RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES

BANGALORE, KARNATAKA.

PROFORMA FOR REGISTRATION OF SUBJECT FOR

DISSERTATION

Mrs. V.VIJAYALAKSHMI

I year M.sc Nursing

Medical Surgical Nursing

Year 2008-2009

PADMASHREE INSTITUTE OF NURSING

NAGARBHAVI CIRCLE

BANGALORE - 560 072.

RAJIV GANDHI UNIVERSITY OF HEALTH SCIENCES BANGALORE, KARNATAKA

PROFORMA FOR REGISTRATION OF SUBJECT FOR DISSERTATION

1. NAME OF THE CANDIDATE AND ADDRESS

Mrs.V.VIJAYALAKSHMI.I year M.sc Nursing,Padmashree Institute of Nursing,Nagarbhavi circle,Bangalore-560 072.

2. NAME OF THE INSTITUTION

Padmashree Institute of Nursing, Bangalore.

3. COURSE OF THE STUDY AND SUBJECT

I year M.Sc Nursing,Medical Surgical Nursing.

4. DATE OF ADMISSION TO THE COURSE

30th June 2008

5. TITLE OF THE STUDY Assessment of effectiveness of planned teaching programme onknowledge regarding dietary management among patients with cirrhosis of liver.

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6. BRIEF RESUME OF THE INTENTED WORK

6.1 INTRODUCTION

The word “cirrhosis” derives from Greek word “kirrhos” meaning tawny.

(The orange yellow colour of the diseased liver). Rene Laennec who gave the

name cirrhosis in 1819.1

Cirrhosis is ranked as the ninth leading cause of death in the United States

and the fourth leading cause of death in persons between 35 and 54 years of age.2

Cirrhosis is slowly progressive diseases causing irreversible scarring and

nodularity of liver in response to chronic injury from a variety of causes. This

process distorts the normal liver architecture, interferes with blood flow through the

liver and disrupts the bio-chemical function of the liver.3

The majority of cirrhosis of liver are caused by excessive alcohol

consumption, the condition is referred to as alcoholic cirrhosis and other causes are

obstruction of the bile ducts, virus, auto immune hepatitis, prolonged constrictive

pericarditis, decompensated corpulmonale, infiltratative diseases such as

amyloidosis, glycogen storage diseases, hemochromatosis. Alcohol cirrhosis is also

called portal or nutritional cirrhosis is usually associated with alcohol abuse. The

change is uncomplicated accumulation of fat in the liver, potentially reversible if the

person stops drinking alcohol. If the alcohol abuse continues widespread scar

formation occurs throughout the life.4

There are four types of cirrhosis of liver as follows, Alcohol cirrhosis or

nutritional cirrhosis, Post necrotic cirrhosis, Biliary cirrhosis and Cardiac cirrhosis.

It’s characterized by nausea vomiting changes in bowel habits, pain and enlargement

2

of liver and spleen and slight weight loss. Later manifestations are skin lesions,

jaundice, and hematological problems like leucopenia, anemia, thrombocytopenia,

and spider angiomas.5

In cirrhosis, the liver functions are identified by enzymes levels including

alkaline phosphates, Alainin amino transferase, activated clotting time, Y-Glutamyl

trans peptidases are initially elevated. The prothrombin time is prolonged and

bilirubin metabolism is altered. Liver biopsy may be performed to identify liver cell

changes and alterations in the lobular structure. Paracentesis may be helpful in

establishing a diagnosis.6

Cirrhosis changes the structure of the liver and blood vessels that nourish it. The

disease reduces the liver ability to manufacture proteins and process hormone,

nutrition’s and medications. Cirrhosis gets worse over the time and can become

potentially life threatening. Complications of cirrhosis of liver are variceal bleeding,

spontaneous bacterial peritonitis, hepatocellular carcinoma, hepatorenal syndrome,

hepatic encephalopathy and hepatopulmonary syndrome, excessive bleeding,

Impotence, Liver cancer, Coma due to accumulated ammonia and body wastes, liver

failure and leads to death. Proper dietary management may help to prevent or delay

complication, reduce hospitalization and improve survival.7

Cirrhosis of liver is treated with administration of B-complex vitamins.

diuretics, dietary pattern and liver transplantation. The diet for the patient with

cirrhosis without complications is high in calories (3000Kcal/day) with high

carbohydrate content and moderate to low fat levels. Low protein diets were

routinely recommended for patients with cirrhosis in hopes of decreasing intestinal

ammonia production and preventing exacerbations of hepatic encephalopathy.

Sufficient carbohydrate intake must be provided to maintain a minimum intake of

1500-2000 calories to prevent hypoglycemia and catabolism. Glucose polymer is

protein free and can be used as source of calories. It can be given orally or

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nasogastric tube. The patient with ascites and edema is on a low sodium diet. The

degree of sodium restrictions varies depending on the patient’s condition. The

patient needs instruction regarding degree of restriction. The patient should be

advised to read the labels. Foods high in proteins usually have large amounts of

sodium.8

"A healthy liver is very soft, while a liver with early disease begins to

stiffen. A liver with cirrhosis, advanced liver disease, can be rock hard".9

6.2 NEED FOR THE STUDY

The risk of death due to cirrhosis is increased twelve fold, if one excludes the

direct consequences of the liver disease, there is still a fivefold increased risk of

death in all disease categories. Studies have recently suggested that coffee

consumption may protect against cirrhosis, especially alcoholic cirrhosis.10

The increasing prevalence of obesity and the metabolic syndrome increases the

incidence of cirrhosis secondary to nonalcoholic fatty liver disease especially in

developed countries. Cirrhosis of liver is important causes of morbidity and

mortality in the world.11

Nutrition is important in the management of cirrhosis, a well balanced diet

including plenty of fruits, vegetables, milk can allow for optimal function of liver

cells. Excessive protein intake should be avoided especially in patients with more

advanced disease. Cirrhotic patients must completely avoid alcohol and they have to

take only lean proteins such as fish, sea food, chicken breast, red meats, black beans,

barely or cracked wheat. Good sources of vitamins, minerals and antioxidants that

help the liver detoxify and heal. Patients with cirrhosis should avoid eating

uncooked shellfish, which may carry organism that can cause cirrhosis or other

diseases.12

4

Individuals with cirrhosis are at risk for many potential complications.

Complications can be managed or detected early with proper management. The most

lethal of these complications is bleeding, esophageal varices and ascites. Ascites can

be treated with dietary modifications and a diuretic regimen.13

Studies reported that patients with cirrhosis had a 4-year mortality of >60%.

Nutrition intervention has been shown to play a positive role. Recent studies have

indicated anti-alpha therapy, alternative medicinal agents such as milk thistle and S-

adenosylmethionine may be effective in cirrhosis. Treatment of the complications of

liver disease can improve the quality of life and in some cases decrease short-term

mortality.14

Nutritional management for patients with cirrhosis is difficult and nutritional

care hasn’t been established yet at present. Since the number of liver cancer patients

by appropriate nutritional care is very important for the treatment of liver cancer at

present, basic clinical research is expected to grow in the future.15

Approximately 20% patient with chronic hepatitis C and 10% to 20% of those

with chronic hepatitis B will develop cirrhosis.

In 2001several studies were compared to determine the effectiveness of milk

thistle in treating cirrhosis and other liver diseases. The active component of milk

thistle, silymarin, promotes liver protein synthesis. Studies show that improved

survival among cirrhosis patients who use milk thistle.16

Clinical and biochemical signs of protein-calorie malnutrition are associated

with liver disease. Malnutrition increases the number of complications and makes

patient's prognosis worse. Early started nutritional support is an important medical

strategy to limit malnutrition and to maintain liver functions.17

5

A comparative study was done on Nocturnal nutritional supplementation. A

total of 103 patients (68 male, 35 female) were randomized to receive daytime and

nighttime supplementary nutrition (710 kcal/day). Primary etiology of liver disease

was chronic viral hepatitis (67), alcohol (15), cholestatic (6), and other diseases (15).

Total body protein was measured by neutron activation analysis at baseline, 3, 6,

and 12 months. The findings suggested that no significant changes in total body

protein in the daytime group. Daily energy and protein intakes at 3 months were

higher than at baseline in both groups (P < 0.0001) and these changes did not differ

between the groups. The study concluded that provision of a nighttime feed to

patients with cirrhosis results in body protein accretion equivalent to about 2 kg of

lean tissue sustained over 12 months. This improved nutritional status may have

important implications for the clinical course of this patients.18

The investigators own personal experience in the clinical area where she had

come across many patients with cirrhosis of liver and the nutritional problems faced

by these patients, prompted her to take this problem for her research.

6.3 STATEMENT OF THE PROBLEM

6

A study to assess the effectiveness of planned teaching programme on

knowledge regarding dietary management among patients with cirrhosis of

liver in selected hospitals, Bangalore.

6.4 OBJECTIVES OF THE STUDY

1. To assess the existing knowledge regarding dietary management among

patients with cirrhosis of liver.

2 .To assess the post test knowledge regarding dietary management among

patients with cirrhosis of liver.

3. To assess the effectiveness of planned teaching programme regarding dietary

management among patients with cirrhosis of liver.

4. To associate the post test knowledge regarding dietary management among

patients with cirrhosis of liver with their selected demographic variables.

6.5 OPERATIONAL DEFINITIONS:

1. Effectiveness

It refers to the extent to which planned teaching programme regarding dietary

management improves the knowledge among patients with cirrhosis of liver.

2. Planned teaching programme

It refers to systematically developed instructional aids regarding dietary

management among patients with cirrhosis of liver.

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3. Knowledge

It refers to awareness and level of understanding among patients with

cirrhosis of liver as measured by a structured questionnaire.

4. Dietary management

It refers to conservative and therapeutic dietary measures taken by

patients with cirrhosis of liver.

5. Patients

It refers to the persons who are suffering from patients with cirrhosis of

liver problems and admitted in medical wards of selected hospitals,

Bangalore.

6. Cirrhosis of liver

It refers to slowly progressive disease, causing irreversible scarring and

nodularity of the liver.

6.6 ASSUMPTIONS

1. Patients with cirrhosis of liver may have inadequate knowledge regarding

dietary management.

2. Planned teaching programme may improve the knowledge regarding dietary

management among patients with cirrhosis of liver.

3. Patients knowledge regarding dietary management among patients with

cirrhosis of liver may vary with their selected demographic variables.

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6.7 RESEARCH HYPOTHESES

H1 – There is a significant difference between the mean pre-test and post-test

knowledge regarding the dietary management among patients with

cirrhosis of liver.

H2- There is a significant association between posttest knowledge regarding

dietary management among patients with cirrhosis of liver with their

selected demographic variables.

6.8 REVIEW OF LITERATURE

A literature review discusses published information in a particular subject

area, and sometimes information in a particular subject area within a certain time

period.19

A descriptive study conducted on liver cirrhosis on nutritional support,

represents the final stage of many chronic liver diseases. These patients have

decreased carbohydrate utilization and storage capacity and increased protein and fat

catabolism leading to depletion of protein and lipid reserves. They concluded that

nutritional therapy brings benefits in the different stages of the disease, it improves

nitrogen balance, decreases the hospital stay, improves liver function, it decreases

the incidence, severity of encephalopathy and improves quality of life.

Supplementation with enteral nutrition may improve protein intake, decrease the

frequency of hospitalization, improve the nutritional status, the immune function

and the disease severity.20

A comparative study was done on Ammonia impairs neutrophil phagocytic

function in liver disease. The study was to determine ammoniagenic diet in patients

9

with cirrhosis, results in neutrophil dysfunction. They concluded that Ammonia

produces neutrophil swelling and impairs neutrophil phagocytosis. The p38

intracellular signaling pathway has been shown to be important in mediating the

ammonia-induced neutrophil dysfunction.21

A descriptive study conducted on malnutrition in end stage liver disease and it

recommends the nutritional support. They found that malnutrition has increasingly

acknowledged as an important prognostic factor, which can influence the clinical

outcome of patients suffering from end-stage liver disease. Malnutrition should alert

clinicians to the same extent, as do other complications such as ascites and hepatic

encephalopathy. Enteral nutrition improves nutritional status and liver function,

reduces complications, prolongs survival and is therefore indicated.22

A study was done on many patients with chronic alcohol abuse present a

clinical picture of malnourishment, because of reduced intake of essential nutrients

precludes an appropriate digestion and absorption of the different essential elements,

vitamins, and minerals. It interferes with normal metabolism. Nutritional supports

may be effective to improve alcoholic liver disease. A balanced diet, vitamin

supplements, and pharmacological therapy with antioxidants in order to recover

depleted glutathione deposits are recommended.23

A descriptive study was done on Nutrition in liver cirrhosis. Malnutrition is

highly prevalent among patients with liver cirrhosis. A reduced nutritional status,

i.e., protein energy malnutrition, has prognostic significance resulting in increased

morbidity and mortality rate. The result concluded that a sufficient daily energy

supply should be guaranteed in patients with cirrhosis of liver the increased turnover

of amino acids requires a sufficient protein supplementation. Additional substitution

of vitamins and trace elements is indicated when symptoms of deficiency are

apparent. Nutritional advice in patients with cirrhosis requires an individual

management regarding the dominating complications of the disease.24

10

An experimental randomized study conducted on Branched-Chain Amino Acid.

For 48 patients with cirrhosis of liver received late-evening supplementation with

the branched-chain amino acid -enriched nutrient mixture, for 3 months. For

another group they had given ordinary food, such as a rice ball or bread, for 3

months. The result shows that serum albumin level, nitrogen balance, and

respiratory quotient were significantly improved by the branched-chain amino acid

mixture but not by ordinary food. They concluded that long-term oral

supplementation with it branched-chain amino acid mixture better than ordinary

food in a late evening snack in improving the serum albumin level and the energy

metabolism in patients with cirrhosis.25

An experimental study conducted on obesity increase the risk for liver

cancer in patients with cirrhosis of liver and long-term oral supplementation with

branched-chain amino acid granules inhibits liver carcinogenesis in heavier patients

with cirrhosis of liver. The result shows that the risk for liver cancer was

significantly higher for males, patients with an alpha-fetoprotein level of 20ng/mL

or higher and patients with higher body mass index. They concluded that, the risk

for liver cancer was significantly reduced in the group with a body mass index of 25

or higher and with an alpha-fetoprotein level of 20ng/mL or higher. Oral

supplemental treatment with branched-chain amino acid may reduce the risk of liver

cancer in cirrhotic patients.26

A study conducted on dietary antioxidant compounds and liver health,

founded that Chronic liver damage is a widespread pathology characterized by a

progressive evolution from steatosis to chronic hepatitis, fibrosis, cirrhosis, and

hepatocellular carcinoma. The study suggests that the use of antioxidants have been

proposed as therapeutic diet like lycopene-rich foods. Alpha-tocopherol, beta-

carotene, Quercetin, silymarin, esculetin and thyme are maintaining the liver

health.27

11

An experimental study conducted on the impact of carnitine on serum

ammonia concentration and lipid metabolism in patients with alcoholic liver

cirrhosis suggested that Carnitine taking part in liver lipid metabolism might be a

potentially effective drug. And result show a significant improvement was observed

in the group of patients treated with L-carnitine L-aspartate (p < 0.003), and among

those treated with L-isocarnitine (p = 0.005). L-carnitine lowers the serum ammonia

concentration and improves lipid metabolism.28

7. MATERIALS AND METHODS

7.1 SOURCES OF DATA

The data will be collected from the patients with cirrhosis of liver who are

admitted in medical wards of selected hospitals, Bangalore.

7.2 METHODS OF DATA COLLECTION:

i. Research design:

Quasi experimental - one group pretest posttest design.

ii. Variables:

Dependent variables: level of knowledge on dietary management among

patients with cirrhosis of liver.

Independent variables: Planned teaching programme on dietary management

among patients with cirrhosis of liver.

iii. Setting:

Medical wards of selected hospitals, Bangalore.

iv. Population

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All patients with cirrhosis of liver admitted in medical wards.

v. Sample:

Patients with cirrhosis of liver who fulfill the inclusive criteria will be

considered as samples and the sample size is 60.

vi. Criteria for sample selection

Inclusive criteria:

The study includes:

1. Both male & female patients with diagnosis of cirrhosis of liver.

2. Patients who can understand kannada / English.

3. Patients who are willing to participate

Exclusive criteria:

The study exclude:

1. Patients who have developed complications like liver cancer, liver failure.

vii. Sampling technique:

Non – probability convenience sampling technique.

viii. Tools for data collection:

The tool consists of two sections:

Section A: Demographic data includes age, gender, educational status,

occupation, family income, dietary habits, personal habits like smoking,

alcohol, exercise, disease condition, sources of information.

13

Section B: Structured questionnaire will be used to assess the knowledge

regarding dietary management among patients with cirrhosis of liver.

ix. Method of data collection

After obtaining, the permission from concerned authorities and informed

consent from the samples, the data will be collected in three phases:

Phase I: A pre-test will be conducted to patients with cirrhosis of liver using a

questionnaire to assess their knowledge regarding dietary management.

Phase II: A planned teaching programme on dietary management will be

conducted for 45mts on the same day immediately after the pretest.

Phase III: After an interval of seven days, a posttest will be conducted for the

sample using the same questionnaire for evaluating the effectiveness of

planned teaching programme.

x. Plan for data analysis

The data collected will be analyzed by means of descriptive statistics and

inferential statistics.29

Descriptive statistics: Frequency, percentage distribution, mean, and standard

deviation will be used to analyze the level of knowledge regarding dietary

management among patients with cirrhosis of liver.

Inferential statistics: Paired‘t’ test will be used to compare the pretest and

posttest knowledge. Chi-square test will be used to analyze the association

between posttest knowledge regarding dietary management among patients with

cirrhosis of liver with their selected demographic variables.

xi. Projected outcome:

14

This study will help to assess the existing knowledge of patients with cirrhosis of

liver on dietary management. Administration of planned teaching programme

will help to improve the patient’s knowledge on dietary management and its

significance in preventing the further complaints of cirrhosis of liver.

7.3 Doest the study requires any investigation or interventions to be

conducted on patients or other human or animals?

Yes, planned teaching programme will be administered as an intervention for the

patients with cirrhosis of liver.

7.4 Has ethical clearance been obtained from your institution?

Yes, permission will be obtained from concerned authority of the hospital .The

informed consent will be obtained from the samples. Confidentiality and

privacy of data will be maintained.

8. LIST OF REFERENCES

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Wikipedia.com.

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2. Lewis, Heitkenper, Dirksen, O’Brien, bucher. Medical Surgical Nursing:

Cirrhosis of liver. New Delhi: Elsevier; 2007 P. 1102.

3. Suzannec.Smrltzer, Brunner & Suddarth. Textbook of Medical Surgical

Nursing. Cirrhosis of liver. Philadelphia: Lippincott foren publishers; 1996.

P.1102.

4. B.T. Basavanthappa. Medical Surgical Nursing. Cirrhosis of liver. New Delhi:

Jaypee brothers; 2003. P. 303-04.

5. Joyce M. Black. Medical Surgical Nursing. Cirrhosis of liver. New Delhi: Saunders Elsevier; 2001: p.1336-38.

6. Foucher J, Chanteloup E, Vergniol J. Diagnosis of cirrhosis. 2006/Jan/7;

55(3); P.403-08.

7. Barbara K Timby, Nancy K Smith. Introduction to Medical Surgical Nursing.

Cirrhosis of liver. USA: Williams & Wilkins; 2007. P. 878-92.

8. Iredale JP. Cirrhosis targeted treatments. BMJ. 2003/May/2; 327 (7407);

P. 143–7.

9. Eureka Alert. A Broad spectrum of liver disease. Available from URL\http\\

health.surfwax.com\files\cirrhosis.

10. Sorensen HT, Thulstrup AM, Mellemkjar L. Long-term survival and cause-

specific mortality in patients with cirrhosis of the liver. Journal of clinical

epidemiology. 2007/May/15; 56: (1); P. 88–93.

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11. Lim YS, Kim WR. The global impact of hepatic fibrosis and end-stage liver

disease. Clinical Liver Disease. 2008/Nov;12:(4); P. 733-46.

12. Mörk H. Basics of nutrition in cirrhosis of the liver . Kreiskrankenhaus

Nagold .2007 Apr 26;149(17): P.33-4.

13. Troillet FX, Halkic N, Froehlich F, Moradpour D, Gonvers JJ, Denys A.

Complications of liver cirrhosis: 2005 /Jan 19;1:(3); P.249-50, 252-5.

14. Bergheim I, McClain CJ, Arteel GE. Treatment of alcoholic liver disease:

2005;23:(3-4): P.275-84.

15. ABE shintaro. Nutritional management for cirrhosis patients with glucose

intolerance:JJPEN.2000\JAN\8;22(6); P.395-400. Available from URL:/

http://science links japan.com.

16. Walsh, Nancy. Milk Thistle for Liver Disease. Internal Medicine

News:2002/Jan/1; 10(4); P.11-3. Available from URL:/http:// www.tibotec-

virology.com .

17. Kulig G. Nutritional therapy in stable liver cirrhosis: 2000;57(3); P.168-70

18. Plank LD , Gane EJ, Peng S, Muthu C, Mathur S, Gillanders L, McIlroy K,

Donaghy AJ, McCall JL. Nocturnal nutritional supplementation improves

total body protein status of patients with liver cirrhosis: Hepatology.

2008/Aug;48:(2); P. 557-66

19. Polit F Denise and Cheryl Tatano beck. Nursing research. Review of

literature: New Delhi: Lippincott publication; 2008. P. 105-07

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20. Mesejo A, Juan M, Serrano A. Liver cirrhosis on nutritional support: 2008

/feb/23;5(2); P.8-18. Available from URL/ http//www. mesejo_alf@gva.es .

21. Shawcross DL, Wright GA, Stadlbauer V, Hodges SJ, Davies NA.

Ammonia impairs neutrophil phagocytic function in liver disease:2008

Oct;48(4): P.1202.

22. Tsiaousi ET, Hatzitolios AI, Trygonis SK, Savopoulos CG. Malnutrition in

end stage liver disease, recommendations and nutritional support: J

Gastroenterol Hepatol: 2008 Apr; 23(4): P.527-33.

23. Moreno Otero R, Cortes JR. Nutrition and chronic alcohol abuse. Nutr

Hosp. 2008;23(2); P.3-7.

24. Gundling F, Teich N, Strebel HM, Schepp W, Pehl C. Nutrition in liver

cirrhosis. 2007 Jun 15;102(6): P.435-44.

25. Nakaya Y, Okita K, Suzuki K, Moriwaki H, Kato A, Miwa Y, BCAA-

enriched snack improves nutritional state of cirrhosis. 2007 Feb;23(2):

P.113- 20. URL:/http://www. nakaya@nutr.med.tokushima-u.ac.jp .

26. Muto Y, Sato S, Watanabe A, Moriwaki H, Suzuki K, Kato A, Kato M.

Overweight and obesity increase the risk for liver cancer in patients with liver

cirrhosis and long-term oral supplementation with branched-chain amino acid.

Epub 2006 Jul;35(3): P.204-14.

27. Vitaglione P, Morisco F, Caporaso N, Fogliano V. Dietary antioxidant

compounds and liver health.2004;44(7-8):P.575-86.

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28. Łapiński TW, Grzeszczuk A.Klinika Obserwacyjno-Zakazna Akademii

Medycznej w Białymstoku. The impact of carnitine on serum ammonia

concentration and lipid metabolism in patients with alcoholic liver cirrhosis.

2003 Jul;15(85):P.38-41.

29. Veer Bala Restogi. Fundamentals of biostatistics. Data analysis. New Delhi:

Ane Books India; 2008. P.221-40.

9. Signature of the candidate :

10. Remark of the guide :

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11. Name and designation of guide :

11.2. Signature :

11.3. Co-guide :

11.4. Signature :

11.5. Head of the department :

11.6. Signature :

12.1. Remarks of the principal :

12.2. Signature :

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