warning signs (confusion, bleeding, increased ascites)
- Importance of regular medical follow-up
Activity Intolerance
NANDA Domain: Activity/Rest
Fatigue is reported in up to 81% of cirrhosis patients and significantly impacts quality of life. Contributing factors include anemia, malnutrition, metabolic disturbances, sleep dysregulation, and muscle loss.
Assessment Data
Reports of constant tiredness unrelieved by rest
Verbal report of no energy to complete desired activities
Abnormal heart rate or blood pressure response to activity
Exertional dyspnea during self-care activities
Muscular weakness and sarcopenia
Anemia (hemoglobin <12 g/dL in females, <13 g/dL in males)
Sleep disturbances (daytime somnolence, night awakening)
Expected Outcomes
Patient will report increased energy levels
Patient will perform activities of daily living with minimal assistance
Patient will demonstrate appropriate energy conservation techniques
Patient will establish a balance between activity and rest
Patient will participate in progressive physical activity program
Nursing Interventions
Assess fatigue severity using validated tools (e.g., Fatigue Severity Scale)
Provides objective measurement of fatigue and response to interventions
Plan care activities with scheduled rest periods
Prevents exhaustion and optimizes energy utilization
Assist with prioritizing essential activities
Helps patient focus limited energy on most important tasks
Monitor for and treat anemia as prescribed
Improving oxygen-carrying capacity can reduce fatigue
Implement sleep hygiene measures
Improves sleep quality, which can reduce daytime fatigue
Encourage small, frequent, nutrient-dense meals
Provides steady energy without digestive burden
Collaborate with physical therapy for individualized exercise program
Gradually increasing activity improves endurance and muscle strength
Teach energy conservation techniques (sitting while performing tasks, organized work spaces)
Reduces energy expenditure for routine activities
Risk for Infection
Priority: High
NANDA Domain: Safety/Protection
Patients with cirrhosis have a 2-3 fold higher risk of bacterial infections than other hospitalized patients. Infections may precipitate decompensation, hepatic encephalopathy, and hepatorenal syndrome.
Assessment Data
Altered immune function with reduced neutrophil function
Increased intestinal permeability and bacterial translocation
Malnutrition and poor wound healing
Invasive procedures (paracentesis, central lines, endoscopy)
Ascites (risk factor for spontaneous bacterial peritonitis)
Leukopenia due to hypersplenism
History of prior infections (especially SBP)
Expected Outcomes
Patient will remain free from signs and symptoms of infection
Patient will demonstrate proper hand hygiene technique
Patient will maintain normal temperature (36.5-37.5°C)
Patient will identify early signs of infection requiring medical attention
Patient will receive appropriate vaccinations
Nursing Interventions
Monitor for subtle signs of infection (confusion may precede fever)
Patients with cirrhosis may not mount typical febrile responses to infection
Implement strict hand hygiene and standard precautions
Hand hygiene is the most effective method to prevent nosocomial infections
Assess skin integrity daily and provide meticulous skin care
Intact skin provides the first line of defense against pathogens
Use aseptic technique for all invasive procedures
Reduces risk of introducing pathogens during necessary procedures
Administer SBP prophylaxis as prescribed for high-risk patients
Antibiotic prophylaxis reduces risk of spontaneous bacterial peritonitis
Encourage adequate nutrition to support immune function
Proper nutrition helps maintain immune system integrity
Ensure completion of recommended vaccinations (pneumococcal, influenza, hepatitis A/B)
Vaccination prevents common infections in immunocompromised patients
Monitor laboratory values (WBC, neutrophil count, inflammatory markers)
Provides early indication of infection even before symptoms appear
Common Infections in Cirrhosis:
- Spontaneous Bacterial Peritonitis (SBP): Often presents with subtle symptoms including mild abdominal pain, worsening ascites, or encephalopathy
- Urinary Tract Infections: Second most common infection in cirrhosis
- Pneumonia: More common in hospitalized patients with cirrhosis
- Cellulitis: Associated with edema in lower extremities
Impaired Social Interaction
NANDA Domain: Role Relationships
Cirrhosis can significantly impact social functioning due to physical limitations, stigma (especially with alcohol-related disease), and complications like encephalopathy affecting behavior.
Assessment Data
Reported difficulty in social situations
Withdrawal from previously enjoyed social activities
Expressed feelings of isolation or rejection
Stigma associated with liver disease, especially if alcohol-related
Visible physical changes affecting self-confidence
Energy limitations impacting social participation
Embarrassment about symptoms (ascites, encephalopathy)
Expected Outcomes
Patient will express satisfaction with social interactions
Patient will identify strategies to manage social situations
Patient will participate in meaningful social activities
Patient will utilize available support systems
Patient will express decreased feelings of stigma or social isolation
Nursing Interventions
Assess impact of disease on social relationships and roles
Establishes baseline for planning appropriate interventions
Encourage expression of feelings about social changes
Validates experiences and helps identify specific concerns
Provide information about support groups for liver disease
Connects patient with peers who understand unique challenges
Educate family members about disease process and needed support
Improves family understanding and reduces potential conflict
Assist patient in developing coping strategies for social situations
Provides tools for managing challenging social interactions
Recommend scheduling social activities during peak energy times
Matches social engagement with periods of best functioning
Refer to social work for community resource connections
Provides access to practical support for social engagement
Address alcohol use disorder when present with compassionate approach
Non-judgmental approach reduces stigma and enhances recovery
Disturbed Sensory Perception
NANDA Domain: Perception/Cognition
Neurotoxins accumulating in cirrhosis can affect sensory perception and cognitive function, ranging from subtle changes to overt encephalopathy.
Assessment Data
Altered response to environmental stimuli
Changes in cognitive processing and problem-solving
Altered concentration and attention span
Changes in sensory acuity (visual, auditory)
Disorientation to time, place, or person
Impaired psychomotor abilities (tremor, coordination)
Hallucinations or illusions in advanced stages
Expected Outcomes
Patient will demonstrate improved sensory-perceptual function
Patient will maintain orientation to person, place, and time
Patient/caregiver will recognize early signs of sensory disturbances
Patient will maintain safety despite sensory alterations
Patient will use compensatory techniques for sensory deficits
Nursing Interventions
Assess cognitive function with validated tools (Mini-Mental State Exam, Number Connection Test)
Provides objective measurement of cognitive changes over time
Create a calm, structured environment with minimal stimulation
Reduces confusion and sensory overload
Provide orientation cues (clock, calendar, familiar objects)
Reinforces orientation to time and place
Use short, simple sentences and allow extra time for response
Accommodates cognitive processing delays
Implement safety measures based on perceptual deficits
Prevents injury from misperception of environment
Monitor and treat underlying causes (encephalopathy, electrolyte imbalances)
Addressing root causes may improve sensory function
Educate caregivers about sensory-perceptual changes
Increases understanding and appropriate responses to altered perception
Schedule activities during periods of greatest alertness
Maximizes participation and comprehension
Imbalanced Nutrition: More Than Body Requirements
NANDA Domain: Nutrition
Non-alcoholic fatty liver disease (NAFLD) is a leading cause of cirrhosis, particularly in patients with obesity, diabetes, and metabolic syndrome. Weight management is crucial while preserving lean mass.
Assessment Data
BMI >30 kg/m² with sarcopenia (sarcopenic obesity)
Waist circumference >102 cm (men) or >88 cm (women)
History of metabolic syndrome components
Elevated liver enzymes associated with fatty infiltration
Sedentary lifestyle or limited physical activity
Poor dietary habits (high saturated fat, refined carbohydrates)
Insulin resistance or type 2 diabetes
Expected Outcomes
Patient will achieve gradual weight loss while maintaining muscle mass
Patient will demonstrate improved glycemic control
Patient will follow a liver-healthy diet pattern
Patient will engage in regular physical activity as tolerated
Patient will demonstrate improved metabolic parameters
Nursing Interventions
Consult with dietitian for individualized nutritional plan
Expert guidance ensures nutritional needs are met while supporting weight loss
Recommend Mediterranean diet pattern
Has demonstrated benefits for NAFLD and metabolic health
Encourage moderate weight loss of 0.5-1 kg per week
Gradual weight loss preserves muscle mass while reducing fat
Promote resistance training in addition to aerobic exercise
Helps preserve muscle mass during weight loss
Monitor insulin sensitivity and glycemic control
Improvements in these parameters indicate treatment effectiveness
Recommend avoiding fructose-sweetened beverages and processed foods
These foods contribute to hepatic fat accumulation
Encourage adequate protein intake (1.2-1.5 g/kg/day)
Prevents muscle loss during caloric restriction
Monitor liver function tests and imaging for improvement in steatosis
Provides objective evidence of intervention effectiveness
Mediterranean Diet Components for NAFLD:
- High in monounsaturated fats (olive oil)
- Rich in omega-3 fatty acids (fatty fish)
- Abundant fruits, vegetables, and fiber
- Whole grains instead of refined carbohydrates
- Limited red meat
- Moderate consumption of lean protein
Chronic Pain
NANDA Domain: Comfort
Pain in cirrhosis may arise from hepatomegaly, ascites, muscle cramps, or complications. Pain management is challenging due to altered medication metabolism and risk of hepatic encephalopathy.
Assessment Data
Reports of persistent or recurrent abdominal pain
Muscle cramps, particularly nocturnal leg cramps
Discomfort from tense ascites
Verbal or nonverbal pain behaviors
Right upper quadrant tenderness with hepatomegaly
Joint pain related to fluid retention
Self-limiting of activities due to discomfort
Expected Outcomes
Patient will report decreased pain intensity using pain scale
Patient will identify effective non-pharmacological pain management strategies
Patient will demonstrate increased participation in activities
Patient will verbalize understanding of safe pain management in liver disease
Patient will maintain cognitive function while achieving pain control
Nursing Interventions
Assess pain comprehensively using appropriate scales
Thorough assessment guides appropriate intervention selection
Administer acetaminophen as prescribed, not exceeding 2-3 g/day
Acetaminophen at reduced doses is generally safe in stable cirrhosis
Avoid NSAIDs due to bleeding risk and renal effects
NSAIDs increase risk of GI bleeding and can precipitate renal failure
Apply heat/cold therapy for localized pain
Non-pharmacological approaches avoid medication-related risks
Teach relaxation techniques and distraction methods
Cognitive strategies can reduce pain perception
Position for comfort with pillows supporting painful areas
Proper positioning can reduce strain on painful areas
Monitor for signs of hepatic encephalopathy if opioids are prescribed
Opioids may precipitate or worsen encephalopathy
Administer quinine (if prescribed) for muscle cramps
May reduce frequency and severity of muscle cramps
Pain Management Considerations in Cirrhosis:
- Acetaminophen: Limit to 2-3 g/day in stable cirrhosis; avoid in acute liver failure
- NSAIDs: Contraindicated due to bleeding risk and renal effects
- Opioids: Use with extreme caution; start with 50% of normal dose and monitor closely for encephalopathy
- Tramadol: Not recommended due to seizure risk and hepatic metabolism
- Avoid sedatives when possible to prevent worsening of encephalopathy
Risk for Impaired Liver Function
Priority: High
NANDA Domain: Safety/Protection
Preventing further liver damage is essential in cirrhosis management. This involves addressing modifiable risk factors and monitoring for early signs of decompensation.
Assessment Data
Ongoing alcohol consumption or substance use
Use of hepatotoxic medications
Uncontrolled metabolic conditions (diabetes, obesity)
Exposure to hepatitis viruses
Rising liver enzymes or worsening synthetic function
Development of new cirrhosis complications
Medication non-adherence
Expected Outcomes
Patient will demonstrate stable liver function tests
Patient will adhere to hepatoprotective practices
Patient will avoid hepatotoxic substances
Patient will maintain stable Child-Pugh or MELD score
Patient will identify early signs of decompensation
Nursing Interventions
Educate about absolute alcohol abstinence
Alcohol cessation may slow disease progression even in non-alcoholic cirrhosis
Screen all medications for potential hepatotoxicity
Many medications require dose adjustment or avoidance in cirrhosis
Provide hepatitis A and B vaccination if not immune
Superimposed viral hepatitis can cause acute decompensation
Monitor liver function tests and markers of synthetic function
Provides early indication of worsening liver function
Refer for addiction treatment if needed
Professional support increases success in maintaining abstinence
Educate about medication adherence importance
Regular use of prescribed medications helps prevent complications
Provide education about potential hepatotoxins (herbal supplements, certain foods)
Many patients are unaware of non-medication hepatotoxins
Ensure regular medical follow-up with hepatology team
Consistent monitoring allows early intervention for complications
Warning Signs of Decompensation:
Teach patients and caregivers to seek immediate medical attention for:
- New or worsening ascites
- Mental status changes or confusion
- Any bleeding (especially vomiting blood or black stools)
- Increasing jaundice
- Fever
- Significant decrease in urine output