Nursing Care of Patients With Cirrhosis: The LiverHope Nursing Project.

Cirrhosis is a complex disease that is associated with disturbances in different organs besides the liver, including kidneys, heart, arterial circulation, lungs, gut, and brain. As a consequence, patients develop a number of complications that result in frequent hospital admissions and high morbidity and mortality. Patients with cirrhosis require constant and rigorous monitoring both in and outside the hospital. In this context, the role of nurses in the care of patients with cirrhosis has not been sufficiently emphasized and there is very limited information about nursing care of patients with cirrhosis compared with other chronic diseases. The current article provides a review of nursing care for the different complications of patients with cirrhosis. Nurses with specific knowledge on liver diseases should be incorporated into multidisciplinary teams managing patients with cirrhosis, both inpatient and outpatient. Conclusion: Nurses play an important role in the management and prevention of complications of the disease and improvement in patients' quality of life and bridge the gap between clinicians and families, between primary care and hospital care, and provide medical education to patients and caregivers.

The impact on patients of a nurse-led clinical service in gastroenterology.

Higher rates of chronic liver disease have resulted in a significant increase in the number of patients needing regular abdominal paracentesis for ascites. Waiting times for admission at the Royal Wolverhampton NHS Trust had become longer and delays in intervention and treatment became inevitable. In 2014, the Trust developed a nurse-led abdominal paracentesis day-case service. A qualitative evaluation of the service was conducted using in-depth patient interviews and surveys to determine the impact of the service, including how the new nursing role affected the patient experience. The results show that the nurse-led clinical service in gastroenterology positively impacts patients' experiences. Following this innovation, the service was extended to provide intravenous infusions for gastroenterology patients via the day-case unit. With appropriate training and competency assessments, nurses can now perform selected medical procedures safely and effectively, thereby facilitating nursing staff to expand and develop their roles. This development has substantial implications for nursing and is an important contribution to the debate on the future direction of the nursing profession.

Efluente peritoneal turbio sin peritonitis en pacientes con insuficiencia cardiaca refractaria en programa de ultrafiltración peritoneal / Cloudy peritoneal effluent without peritonitis in patients with refractory heart failure undergoing peritoneal ultrafiltration

En los pacientes con insuficiencia cardiaca refractaria en programa de ultrafiltración peritoneal no es infrecuente la presencia de líquido turbio en ausencia de otros criterios de infección peritoneal. El objetivo del estudio fue analizar si la presencia de drenado peritoneal turbio se corresponde con la presencia de infección peritoneal. Se realizó un estudio observacional prospectivo entre Diciembre de 2014 y Marzo de 2015, en el que se incluyeron pacientes con insuficiencia cardiaca refractaria. Se analizaron 4 muestras de cada paciente, separadas por 15 días, de forma programada. Los cultivos bacteriológicos se realizaron en las muestras que presentaban un recuento leucocitario superior a 100 leucocitos/μl. Se recogieron datos epidemiológicos y clínicos de los pacientes, como la patología de base responsable de la insuficiencia cardiaca y las proteínas presentes en el efluente peritoneal. Se evaluaron 13 pacientes, 77% varones, edad media de 71±8 años. Se recogieron un total de 51 muestras; de ellas, en 5 muestras (9.8%) procedentes de 4 pacientes (31% del total de pacientes), el efluente peritoneal era turbio. En 2 de ellos el recuento leucocitario fue inferior a 100 leucocitos/μl mientras que en los otros 2 pacientes el recuento fue superior, con polimorfonucleares por debajo del 50% y cultivos sin crecimiento bacteriano. No hubo relación entre la celularidad y las enfermedades de base. Consideramos que la presencia de turbidez en el efluente peritoneal de los pacientes con Insuficiencia Cardiaca no siempre se corresponde con la existencia de infección peritoneal (AU)

In patients with refractory heart failure undergoing peritoneal ultrafiltration it is not uncommon for the presence of turbid liquid in the absence of other criteria of peritoneal infection. The aim of the study was to analyze whether the presence of peritoneal drainage cloudy corresponds to the presence of peritoneal infection. A prospective observational study between December 2014 and March 2015 was performed, which included patients with refractory heart failure. They analyzed 4 samples of each patient, separated by 15 days, programmatically. Bacterial cultures were performed on samples that had a white blood cell count above 100 cells/μl. Epidemiological and clinical data of patients, as the pathology of heart failure responsible base and the proteins present in the peritoneal effluent were collected. 13 patients, 77 % male, mean age 71 ± 8 years were evaluated. A total of 51 samples were collected; of then, 5 samples (9.8 %) from 4 patients (31 % of all patients), peritoneal effluent was cloudy. In 2 of then the white blood cell count was less than 100 cells/μl. whereas in the other 2 patients the count was higher, with polymorfonuclear below 50% and no growth crops. There was no relationship between the cellularity and the underlying diseases. We believe that the presence of turbidity in the peritoneal effluent of patients with heart failure not correspond to the existence of peritoneal infection (AU)

Management of non-ovarian cancer malignant ascites through indwelling catheter drainage.

BACKGROUNDS: Intra-abdominal placement of the Central Venous Catheter (CVC) was conducted to manage the ascites-related symptoms of non-ovarian cancer patients. The aim of this study is to document the efficacy of symptom relief and conduct survival analysis of non-ovarian cancer patients with malignant ascites who received paracentesis and indwelling catheter drainage. METHODS: Seventy eight patients received paracentesis and drainage. All patients who met the inclusion criteria were included in this study. The overall survival (OS) was defined as the interval between initial diagnosis and death. Since-paracentesis survival (SP-Survival) was defined as the interval between initial paracentesis and death. RESULTS: Hepatic cancer was the most frequent original cancer in this study. Peritoneal catheters remained in situ for a median of 13 days. No immediate complications, such as perforation of a viscus or excessive bleeding, were encountered during placement. All ascites-related symptoms improved after drainage compared with the baseline. There was a statistically significant improvement in the mean score for abdominal swelling (p < 0.001), anorexia (p = 0.023) and constipation (p = 0.045). Cancer type was shown to be an independent prognostic factor for overall survival length (p = 0.001). Serum albumin was an independent prognostic factor for SP-survival (p = 0.02). CONCLUSIONS: Paracentesis and indwelling catheter drainage through CVC set is a useful method for improving painful symptom. Further research is needed to validate the findings.

[Effects of head posture on oxygenation saturation, comfort, and dyspnea in patients with liver cirrhosis-related ascites].

BACKGROUND: Chronic liver disease and cirrhosis are collectively ranked as the ninth most prevalent cause of death in Taiwan. Ascites is the most common comorbidity associated with liver cirrhosis. Different body postures affect pulmonary ventilation and arterial oxygen partial pressure. Thus, ensuring proper body posture in patients is an important clinical nursing intervention that significantly affects the recovery of patients. PURPOSE: This study investigates the effects of head posture on oxygenation saturation, comfort, and dyspnea in patients with liver cirrhosis-related ascites. METHODS: A quasi-experimental study design was used. A total of 252 participants were recruited from a medical centre hospital in Taiwan. Participants were allocated randomly into three groups of bed-elevation angles: 15 degrees, 30 degrees, and 45 degrees. The physiological indices were measured at 5, 10, 15, 20, 25, and 30 minutes in order to investigate the change in oxygenation saturations that were attributable to the different angles. Data were analyzed using descriptive statistics. The generalized estimating equation (GEE) was used for statistical analysis, with the level of significance set at: α = .05. RESULTS: After controlling for confounding variables, the results showed that patients in the three groups earned similar scores for the degree of difficulty in the oxygen values. The supine group earned significantly different scores than the other two groups in terms of blood oxygen values related to time to change the angle of the three groups at five minutes after adjusting the angle (p < .01). This study found no differences among the three groups in terms of comfort. In terms of breathing, this study found a significant difference between 45-degree and 15-degree supine dyspnea (p < .05). Therefore, patients with ascites at 15 degrees supine and with better access to better oxygen saturation had superior results to their peers at 30 degrees and 45 degrees supine. Furthermore, this group was less likely to perceive breathing difficulties. CONCLUSIONS / IMPLICATIONS FOR PRACTICE: The results of this study may guide health education and care for nurses in order to improve the quality of care for patients with chronic liver disease / cirrhosis with concomitant ascites.

Papel de la enfermera durante el proceso de realización de una paracentesis / The role of nurses during the paracentesis procedure

OBJETIVOS: conocer el papel del profesional de la Enfermería en el proceso de realización de una la paracentesis, basado en la evidencia científica, a fin de diseñar posteriormente una guía clínica y mejorar la calidad de los cuidados a los pacientes. MÉTODO: revisión narrativa en la que se lleva a cabo una búsqueda bibliográfica en las bases de datos de Medline, Cinahl, Cochrane Library y UpToDate, así como en bases de datos de Guías clínicas: Guidelines International Networks, Practice Guideline, National Guideline Clearinghouse, New Zealand Clinical Guidelines Group, Primary Care Clinical Practice Guidelines y Scottish Interncollegiate Guidelines Network. Se consultaron igualmente las bases de datos de guías clínicas del Hospital General Universitario Gregorio Marañón de Madrid, del Complexo Hospitalario Universitario de Vigo y del Club Internacional de la Ascitis. RESULTADOS Y CONCLUSIONES: se seleccionaron 15 artículos y tras el análisis de los hallazgos obtenidos se establecieron tres categorías en las que se describe el papel que la enfermera desempeña en la paracentesis: cuidados que proporciona la enfermera antes, durante y después del procedimiento. Además de cada una de las intervenciones enfermeras en cada fase del mismo, se observa como muy importante la presencia de un profesional enfermero que valorará al paciente de manera holística. En un futuro inmediato se implantará una guía clínica que se diseñará con base en los resultados obtenidos y se revisarán en un año todos los aspectos que se han considerado para esta guía, así como la literatura científica que se haya podido publicar valorando los puntos a mejorar. Entre las limitaciones de este trabajo cabe señalar la baja calidad metodológica de los artículos seleccionados y la poca bibliografía referente al tema, por lo que convendría realizar estudios con diseños metodológicos más rigurosos y de mayor calidad para poder tener más impacto en la práctica clínica

OBJECTIVES: to learn about the role of the Nursing Professional during the paracentesis procedure, based on scientific evidence, with the aim of designing clinical guidelines, and improving the quality of patient care. METHOD: a narrative review, where a bibliographic search was conducted in the Medline, Cinahl, Cochrane Library and UpToDate databases, as well as in Clinical Guidelines Databases: Guidelines International Networks, Practice Guideline, National Guideline Clearinghouse, New Zealand Clinical Guidelines Group, Primary Care Clinical Practice Guidelines and Scottish Intercollegiate Guidelines Network. The Clinical Guidelines Databases from the Hospital General Universitario Gregorio Marañón in Madrid, the Complexo Hospitalario Universitario de Vigo and the International Ascites Club were also consulted. RESULTS AND CONCLUSIONS: fifteen articles were selected, and after the analysis of the findings obtained, three categories were established, describing the role played by nurses during paracentesis: the care provided by nurses before, during and after the procedure. Apart from each of the nursing interventions at each stage of said procedure, the presence of a nursing professional to assess the patient in a holistic way was considered very important. In the near future, clinical guidelines will be implemented, that will have been designed based on the results obtained, and all aspects considered for these guidelines will be reviewed at one year, as well as the scientific literature which may have been published, assessing those items to be improved. Among the limitations of this study, we must point out the low methodological quality of the articles selected, and the little bibliography available about this matter; therefore, it would be convenient to conduct studies under stricter methodological designs, with higher quality, in order to have a higher impact on clinical practice

Outpatient interventions for hepatology patients with fluid retention: a review and synthesis of the literature.

Cirrhosis of the liver was the 12th leading cause of death in the United States, according to the 2010 Vital Statistics Report. Cirrhosis is responsible for more than 150,000 hospitalizations each year. Similar to heart failure, severe fluid retention in cirrhotic patients leads to hospitalizations and increase in resource utilization. Outpatient interventions can be used to decrease preventable hospitalizations. The existing literature was explored to determine what interventions can be implemented in an outpatient setting that may reduce or prevent hospital admissions for cirrhotic patients with fluid retention. Seventeen articles were included in the review of the literature. There were 9 randomized controlled trials that yielded a total of 1,694 patients. One meta-analysis yielded 5 randomized controlled trials with 330 patients. Three cohort studies yielded 86 patients. One systematic review yielded 2,115 articles and 2 literature reviews yielded 110 articles. One report from an expert committee was included in the review. Findings from the studies identified 6 main interventions that can be used for outpatient management of cirrhotic patients with fluid retention and may prevent related hospitalizations. These include dietary sodium restriction, diuretics, daily weights, albumin infusions and paracentesis, placement of a transjugular intrahepatic portosystemic shunt, and telephone management.

Managing ascites in patients with chronic liver disease.

This article discusses the pathophysiology of ascites, a complication associated with chronic liver disease. The diagnosis and grading of ascites and assessment of patients with the condition are explored. In addition, the nursing and medical management of ascites is discussed, and recommendations for interdisciplinary working and education are suggested. Nursing knowledge of this complication is essential to ensure that patients with ascites are cared for effectively and that their comfort is maximised.

Management of patients with complications of cirrhosis.

Cirrhosis results from repeated hepatocellular injury over time, leading to portal hypertension and the development of ascites, hepatic encephalopathy, and varices. Despite improvements in medical care for patients with cirrhosis, mortality from infection, renal failure, and hepatocellular carcinoma remain high.

Review of the literature and description of a case of sclerosing encapsulating peritonitis requiring home parenteral nutrition.

We present a case of a 48 year old HIV patient, who had recurrent episodes of ascites since 2007. His history includes ischaemic heart disease, for which he was treated with atenolol from 2005 to 2007, and Type 2 diabetes; he was later started on propranolol 40  mg twice a day from 2007 for Didanosine-induced portal hypertension. Because of negative cultures and neutrophil count < 250 cells/µL, spontaneous bacterial peritonitis was excluded. However, some low grade-peritoneal irritation cannot be ruled out because his CRP varied from 24 to 258, during 2007 - 2009, without any other obvious inflammatory cause. He was finally diagnosed in July 2009 with sclerosing encapsulating peritonitis (SEP) based on clinical features of intestinal obstruction, histology and imaging, including computed tomography and magnetic resonance imaging. Propranolol was stopped in November 2009.  Because of the patient's severe intestinal obstruction, he was started on parenteral nutrition 2  L/day. Since then, his CRP has returned to normal levels and there is a great improvement of his clinical features. This case demonstrates beta-blockers as a potential cause of SEP, while the presence of some low-grade peritoneal inflammation leading to SEP is also very likely.

Peritoneal and pleural ports for management of refractory ascites and pleural effusions: assessment of impact on patient quality of life and hospice/home nursing care.

PURPOSE: Patients with end-stage malignancies often have refractory ascites or pleural effusions requiring repeated paracenteses or thoracenteses. Subcutaneous peritoneal and pleural port catheters are an alternative therapeutic option. We evaluate the clinical utility of this approach and the impact on quality of life (QOL) and home/hospice care. MATERIALS AND METHODS: Thirty ports were placed, 16 peritoneal and 14 pleural, in patients with a mean age of 62 years. Retrospective chart review and interviews were held with patients and nursing care providers. Mean follow-up was 59 days. RESULTS: On a 10-point scale, QOL improvement, compared to that prior to port placement, was rated a mean of 9.5 by patients and 9.0 by the nursing staff. Both patients and nurses reported a high degree of convenience (rated at 9.7 and 9.6, respectively) and improvement of symptoms and comfort (9.6 and 9.3, respectively). Nursing staff reported a high degree of comfort (9.9) using the aspiration ports. Six of 14 pleural ports were removed following pleurodesis. One pleural port was removed due to patient discomfort and another due to pneumothorax. Two patients with pleural ports developed tumor seeding in the subcutaneous tissues. Of 14 peritoneal ports, 3 required removal for leaking and probable chemical cellulitis. Four became temporarily occluded with patency restored using tissue plasminogen activator (TPA) infusion. CONCLUSIONS: Peritoneal and pleural ports offer a convenient and relatively safe alternative to frequent paracenteses/thoracenteses in the management of refractory ascites and pleural effusions. This approach can improve the QOL for patients with end-stage disease.

Metastases involving the gastrointestinal system.

OBJECTIVES: To provide a review of metastases involving the gastrointestinal system, including the specific problems of liver metastasis, bowel obstruction, ascites, biliary obstruction, and gastrointestinal fistulas. DATA SOURCES: Research studies, review articles, and book chapters. CONCLUSIONS: When metastasis involves the gastrointestinal tract, the emotional distress is coupled with debilitating symptoms and marked nutritional deficits. Treatment decisions must consider potential benefits and risks and affect on quality of life. IMPLICATIONS FOR NURSING PRACTICE: An understanding of the disease process and alternative treatment interventions will assist nurses to effectively anticipate and manage symptoms that may develop and educate patients and families so they can participate in decisions regarding their treatment.

Metastases that interfere with circulation.

OBJECTIVES: To review the nursing implications of select circulatory problems caused by metastatic cancer. DATA SOURCES: Journal articles, research studies, and book chapters relating to circulatory problems associated with metastatic disease. CONCLUSIONS: During the metastatic process, tumor cells can interfere with circulation. As a result, circulatory impairments can range from life threatening to manifestations that may alter a person's quality of life. IMPLICATIONS FOR NURSING PRACTICE: Oncology nurses have a responsibility to seek current knowledge about therapeutic and supportive care for persons experiencing circulatory alterations. Collaboration with colleagues can facilitate patient care in these clinical situations. Patient education can be supportive and may enhance optimal outcomes.

New strategies for the management of malignant ascites.

Intractable malignant ascites accounts for 6% of all hospice admissions. The onset of malignant ascites indicates a poor prognosis, hence minimal supportive therapy is indicated. This paper examines the method of control for malignant ascites presently available to patients, examines their limitations and proposes new strategies for managing intractable malignant ascites. Ascites is discussed in terms of its pathology--that is, as a form of lymphoedema. With this in mind treatment is proposed based upon principles incorporated into lymphoedema management. Nurses have taken a dominant role in the care of patients with lymphoedema and there appears no reason why ascites management cannot become the remit of nurses offering appropriate, but predominantly palliative therapy.

Managing ascites via the Tenckhoff catheter.

Ascites is a serious and uncomfortable symptom experienced by a significant percentage of cancer patients. The use of the Tenckhoff catheter provides rapid relief of the mechanical effects of ascites. When this technology is used in the hospital or in the home, nurses act to prevent complications and inform patients and families about safety and other issues.