Nutritional Status and Informational Needs for Patients with Liver Cirrhosis

Subjects and Methods: A descriptive exploratory design was used in this study. The present study conducted in tropical medicine and gastroenterology units at Zagazig University Hospitals, A purposive sample of 115 patients, The study lasted from the beginning of October 2016 to the end of May 2017 .Three tools were used for collection of data, first tool was a structured interview questionnaire consisted of personal characteristics of patients, second tool was nutritional assessment form, third tool was informational needs questionnaire.


INTRODUCTION
Hepatitis C virus is one of the chief causes of chronic liver disease.Hepatitis C related liver disease encompasses a wide spectrum ranging from chronic hepatitis C to compensated cirrhosis and eventually to decompensated cirrhosis and hepatocellular carcinoma [1].Cirrhosis is the final common pathway for the majority of liver diseases, and is a complex chronic condition that causes population mortality rates of approximately 5-10 per 100,000 person-years worldwide [2].Nutrition is an integral part of health maintenance.Progressive deterioration of nutritional status has been associated with poor outcome in cirrhotic patients [3].Proteinenergy malnutrition (PEM) is highly prevalent in patients with liver disease and leads to serious repercussions on the general state, having a direct impact on cirrhotic patient prognosis, deteriorating liver function, adversely affecting the clinical evolution [4].The prevalence of malnutrition in decompensated cirrhosis ranges from 60%-100%, while 20%-30% of patients with compensated cirrhosis are also malnourished [5].The pathogenesis of malnutrition in chronic liver diseases is multifactorial and includes a reduction in nutrient and calorie intake because of anorexia and dietary restrictions, impaired intestinal absorption, abnormalities of carbohydrate, lipid and protein metabolism and increased proinflammatory cytokine levels resulting in a hypermetabolic state that may occur in advanced liver disease stages [6].Therefore for nutritional management of liver cirrhosis patients it is important to precisely assess the patient's nutritional intake and to establish effective nutritional education programs [7].The term supportive care needs encompasses the physical, informational, emotional, practical, social and spiritual needs of an individual with chronic disease.[8].Information need' is defined as a deficiency of information or skill related to a domain of life that is relevant to the patient.Usually patients require information concerning their disease and related care, in addition to side effects, complications, and health-related problems.It is also important to obtain information concerning additional care, daily activities, practical solutions, and financial issues.[9].Inadequate selfmanagement skills and knowledge can lead to serious and detrimental changes in quality of life, as well as increased anxiety, distress, and difficulty coping [10].Patient and family teaching is an important nursing role that may make the difference in the ability of the patient and family to adapt to chronic conditions .Well-informed, educated patients are more likely than uninformed patients to be concerned about their health and to do what is necessary to maintain it [11].
The aim of the study was to assess nutritional status and informational needs for patients with liver cirrhosis.

SUBJECTS AND METHODS
A descriptive exploratory design was utilized in the study.Study was conducted in tropical medicine and gastroenterology units at Zagazig University Hospitals.Field work of this study was executed in 6 months, starting from October 2016 to May 2017.

Subjects:
A purposive sample of 115 adult patients with liver cirrhosis, they were selected randomly.

Content validity and Reliability:
Content validity was used for the modified tools and the designed booklet to determine whether the tools covered the aim or not.It developed by a jury of 5 experts ,four professors from faculty of Nursing, Zagazig University and one lecturer of medical department from the Faculty of Medicine, Zagazig University, And one lecturer of Biochemistry department from the faculty of medicine.
Reliability was done by using Cronbach test [16].It was used to examine whether the subjective Global Assessment, Informational Needs Questionnaire had internal consistency or not.The test was done and the agreement percentage was 89%.

Administrative and Ethical considerations:
The study was ethically approved from the dean of the faculty of Nursing, the manager of Zagazig University Hospitals, the head of tropical medicine and Gastroenterology department, ethics committee at the faculty of nursing and from Ethical committee of faculty of medicine.

Statistical Design:
All collected data were organized, categorized, tabulated, entered, and analyzed by using SPSS (Statistical Package for Social Sciences); a software program version 14, which was applied to frequency tables and statistical significance.The statistical significance and associations were assessed using, descriptive statistics in the form of frequencies and percentages for qualitative variables, and means and standard deviations and medians and interquartile ranges for quantitative variables, a chi-square test(X2).Spearman rank correlation.

RESULTS
The first part of our results was the Demographic characteristics and disease characteristic for patients with liver cirrhosis in the study including; gender, age, residence, marital Status, education, occupation and income (Table 1).
The second part of our results was concerned with disease characteristic; it demonstrated that The main cause of liver cirrhosis was viral hepatitis with 102 cases, studied patients were admitted to the hospital related to ascites, hematemesis and black stools (melena) (40.0 %, 37.4%, 20.9%) respectively).According to Child-Pugh, the highest percentage (40.0%) of the studied patients had Child class B while (20.9%) of them were Child class A (Table 2).
The third part of our results was concerned with nutritional status of studied patient by using different method.According to SGA, malnutrition was present in 73.9% of the patients, and of these 49 patients (42.6%) were moderately and 36 (31.3%) were severely malnourished, the table showed 47.8% of studied patient were under weight, according to TSF and MAC it was found 69.6% and 65.2% of studied patient suffering from malnutrition respectively (Fig. 1, Table 3).
The fourth part of our results was concerned with risk factor affecting on nutritional status, it revealed that 84.3% of the enrolled patients confirmed they had dryness of mouth, 69.5% had decreased of appetite, 60.0% inability to prepare meals (Table 4).
The fifth part of our results was concerned with laboratory assessment of the studied patients and revealed that the percentage below and above cut off more frequent in Hb, PT, Albumin, Na and Ca presenting in 87.0%, 99.1%, 84.3%, 53.0%, 80.9% ( Table 5).
The sixth part of our results was concerned with informational needs for patients; the result explains that the most important informational needs among the studied patients were medical domains 84.4%.In contrast, psychological domains achieved the least important 27.0%.Finally, the total informational needs arranged from moderated to high needs 33.0%, 67.0 % respectively (Table 6).
The seventh part of our results demonstrated that there was statistical significant relation between subjective Global assessment score and patients demographic characteristics, only among their age and income in study (p-value =0.01), p-value =0.003) .There was statistical significant relation between duration of the disease of the patients and their SGA score P-value = 0.0001, there was highly statistically significant relation between SGA score and Child Pugh score p-value = 0.00, there was statistically significant relations between informational needs and patient's age (P-value <0.001), marital status ( P-value = 0.009), and their job (P-value = 0.045).It is noticed that the informational needs was higher among those in younger age group (81.3%), married (71.6%) and employees (93.8).It shows statistically significant negative correlations between total information needs score and number of abnormal signs.On the other hand, number of abnormal signs had statistically significant positive correlation with number of abnormal lab results, statistically significant negative correlation between total informational needs score and patient's age r= 0.520, and Child Pugh r= 0.189.There are also statistically significant positive correlation between SGA and age r= 0.542, duration of illness r= 0.478, Child Pugh r= 0.589, conversely there were significant negative correlation between BMI, weight deficit and SGA score (Tables 7, 8, 9,10,11,12).
In multivariate analysis, indicated that the level of education, female genders were the statistically significant independent positive predictors of higher informational needs score with Standardized Coefficients (0.24, 0.25) respectively.Conversely, patient's age and number of abnormal signs were negative predictors with Standardized Coefficients (-0.41.-0.25) respectively, the model explains 41% of the variation in the information needs score.Age, Child Pugh and duration of illness were the statistically significant independent positive predictors of higher SGA score with Standardized Coefficients (0.22, 0.34, 0.21) respectively.Conversely BMI was statistically significant independent negative predictors of higher SGA score with Standardized Coefficients (-0.25), the model explains 57% of the variation in the SGA scores (Tables 13, 14).[3] in India that found more than one third of studied sample (37.2) suffering from malnutrition by BMI.
Among the anthropometric methods used, %TSF was the one that most frequently diagnosed malnutrition (69.9%).Although it is theoretically possible that the presence of swelling could hide a depletion in adipose tissue and that the frequency of diagnosis of malnutrition could be reduced by the % TSF method, it has been reported that in patients with chronic liver disease, the upper limbs are not the preferential place of swelling , similar finding was reported by Vieira Apart from total abnormal signs, the current study revealed that, there was a statistically significant negative correlation between number of abnormal signs, and informational needs.The negative relation between number of abnormal signs, and needs was confirmed in multivariate analysis.
On summary, Malnutrition is highly prevalent among the patients with liver cirrhosis, it varied according to the method used.The most prioritized informational needs for patients with liver cirrhosis was medical domain whereas the least priority was given to the psychological domain.It also shows that information needs differ based on some socio-demographic and clinical characteristics and physical condition.

: 1 : Part 2 : Part 3 : 2 : 5 :
three tools were used for data collection: Tool I: A Structured interview questionnaire tool for patients was designed by the researcher after revising of related literature and opinions of expertise for content of validity and included the following three parts:  Part Demographic characteristics of patients e.g.(age, sex, marital status, occupation, level of education ….etc).Nutritional profile which contain questions about follow special diet for liver cirrhosis, follow food restriction …etc) [3].Child Pugh score which consists of five items: total bilirubin, serum albumin, international normalized ratio (INR), ascites and hepatic encephalopathy [12].Tool II: Nutritional assessment form for patients was designed by the researcher after revising of related literature and opinions of expertise for content of validity and included the following five parts.Part 1: Subjective Global Assessment [13].Part Risk factor affecting nutritional status.Part 3: anthropometric measurement.Part4: Physical assessment suggestive of malnutrition [14].Part Biochemical measurements.Tool III: Informational Needs Questionnaire [15].

Table ( 1
): Personal characteristics of patients in the study sample (n=115)

Table ( 2
): Disease characteristics of patients in the study sample (n=115)

Table ( 3
): Anthropometric measurements of patients in the study sample (n=115)

Table ( 4
): Risk factors affecting the nutritional status among the studied patients (n=115)

Table ( 7
): Relation between SGA score among the studied patients and their personal characteristics

statistically significant at p<0.01 Table (8):
Relation between SGA score among the studied patients and their disease characteristics

statistically significant at p<0.01 Table (10): Relations
Correlation matrix of needs score, number of abnormal signs and abnormal lab findings between patient's information needs and their disease characteristics and BMI (*) statistically significant at p<0.05 (**) statistically significant at p<0.01Table (11): (*) statistically significant at p<0.05 (**) statistically significant at p<0.01 Table (13): Best fitting multiple linear regression models for the Information Needs Score