Nursing Diagnosis in Patients with Liver Cirrhosis in Use of Feeding Tube

The objective was to identify the most frequent nursing diagnoses labels in patients with liver cirrhosis in use of feeding tube. A descriptive research was carried out in a Brazilian Hospital with 20 adult patients. Systematic data collection utilized the Conceptual Model of Wanda Horta, the first nurse to introduce the concept of Nursing Process in Brazil. The six phases of the nursing diagnostic reasoning proposed by Risner were used; nursing diagnoses were described according to NANDA-I taxonomy II. Patients were mainly male; half of them were middle age adults; they had an average of 12.8 nursing diagnoses labels; and the most frequent were: risk for aspiration and risk for infection. Nurses needed to develop effective skills to properly diagnose in order to provide safe care and improve patient outcomes.


Introduction
Liver cirrhosis is the leading cause of chronic liver disease in developed countries. In the United States of America, liver cirrhosis results in more than 400,000 hospitalizations and in 27,000 deaths annually. In Taiwan, liver cirrhosis and other chronic liver diseases together are the eighth-leading cause of death overall [1]. This patient group also accounts for 75% of unplanned readmissions to the Gastroenterology and Hepatology unit in an Australian hospital [2]. In Brazil, liver cirrhosis was also the eighth-leading cause of death among men and accounted for almost 9% of hospital admissions in 2010 [3]- [6].
The prevalence of malnutrition in these patients is also a challenge, representing 20% to 90%. Malnutrition is an independent risk factor for morbidity and mortality, because it may result in several complications [7]. Therefore, patients who are unable to meet nutrient needs should be considered candidates for enteral feeding tube in order to ensure daily nutritional requirements [8]- [10].
However, the need for a feeding tube may pose patients at great risk for adverse events due to higher probability of bleeding, especially in the presence of esophageal varices, thrombocytopenia or coagulopathy [11]. Thus, it is a concern for health care team to make an accurate and timely diagnosis of such complications and the delivery of the correct treatment to safe management of patients.
Assisting people with liver cirrhosis can be a challenge for all health care professionals, especially for nurses, because these patients are frequently admitted to hospitals due to the evolution of the disease, and they can deteriorate very quickly requiring constant monitoring and surveillance [4]. Nurses need to apply appropriate clinical judgments and clinical decision-making to reduce the frequency of hospital readmissions and to give safe and qualified care. Clinical reasoning enables nurses to make complex decisions in order to improve patients' outcomes [12]. Therefore, the proper management of patients with liver cirrhosis in use of feeding tube should be the focus of all nursing care plan in order to improve symptom management, to reduce the risks associated with further decompensation, and to enhance patient safety.

Background
The constant changes in clinical status of patients with liver cirrhosis require quick and assertive decision-making. With the aim of providing qualified care, nurses have joined forces to build a body of knowledge focused on evidence-based practices to provide competent and safe care to patients with chronic conditions. The Nursing Process (NP) is the main methodological framework for the systematic performance of professional practice, or a technological method that nurses use to foster care, and to help in documenting professional practice. Therefore, the deliberate application of NP may contribute to the quality of care, thus improving nurses visibility and professional recognition [13].
Wanda de Aguiar Horta [14], the first nurse to introduce the concept of NP in Brazil, developed a Nursing Conceptual Model based on Maslow's Theory Human Motivation [15]. This theory is based on Basic Human Needs (BHN), which is classified in five levels: physiological needs, safety, love, esteem and self-realization. In addition to Maslow's BHN, Horta adopted the classification proposed by John Mohana. Therefore, the BHN model proposed by Horta is classified into three levels: psychobiological, psychosocial, and psycho spiritual.
The Conceptual Model of Wanda Horta was used in this study because it may help nurses to collect relevant data within the framework of nursing rather than medicine. Thus, the model may assist nurses in critical thinking and give support to practitioners in outcome identification and development of nursing care plans.
Nursing diagnosis is a process of data analysis that uses clinical reasoning to determine whether nursing interventions are indicated, contributing to the quality of care and patient safety through an evidence-based practice [16] [17]. For each nursing diagnosis, nurses select the appropriate interventions suggested by the nursing intervention classification system [17] [18]. Therefore, the present study is justified by the lack of publications addressing the nursing diagnoses in clinical patients with liver cirrhosis in Brazil and worldwide. Several studies identified the most frequent nursing diagnoses in different populations [19]- [21], but none inpatients with liver cirrhosis. Thus the purpose of this study was to identify the most frequent nursing diagnoses labels in patients with liver cirrhosis in use of feeding tube.

Design
A descriptive research design.

Setting and Sample
The study was carried out in a Brazilian University Hospital, in São Paulo state, from January 2013 to December F. R. E. Gimenes et al. 507 2013. Participants consisted of a convenient sample of 20 adult patients with liver cirrhosis in use of feeding tube. Patients in use of percutaneous enteral feeding tubes were excluded. Unconscious patients or patients with cognitive impairment were included in the study after their family's written consent.
The study was approved by the appropriate ethics committee. Patients and/or their families were assured that their identity would remain confidential and they signed a consent form voluntarily.

Data Collection
A systematic data collection was conducted and it included interaction, observation, and measurement. Data was also collected from other resources, including family and significant others, medical records, results of diagnostic tests, nursing notes, change of shift reports, and health team members. The tool used for data collection was developed by the investigators and it was based on the Conceptual Model of Wanda Horta [22].

Data Analysis and Rigor
The guidelines proposed by Risner [23] was followed for the diagnostic reasoning, which included six phases for analysis and synthesis of data: 1) Relevant patients' data were categorized. In this study the Conceptual Model of Wanda Horta [14] was used with the aim of revealing relationships among cues, thus making missing data more obvious; 2) Missing information and incongruence were identified to indicate areas for further assessment; 3) Related cues were clustered into patterns to combine patients' elements into a whole, with the aim of constructing patterns containing information about patients' response to an actual or potential health problem, and the factors related to the response; 4) Patients' patterns were then compared with normal ranges, values, expectations, and patient baseline information to identify their health-related responses; 5) Based on patients' responses, inferences were made about their health status, condition, or situation in each of the assessment categories; 6) Finally, etiological relationships were proposed to identify factors influencing or contributing to the patients' responses. After analysis and synthesis of all patients' relevant data, the nursing diagnosis was described according to NANDA-I taxonomy II [17], that has three levels: domains, classes, and diagnoses. All nursing diagnoses were analyzed and discussed with a panel of three nurses with experience on the Conceptual Model of Wanda Horta and on NANDA-I taxonomy II. The domains and classes of each nursing diagnosis label were also identified.

Results
The study sample consisted of 20 hospitalized patients with liver cirrhosis in use of feeding tube. From those, 6 (30%) were females and 14 (70%) were males, with an average age of 56.3 and 59.7, respectively. The age range was from 28 to 81 years, and almost half (n = 11) of the patients were middle age adults (from 41 to 64 years).The most common causes of liver cirrhosis were chronic alcoholism (10, 50%), followed by other etiologies (6, 30%), and viral infection (4, 20%). All patients had other comorbidities, including arterial hypertension, diabetes mellitus, or renal disease.
From the analysis and synthesis of patients' relevant data, there were 255 nursing diagnoses labels identified. Each patient had an average of 12.8 nursing diagnoses with a minimum of 9 to maximum of 16; 36 different nursing diagnoses labels were identified in the sample and 12 nursing diagnoses labels showed percentage equal to or greater than 50%.

Discussion
Results showed a total of 255 nursing diagnoses labels, with an average of 12.8 nursing diagnoses labels per patient, and 36 different nursing diagnoses labels. The results differ from previous study conducted in an intensive care unit where 1.087 nursing diagnoses were formulated for 44 critical patients, with a mean of 8.5 diagnoses per patient, and 28 different nursing diagnoses labels [24]. Differences may be due to the methodology used in both studies for data collection and analysis.
Risk for aspiration (00039) and Risk for infection (00004) were the most frequent NANDA-I diagnoses labels found in this study. They were presented in 100% of patients. Similar findings were detected by other authors in critical patients [25] [26].
Risk for aspiration (00039) is common in patients in use of feeding tube, especially in those with chronic liver disease and portal hypertension because they have delayed gastric emptying for both the liquid and solid components [27]. In addition, the cirrhosis of the liver does not allow the free passage of blood that accumulates in the gastrointestinal tract and in the spleen, resulting in chronic congestion in this area. Consequently, indigestion due to intra-abdominal pressure and altered bowel function occur [28].
According to Opilla [29], the presence of a feeding tube also increases secretions from tube irritation, impairment of laryngeal function, and disruption of the esophageal sphincters during intubation, thus contributing to the risk for aspiration. It is worth to note that many patients in this study (25%) also had liver encephalopathy. The decreased level of consciousness in these patients and the altered coordination between breathing and swallowing interferes with the patient's ability to protect the airway [30].
Risk for infection (00004) was also presented in all patients in this study. Bacterial infections are a major complication of liver cirrhosis and a serious burden among patients because they may be a triggering factor for the occurrence of gastrointestinal bleeding, hepatic encephalopathy, kidney failure, and further deteriorate liver  [33]. Thus, nurses need to act towards the reduction of the negative clinical impact of infections in these patients to reduce repeated hospitalizations and impaired health-related quality of life. Another nursing diagnoses were frequent in these patients, including: Bathing self-care deficit (00108), Dressing self-care deficit (00109), Risk for bleeding (00206), Risk for impaired skin integrity (00047), Risk for acute confusion (00173), Risk for falls (00155), Imbalanced nutrition: less than body requirements (00002), and Excess fluid volume (00026). Similar results were identified in previous studies involving critical care patients and patients in chronic conditions [25] [34]. In Taiwan, physical symptoms and psychological distress, including abdominal symptoms, fatigue, fluid retention, loss of appetite, systemic symptoms, decreased attention, and bleeding, were common among patients with liver cirrhosis [35]. These NANDA-I diagnoses require from nurses the ability and skills to identify the patients' health status in order to deliver an individualized nursing care plan focused on patient safety.
Self-care deficits related to activities of daily living (eg. Bathing, dressing, feeding, and toileting) were also frequent in patients because they usually suffer from moderate-to-severe fatigue. In this study, 30% of patients presented with fatigue (00093) that can result in decreased motivation, depression, reduced physical activity, and constraints on daily life [1] [36]. Nursing interventions should focus on the maintenance of physical and psychological comfort for these patients to improve their quality of life and to reduce the risks for other injuries, such as falls.
Another potential risk for patients living with liver cirrhosis is the clinical bleeding, most frequently caused by esophageal varices, gastric varices or portal hypertensive gastropathy. In this study, 15% of patients presented esophageal varices and 10% presented portal hypertension at the hospital admission. In chronic liver disease, vitamin K absorption by the liver is decreased. Therefore, the production of coagulation factors (such as II, VII, IX, and X) does not happen, resulting in prolonged time required for a blood sample to clot [4]. Moreover, hospitalized patients with liver cirrhosis require frequent invasive procedures (e.g., peripheral venous catheter for transfusions and the administration of medications and other solutions; venous and arterial puncture for blood samplings; and paracentesis), which may cause complications such as bleeding.
Thrombocytopenia is also a common and persistent problem in cirrhotic patients [7]. In this study, 30% of patients had previous gastrointestinal hemorrhage at the hospital admission, thus the risk for another hemorrhage is real. Variceal bleeding may cause upper gastrointestinal hemorrhage due to portal hypertension. It remains one of the most important complications of chronic liver disease and one of the largest causes of mortality in this group [2] [37]. These patients have a permanent state of hyperdynamic circulation, with pronounced splanchnic vasodilatation. Further bleeding can occur in 60% of patients, with a mortality of up to 33%. Prevention of bleeding is therefore an essential part of the management of these patients [38]. However, the management of patients with acute gastrointestinal bleeding includes not only treatment and control of active bleeding but also the prevention of further bleeding, infections, and renal failure [39].
It is worth to note that 70% of patients had Risk for falls (00155), 35% were elderly, and 25% had Acute confusion (00128). The liver's inability to detoxify the blood results in increased blood circulation of ammonia and other toxic metabolites [4]. The increased concentration of ammonia in the blood causes brain dysfunction and injury, contributing to the hepatic encephalopathy. In the first stage of the hepatic encephalopathy, patients may experience discrete mental changes, as well as motor disorders. As the problem persists, patients may demonstrate mental confusion, mood swings, and sleep pattern changes. All these manifestations, when present, increase the risk for falling. In addition, the incidence of falls in patients over 60 years is almost three times higher than in older adults [40].
Imbalanced nutrition: less than body requirements (00002) was also frequent in these patients (60%). These results differ from those found by Park [41] in patients with heart failure. According to the author, Imbalanced nutrition: less than body requirements (00002) was detected only in 2.7% of patients. Researchers [26] [24] also found different results in intensive care units. In both studies, Imbalanced nutrition: less than body requirements (00002) was detected in 5% of patients. The results differ from the others, perhaps because of patients profile comprising the samples. It is worth to consider that malnutrition is prevalent in patients with liver cirrhosis because the evolution of the disease. According to Tai et al. [9] malnutrition was present in 50% of Malaysian pa-tients and the mean caloric intake was low at 15.2 kcal/kg/day. Thus, patients with end stage hepatic failure will present with muscle wasting, decreased fat stores, and overt cachexia [42].
Excess fluid volume (00026) is another common complication in patients with liver cirrhosis because the synthesis of proteins, such as albumin, is impaired. This nursing diagnosis was detected in 60% of all patients. Vargas and França [43] found Excess fluid volume (00026) in a case study conducted in a Brazilian hospital with a patient with liver cirrhosis. Hypoalbuminemia decreases the plasma oncotic pressure deflecting the balance of hemodynamic forces to the accumulation of fluid in interstitial spaces, thus resulting in peripheral edema and ascites. In addition, the liver failure to metabolize aldosterone resulting in increased retention of sodium and water by the kidneys, and in increased potassium excretion [44]. As the problem persists, the retention of sodium and water contributes to the increased blood volume that may cause cardiac overload and hence pulmonary edema.
In relation to the most prevalent NANDA-I domain found in this study, the results were similar to those identified by Park [41] in patients with heart failure. The author also found Physical injury as the most frequently used NANDA-I class in this population. In one study conducted with liver transplant patients, researchers [45] found that the domains mostly affected by patients were activity/rest, safety/protection, elimination and exchange, and comfort. Thus, it is important to identify the specific interventions commonly delivered for specified groups of patients [46] in order to improve patient outcomes and deliver safe care.
Liver cirrhosis is a progressive illness that may culminate in multiple system organ failure and death [47], requiring appropriate health care management, especially from nurses that should act in order to prevent further complications and to improve patient outcomes.
The results of this study sustain that nursing diagnoses should be seen as the basis for independent and collaborative actions because they provide direction for nursing interventions. Thus, nurses need to list nursing diagnoses during the process of care to reflect patients' changing condition and responses in order to individualize patient care.

Limitations
This study presented limitations. Nursing diagnoses labels were identified only in hospitalized patients. In addition, only 20 patients participated in this research, thus future studies should be conducted in multiple healthcare settings, such as ambulatory care, and with larger samples.

Conclusion
The most frequent nursing diagnoses labels identified in patients with liver cirrhosis in use of feeding tube were Risk for aspiration (00039) and Risk for infection (00004), requiring from nurses appropriate management of complications. This was the first research conducted in a practice setting with patients with liver cirrhosis. These findings supported that the identification of the most frequent nursing diagnoses in specific population helped nurses to identify the focus of care in patients with complex health problems and to prevent future complications associated with the evolution of disease.