Integrated Nursing Practice

Cirrhosis takes place when the liver is permanently damaged due to replacement of healthy tissue with scar tissue. It is developed over several years which gradually cease the workability of the liver. It is one of the significant causes of death in Australia. Intervention for cirrhosis requires high amount of financial and other resources every year in Australia. The current study will consider the case study of Murray brown that is diagnosed with liver cirrhosis. Based on this case study the pathophysiology of cirrhosis in the light of the symptoms of Murray will be discussed. Analyzing the current case and requirements of the client, a intervention and follow-up planning will be developed. Risk factors that are likely to work behind being affected by this disease will also be identified. Medications and their pharmacokinetics and pharmacodynamics will be identified.

Liver Cirrhosis can be considered as an abnormality in the function of the liver due destructions of hepatocyte cells which is the reason that it is referred as hepatic cirrhosis. There are several causes that can cause liver cirrhosis in long termb. These are hepatitis B and C infection or consumption of high amount of alcohol over many years. These lead to the damage of the hepatocytes causing inflammation and turning the living cells into fibrotic ones (Yuli, Jing & Mei JIANG, 2019). 

Fibrosis is caused by the stellate cells that are located into the perisinusoidal space being surrounded by hepatocytes and sinusoid. Though the main role of the stellate cells is to store vitamin A, however, due to fibrosis paracrines make these cells active and change after the injury of hepatocytes take place. Stellate cells starts to transform the growth factor β1(TGF -β1) (Fabrellas et al., 2020). Accumulation of these growth factors lead to result in development of collagen significantly contributes to fibrosis and growth of the connective tissue. Tissue inhibitors such as Metalloproteinases 1 and 2 (TIMP 1 and 2), causes breakdown of the fibrotic tissues. In a simpler term, when the health liver parenchyma is replaced by the fibrotic tissue in liver forming scars that are irreversible can be considered as cirrhosis of the liver.

It has been identified from the case study that Murray used to drink heaviliy for twent years though he was diagnosed with cirrhosis 12 years ago. As per Murray, he was sober for the last two years. Symptoms that Murray has demonstrated include nausea, anorexia, abdominal discomfort. Additionally, physical examinations have found that Murray is malnourished and developed moderate ascites. Murray has jaundice of skin and sclera. He also has 4+ pitting oedema in his bilateral lower limbs. Additionally, the spleen and the liver have been observed to be palpable. The initial blood test report adds that levels of AST, bilirubin and ALT are increased. The death of the hepatocytes occurs due to the reason of constant exposure of the liver cells with toxic substance such as alcohol. As mentioned by Gimenes et al. (2017), non-functional connective tissues developed due to necrosis of the hepatocytes that causes an immune response in the liver.

The capacity of oral intake and absorption of the nutritional factors reduces which leads to malnourishment and anorexia. Several functions of the liver include formation of protein in the blood, factors for clotting, carrying and transporting the proteins to the body part where it is needed and optimise the level of albumin (Kimbell et al., 2018). The biles produced by the liver works as a filter for blood that returns from the digestive system, the blood is screened by Kupffer cells for bacteria which lead to metabolism of the drugs into the body. Disruption of these body processes lead to malnourishment and anorexia. Along with this, Murray is also facing diarrhoea and ascites that have also led Murray to decrease has oral intake. One of the major reasons behind vomiting blood is oesophageal varices. Apart from that, accumulation of un-conjugated bilirubin led to jaundice of sclera and skin.

There is a requirement of further assessment of Murray for developing understanding of health condition. History assessment will be conducted in the current case including physical and psychosocial assessment. As influenced by Gimenes et al., (2016), Murray is required to be assessed to understand if he has any symptoms such as high temperature, any changes in behavior, and change in the bowel habit. Gum, Stools and skin are also required to be assessed to identify if any bleeding occurs. Assessments will also address if any sign is shown by Murray such as palmar and erythema. The tolerance level, changes in lifestyle can also be addressed.

The goal of the follow up care is to enhance the sense of control within Murray so that he can effectively live his everyday life after being released. The follow up process will not merely include regular health checkup and suggestion. Rather, Murray is required to be provided with coordinated care support and guidance. This guidance will follow an addiction treatment. Murray is required to be assured with regular clinical supervision and he is required to be guided for performing certain rejuvenating tasks after he gets back into everyday life. The follow up care will be concerned about how much the patient is capable of sustaining sobriety (Hjorth et al., 2018). The family members of the client are required to be included in the treatment process. Collaboration can be established with them to ensure that they can assist the patient after he returns from healthcare organization.

The role of the community nurse includes mainly promotion of health. It is the responsibility of the community nurse to help Murray coping with the symptoms of the disease he is diagnosed with. Different factors such as inability to maintain health suggestions might lead to development of further complication. Here, the nurse is responsible for preventing development of complications. Additionally, family members of the patients are required to be aware of different aspects of the disease such as caring, medication, progress and others so that stress induced by the health condition of Murray can be reduced. The damage of asphyxia is required to be monitored in order to understand the vomiting condition of the client. The blood volume is also required to be assessed regularly. The skin disintegration is required to be prevented by the community nurse (Matthews et al., 2019). The oedematous lower extremities are required to be elevated. The patient is required to be provided with disease related education and proper communication is required to be established so that the psychological problems related to the body image can be resolved.

There are a number of risk factors associated with cirrhosis. These factors are responsible for increasing possibility of developing this health condition. It has been identified previously that the factors that causes damage to the liver cells lead to cirrhosis of liver. Injury can be caused by inflammation from hepatitis B or C (Hearn, Ellington & Jones, 2018). The formation of acetaldehyde and blockage in metabolizing of fat is resulted from alcohol use which is also a major risk factor for developing cirrhosis. A similar mechanism is observed in the case of steatohepatitis where accumulation of fat leads to severe injury in the liver. Apart from that, diabetes, steroid treatment and malnutrition of protein cause similar damage to the liver. Primarily these cause biliary cirrhosis, primary sclerosing cholangitis and others. In the current context that is prominent and has potential to harm further is alcohol use.

Therefore, there is a need for lifestyle modification which can be possible with the help of Murray and his family members. Education related to quitting smoking, drinking and other vital modification of lifestyle of the patient. Nazareth et al. (2016) suggests that it is required to develop client’s mental readiness for quitting alcohol consumption and smoking. Therefore, the nurse will educate the client and his family about the aversive impacts of the smoking and drinking. This is highly required as consumption of alcohol is responsible for damage of the liver tissue and gastric stimulation due to smoking. This might worsen the condition of Murray and bleeding can reoccur. Changes in the diet of Murray are also required to be considered in the lifestyle modification process. A low ammonia diet is required to be planned for the current patient so that may prevent the development of encephalopathy and decrease issues related to malnourishment. Apart from that, Murray is facing different health related problems which might cause psychological distress. Along with this, he is also unable to attend the family functions and cannot move freely (Atya et al., 2019). These might increase chances of developing psychological issues for which Murray is required to be engaged in indoor activities such as healthy exercise.

Medications that would be prescribed to Murray include Disulfiram which can be used for preventing chronic alcoholism by inducing unpleasantness with smallest amount of alcohol usage. Ofloxacin can be prescribed for preventing infections in liver. Octreotide will be helpful for preventing further hemorrhage of esophageal varices.

Complete absorption of Disulfiram after consuming it through oral administration, effects will be observable after 3 to 12 hours. This medication is “lipid-soluble” leading to initial localization of the tissues namely adipose. This is excreted through urine before which it performs oxidization. More than 5% of the medication can be eliminated through feces (Künzler‐Heule et al., 2016). It prevents the oxidization due to alcohol use by inhibiting aldehyde dehydrogenase at the end of aldehyde stage. Higher level of aldehyde can be produced by this medication as compared to the metabolism change by the normal alcohol.

Ofloxacin is well absorbed in the body through oral administration due to its capability of bioavailability (98%). This spreads over the tissue and the fluids of the body. 10% of the consumed drug is metabolized and 70%-80% is excreted through urine and feces (de Morais et al., 2017). It synthesizes with the bacterial DNA and its action spectrum includes “gram-positive and gram-negative aerobic bacteria”.

The Octreotide is distributed over plasma immediately after injecting. It binds with the serum lipoprotein and albumin preventing increased level of albumin into blood. This is eliminated by the body in a slower process and only 35% of the drug excreted through urine (El-Gohary et al., 2018).

In conclusion, it can be stated that cirrhosis is caused by replacement of healthy tissue of the liver with scarred tissue. Physiological and psychological assessment will be performed by the nurse along with collecting history properly. The community nurse will provide assistance to comfort the client and prevent further infection due to which lifestyle changes such as ammonia free diet is suggested. However, Disulfiram has been found to be most appropriate medication for the condition of Murray.

Reference List for Integrated Nursing Practice

Atya, M. S., Mekkawy, M. M., El-malek, A., Omar, M., & Abd Almeged, A. S. (2019). Effect of Nursing Teaching Guidelines Among Patients with Cirrhosis on Their Knowledge Regarding Minimizing Hepatic Encephalopathy. Assiut Scientific Nursing Journal, 7(18), 1-11. Retrieved on 10 August 2020 from:

de Morais, E. N., Conrad, D., Machado, G. C., de Oliveira Abreu, M., de Mattos, E. M., & da Cruz, S. A. C. (2017). Postoperative complications of liver transplant: evidence for the optimization of nursing care. Revista de Pesquisa: Cuidado é fundamental online, 9(4), 999-1007. Retrieved on 20 August 2020 from:

El-Gohary, M., Moore, M., Roderick, P., Watkins, E., Dash, J., Reinson, T., ... & Sheron, N. (2018). Local care and treatment of liver disease (LOCATE)–A cluster-randomized feasibility study to discover, assess and manage early liver disease in primary care. PLoS One, 13(12), e0208798. Retrieved on 20 August 2020 from:

Fabrellas, N., Carol, M., Palacio, E., Aban, M., Lanzillotti, T., Nicolao, G., ... & Gossard, A. (2020). Nursing Care of Patients With Cirrhosis: The LiverHope Nursing Project. Hepatology, 71(3), 1106-1116. Retrieved on 20 August 2020 from:

Gimenes, F. R. E., Motta, A. P. G., Silva, P. C. D. S. D., Gobbo, A. F. F., Atila, E., & Carvalho, E. C. D. (2017). Identifying nursing interventions associated with the accuracy used nursing diagnoses for patients with liver cirrhosis. Revista Latino-Americana de Enfermagem, 25. Retrieved on 20 August 2020 from:

Gimenes, F. R. E., Reis, R. K., da Silva, P. C. D. S., de Camargo Silva, A. E. B., & Atila, E. (2016). Nursing assessment tool for people with liver cirrhosis. Gastroenterology Nursing, 39(4), 264. Retrieved on 18 August 2020 from:

Hearn, C., Ellington, B. J., & Jones, R. (2018). The role of the nurse practitioner in the management of nonalcoholic fatty liver disease. Gastroenterology Nursing, 41(5), 424-426. Retrieved on 17 August 2020 from:

Hjorth, M., Sjöberg, D., Svanberg, A., Kaminsky, E., Langenskiöld, S., & Rorsman, F. (2018). Nurse-led clinic for patients with liver cirrhosis—effects on health-related quality of life: study protocol of a pragmatic multicentre randomised controlled trial. BMJ open, 8(10), e023064. Retrieved on 20 August 2020 from:

Kimbell, B., Murray, S. A., Byrne, H., Baird, A., Hayes, P. C., MacGilchrist, A., ... & Kendall, M. (2018). Palliative care for people with advanced liver disease: a feasibility trial of a supportive care liver nurse specialist. Palliative medicine, 32(5), 919-929. Retrieved on 19 August 2020 from:

Künzler‐Heule, P., Beckmann, S., Mahrer‐Imhof, R., Semela, D., & Händler‐Schuster, D. (2016). Being an informal caregiver for a relative with liver cirrhosis and overt hepatic encephalopathy: a phenomenological study. Journal of clinical nursing, 25(17-18), 2559-2568. Retrieved on 18 August 2020 from:

Matthews, K., MacGilchrist, A., Coulter‐Smith, M., Jones, J., & Cetnarskyj, R. (2019). A nurse‐led FibroScan® outreach clinic encourages socially deprived heavy drinkers to engage with liver services. Journal of Clinical Nursing, 28(3-4), 650-662. Retrieved on 19 August 2020 from:

Nazareth, S., Leembruggen, N., Tuma, R., Chen, S. L., Rao, S., Kontorinis, N., & Cheng, W. (2016). Nurse‐led hepatocellular carcinoma surveillance clinic provides an effective method of monitoring patients with cirrhosis. International Journal of Nursing Practice, 22, 3-11. Retrieved on 18 August 2020 from:

Yuli, G. O. U., Jing, Y. I., & Mei JIANG, C. C. (2019). Analysis on effects of comprehensive nursing care applied in interventional therapy for patients with liver cirrhosis and liver cancer. Iranian Journal of Public Health, 48(3), 494. Retrieved on 20 August 2020 from:

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