Mini Case Study

NOTRE DAME UNIVERSITYCOLLEGE OF HEALTH SCIENCES

COTABATO CITY

A Mini Case Study on

LIVER CIRRHOSIS

Submitted by:

ARAGON, Mikhail S.BALDIVINO, Apriel Joy D.DADANG, Shermane C.GOROSPE, Irish Kate A.GUIAMAN, Baisarah Q.PANDITA, Mohaima W.

RUBI, Beverly Joy A.SUMAMPAO, Diamond M.

SUYOM, Jessieden E.

BSN 2CGroup 3 MTW

February 2, 2011

I. Introduction………………………………………1

II. Objectives………………………………………..2

III. Baseline Information……………………………3

IV. History of Illness………………………………..4

V. Physical Assessment……………………………..5

VI. Anatomy & Physiology………………………….7

VII. Pathophysiology………………………………..13

VIII. Doctor’s Order (Course in the hospital)………15

IX. Laboratory Study………………………………..16

X. Drug Study……………………………………….18

XI. Nursing Care Plan……………………………….25

XII. Prognosis………………………………………..31

XIII. Discharge Summary Plan……………………...32

XIV. Recommendation……………………………....33

XV. Bibliography…………………………………….34

TABLE OF CONTENTS

As we all know, liver is one of the most important organ of our body. It is the largest gland and can be considered a chemical factory that manufactures, stores, alters, and excretes a large number of substances involved in metabolism. Thus, a problem in the liver may greatly affect the processes in our body.

The term "cirrhosis" was first used by René Laënnec (1781–1826) to describe the abnormal liver color of individuals with alcohol-induced liver disease. The word cirrhosis comes from the Greek word kirrhos, the name for a yellowish-brown color. Cirrhosis is the final common pathway for a variety of liver diseases, occurs when excessive fibrosis results in the conversion of normal liver architecture into structurally abnormal nodules.

It is an irreversible and life threatening complication one may encounter in her/his life. It is also a public health concern because of its associated mortality and morbidity.

The exact prevalence of cirrhosis is unknown, but it has been estimated, through autopsies, to be between 5 and 10 percent. Incidence of cirrhosis varies by country and region, and reflects relative contributions from different risk factors. In countries where alcohol consumption is common, alcoholic cirrhosis is the major contributor to the overall prevalence of cirrhosis. It has been estimated that alcoholic cirrhosis develops in women drinking at least 20 grams of alcohol a day for 5 to 10 years, and in men drinking at least 40 grams per day for the same period. In the Philippines, an autopsy material from the Philippine General Hospital from 1953 to 1962 revealed that 72.5% of liver cancers were associated with cirrhosis.

Liver cirrhosis has becoming the leading cause of liver cancer in the Philippines. Early detection and diagnosing of it can greatly help in preventing further damage in the liver, if not it may lead to another complication called ascites which is the accumulation of fluid in the peritoneal cavity that makes this condition more severe. The only available and definitive treatment is liver transplantation. Cirrhosis is, however, preventable in most cases. A healthy diet is encouraged, as cirrhosis may be an energy-consuming process. Close follow-up is often necessary. Antibiotics will be prescribed for infections, and various medications can help with itching. Furthermore, underlying causes should be given emphasis, since alcoholism is the main problem here, the patient must be advice to abstain from taking alcohol. Self-discipline is the key to a good health.

1

INTRODUCTION

General objectives:

This case study aims to come up with a more in-depth understanding of the disease Liver Cirrhosis, for us to be able to come up with the best nursing care plan in the care of patients with the said disease.

Specific objectives:

• To organize patient’s data to establish good background information.

• To be able to know the pathophysiological basis of the disease.

• To know clinical manifestations of the disease.

• To make and decide on different nursing care plans.

• To formulate different nursing interventions.

• To know the laboratory and diagnostic tests the client had undergone.

• To better understand the medication given to the client.

• To enhance awareness of the group to the disease.

• To be able to learn what actions should be taken when dealing with the patient.

2

OBJECTIVES

__________________________________

NAME: Mr. T

AGE: 55 years old

SEX: Male

CIVIL STATUS: Single

NATIONALITY: Filipino

ADDRESS: Anunan, MidasayapCotabato

DATE OF BIRTH: October 22, 1955

OCCUPATION: Sprays fertilizers on raw mangoes

RELIGION: Roman Catholic

________________________________________________

DATE OFADMISSION: January 10, 2011

TIME OF ADMISSION: 2:40pm

ATTENDING PHYSICIAN: Dr. Padua

CHIEF COMPLAINT: Abdominal distention

ADMITTING DIAGNOSIS: Liver Cirrhosis with Ascites

3

BASELINE INFORMATION

Past Illness History

The patient, Mr. T, a 55 year old man, starts drinking alcoholic drinks such as lambanog and tanduay when he was 15 years old because of family and peer influence. His father was also a heavy drinker. Mr. T consumes at about 4-5 bottles of Tanduay (long-neck type) daily, but has no other vice than that. He had no past medical diseases before.

Family History

Mother has leukemia; father has hypertension

Present Illness History

The patient, Mr. T, had been drinking alcoholic drinks for about 40 years now. He had his X-ray & Ultrasound Laboratory Tests on November 20 and 22, 2010 because of feelings of discomfort and abdominal pain, and vomiting. Results revealed that he has elevated diaphragm likely due to intra-abdominal lesion, and normal sized kidneys with diffuse parenchymal disease, ascites.

On December 13, 2010, was the onset of his abdominal distention.It was only on January 10, 2011 that he was admitted at Midsayap

Community Doctor’s Hospital under the supervision of Dr. Padua. He has abdominal distention because of ascites and edema (grade 3) on feet. And has paracentesis to drain fluids in his body. An X-ray and ultrasound tests was scheduled but unfortunately no tests had gone.

4

HISTORY OF ILLNESS

PHYSICAL ASSESSMENT

I. GENERAL PHYSICAL SURVEY

A. Appearance and Behavior

1. Age, Sex, and Race -55 years old, Male, Asian

2. Body Build -Proportionate to age, Tall, Skinny

3. Posture and Gait -Assymetrical posture and coordinate

4. Hygiene and Grooming -Clean and neatly dress, nails are not well-trimmed, fixed hair

5. Dress -Appropriate to age, place and climate

6. Odor of the body and breath -No foul smelling noted on body and breath

7. Apparent state of health -Physically, mentally, and emotionally unfit due to the disease condition.

8. Attitude -Cooperative with treatment and conversation

9. Affect and mood -Coherent, responds appropriately with discussed topics and expressed feelings appropriate to his condition.

10. Speech -Slightly clear, soft and weak, spontaneous and consistent in his stories

11. Thought Process -Oriented but thoughts are slightly unorganized.

B. Vital Signs

Temperature: 36 °CRespiratory Rate: 20 breaths per minuteHeart Rate: 85 beats per minuteBlood Pressure: 150/120 mmHg

II. SKIN

Mild jaundice was noted on his skin. He has dry skin with a rough texture. Dry wounds noted due to itching, has edematous feet grade 3. Hair is well distributed on both parts of the body, nails are not properly trimmed, yellowish in color and traces of dirt were noted, angle is about 160°.

III. HEAD

Skull is round, smooth skull contour, uniform consistency, absence of nodule or mass with symmetrical facial features and movements. Has sparse hair on head.

5

IV. EYES

Eyebrows are evenly distributed, symmetrically aligned, equal movement, eyelashes are equally distributed, curved, slightly outward. Eyelids skin is intact, closes symmetrically, bilateral blinking, bulbar conjunctiva is clear with tiny vessel, and palpebral conjunctiva is pink with no discharge. Sclera appears moist and slightly yellowish.

V. EARS

Ears are symmetrical and color same as face, firm and not tender. Pinna coils after it folded, short hearing range at about ½-1meter.Presence of mass, lesions, lacerations, bruises, swelling were not seen upon inspection.

VI. MOUTH

Dried lips, yellowish teeth, pale gums. Tongue in central location, pink in color, no lesions, moves freely, no tenderness, no palpable nodules, uvula is position on midline of soft palate. Tonsils are not inflamed.

VII. NOSE

Nose is symmetrical and straight, without nasal discharge, uniform in color, not tender, no lesions, nasal septum is intact and located in the midline. External surface of the patient’s nose is smooth and oily.

VIII. NECK

Patient can move his neck freely without any difficulty. Neck can properly support the head. No lesions, masses, deformities noted upon inspection.

IX. CHEST/LUNGS

Chest is slightly elevated on the right. There were no presence of scars, lesions and masses noted. Respiratory rate is 20 cycles per minute. Breath sounds were clear on both lungs.

X. ABDOMEN

Patient’s abdomen is distended, and abdominal girth measures 94cm. A large scarwas noted on his left abdomen.

XI. GENITO-URINARY

Patient verbalized no pain or difficulty upon defecation and urination.

XII. UPPER EXTREMITIES

Patient’s upper limbs, shoulders and arms were symmetrical. No deformities and swelling noted. No tenderness on the bones of the wrists and fingers. No structural deviations. Patient has IVF of PNSS 1L @ KVO infusing well @ left cephalic vein.

XIII. LOWER EXTREMITIES

Patient’s legs are symmetrical. Has a grade 3 edema on feet noted. Patient has difficulty ambulating because of intolerance due by his paracentesis.

6

ANATOMY & PHYSIOLOGY

Anatomy of the liver:

The liver is located in the upper right-hand portion of the abdominal cavity, beneath the diaphragm, and on top of the stomach, right kidney, and intestines. Shaped like a cone, the liver is a dark reddish-brown organ that weighs about 3 pounds.There are two distinct sources that supply blood to the liver, including the following:

oxygenated blood flows in from the hepatic artery nutrient-rich blood flows in from the hepatic portal vein

The liver holds about one pint (13 percent) of the body's blood supply at any given moment. The liver consists of two main lobes, both of which are made up of thousands of lobules. These lobules are connected to small ducts that connect with larger ducts to ultimately form the hepatic duct. The hepatic duct transports the bile produced by the liver cells to the gallbladder and duodenum (the first part of the small intestine).

Functions of the liver:

The liver regulates most chemical levels in the blood and excretes a product called bile, which helps carry away waste products from the liver. All the blood leaving the stomach and intestines passes through the liver. The liver processes this blood and breaks down the nutrients and drugs into forms that are easier to use for the rest of the body. More than 500 vital functions have been identified with the liver. Some of the more well-known functions include the following:

production of bile, which helps carry away waste and break down fats in the small intestine during digestion

production of certain proteins for blood plasma production of cholesterol and special proteins to help carry fats through the body conversion of excess glucose into glycogen for storage (glycogen can later be converted

back to glucose for energy) regulation of blood levels of amino acids, which form the building blocks of proteins processing of hemoglobin for use of its iron content (the liver stores iron) conversion of poisonous ammonia to urea (urea is an end product of protein metabolism

and is excreted in the urine)7

clearing the blood of drugs and other poisonous substances regulating blood clotting resisting infections by producing immune factors and removing bacteria from the

ANATOMY & PHYSIOLOGY

bloodstream

When the liver has broken down harmful substances, its by-products are excreted into the bile or blood. Bile by-products enter the intestine and ultimately leave the body in the form of feces. Blood by-products are filtered out by the kidneys, and leave the body in the form of urine.

The liver consist of two large lobes, right and left, and fills the upper right and center of the abdominal cavity, just below the diaphragm. The structural unit of the liver is the liver lobule, a roughly hexagonal column of liver cells (hepatocytes). Between adjacent lobules are branches of the hepatic artery and portal vein. The capillaries of a lobule are sinusoids, large and very permeable vessels between the rows of liver cells. The sinusoids receive blood from both the hepatic artery and the portal vein, and it is with this mixture of blood that the liver cells carry out their functions. The hepatic artery brings oxygenated blood, and the portal vein brings blood from the digestive organs and spleen. Each lobules has a central vein. The central veins of all the lobules unite to form the hepatic veins, which take blood out of the liver to the inferior vena cava.

The cells of the liver have many functions, but their only digestive function is the production of bile. bile enters the small ducts, called bile canaliculi, on the liver cells, which unite to form larger ducts and finally merge to form the hepatic duct, which takes bile out of the liver. The hepatic duct unites with the cystic duct of the gallbladder to form the common bile duct, which takes bile to the duodenum.

Bile is mostly water and has an excretory function in that it carries bilirubin and excess cholesterol to the intestines for elimination in feces. The digestive function of bile is accomplished by bile salts, which emulsify fats in the small intestine. Emulsification means that large fat globules are broken into smaller globules. This is mechanical, not chemical, digestion; the fat is still fat but now has more surface area to facilitate chemical digestion.

Production of bile is stimulated by the hormone secretin, which is produced by the duodenum when food enters the small intestine.

LIVER STRUCTUREThe wedge-shaped liver, which is located in the upper right-hand side of the

abdominal cavity, is one of the largest organs in the body. It is divided by the falciform ligament into two lobes, with the left lobe smaller than the right. Each lobe is composed of thousands of hexagonal lobules made up of billions of cells. Tiny tubes known as bile ducts form a network throughout the liver.

LIVER FUNCTIONThe liver is like a chemical processing factory and has many functions. It

secretes a digestive fluid called bile, largely produced from the breakdown products of dietary fat and old red blood cells. The liver also produces proteins, and stores glycogen, iron, and some vitamins. It removes toxins (poisons) and wastes from the blood and converts them into less harmful substances.

8HEPATIC PORTAL SYSTEM

A portal system is an arrangement of blood vessels between two different sets of tissue. Blood from the stomach, spleen, intestines, and pancreas drains into a number of veins, which merge to become the portal vein. This vein transports gastrointestinal blood to the liver, which absorbs and stores nutrients. Detoxified blood enters the inferior vena cava and returns to the heart and lungs for oxygenation and redistribution.

Hepatic portal circulation is a subdivision of system circulation in which blood from the abdominal digestive organs and spleen circulates through the liver before returning to the heart.

Blood from the capillaries of the stomach, small intestine, colon, pancreas, and spleen flows into two large veins, the superior mesenteric vein and the splenic vein, which unite to form the portal vein. The portal vein takes blood to the liver, where it branches extensively and empties blood into the sinusoids, the capillaries of the liver. From the sinusoids, blood flows into hepatic veins, to the inferior vena cava and back to the right atrium. Notice that in this pathway there are two sets of capillaries, and keep in mind that it is in capillaries that exchanges take place.

FOR EXAMPLE:Glucose from carbohydrate digestion is absorbed into the capillaries of the small

intestine; after a big meal this may greatly increase the blood glucose level. I f this blood were to go directly back to the heart and then circulate through the kidneys, some of the glucose might be lost in the urine. However, blood from the small intestine passes first through the liver sinusoids, and the liver cells remove the excess glucose and store it as glycogen. The blood that returns to the heart will then have a blood glucose level in the normal range.

Another example: Alcohol is absorbed into the capillaries of the stomach. If it were to circulate directly throughout the body, the alcohol would rapidly impair the functioning of the brain. Portal circulation, however, takes blood from the stomach to the liver, the organ that can detoxify the alcohol and prevent its detrimental effects on the brain. Of course, if alcohol consumption continues, the blood alcohol level rises faster than the liver’s capacity to detoxify, and the well-known signs of alcohol intoxification appear.

As you can see, this portal circulation pathway enables the liver to modify the blood from the digestive organs and spleen. Some nutrients may be stored or changed, bilirubin from the spleen is excreted into bile, and potential poisons are detoxified before the blood returns to the heart and the rest of the body.

9KIDNEYS

The two kidneys are located in the upper abdominal cavity on either side of the vertebral column, behind the peritoneum (retroperitoneal). The upper portions of the kidneys rest on the lower surface of the diaphragm and are enclosed and protected by the lower rib cage. The kidneys are embedded in adipose tissue that acts as a cushion and is in turn covered by a fibrous connective tissue membrane called the renal fascia, which helps hold the kidneys in place.

Each kidney has an indentation called the hilus on its medial side. At the hilus, the renal artery enters the kidney, and the renal vein and ureter emerge. The renal artery is a branch of the abdominal aorta, and the renal vein returns blood to the inferior vena cava. The ureter carries from the kidney to the urinary bladder.

INTERNAL STRUCTURE OF THE KIDNEY

In a coronal or frontal section of the kidney, three areas can be distinguished. The lateral and middle areas are tissue layers, and the medial area at the hilus is a cavity. The outer tissue layer is called the renal cortex; it is made of renal corpuscles and convoluted tubules. These are parts of the nephron and are described in the next section. The inner tissue layer is the renal medulla., hich is made of loops of Henle and collecting tubules (also parts of the nephron). The renal medulla consists of wedge-shaped pieces called renal pyramids. The tip of each pyramids is its apex or papilla.

The third area is the renal pelvis; this is not a layer of tissues, but rather a cavity formed by the expansion of the ureter within the kidney at the hilus. Funnel-shaped extensions of the renal pelvis , called calyces (singular: calyx), enclose the papillae of the renal pyramids. Urine flows from the renal pyramids into the calyces, then to the renal pelvis and out to the ureter.

THE NEPHRON

The nephron is the structural and functional unit of the kidney. Each kidney contains approximately 1million nephrons. It is in the nephrons, with their associated blood vessels, that urine is formed. Each nephron has two major portions: a renal corpuscle and a renal tubule. Each of these major parts ha further subdivisions.

Renal Corpuscle

A renal corpuscle consists of a glomerulus surrounded by a Bowman’s capsule. The glomerulus is a capillary network that arises from an afferent arteriole and empties into an efferent arteriole. The diameter of the efferent arteriole is smaller than that of the afferent arteriole, which helps maintain a fairly high blood pressure in the glomerulus.

Bowman’s capsule (or glomerular capsule) is the expanded end of a renal tubule; it encloses the glomerulus. The inner layer of Bowman’s capsule is made of podocytes; the name means “foot cells,” and the “feet” of the podocytes are on the surface of the glomerular capillaries. The arrangement of podocytes creates pores, spaces between adjacent “feet,” which make this layer very permeable. The outer layer of Bowman’s capsule has no pores and is not permeable. The spaces between the inner and outer layer of Bowman’s capsule contains renal filtrate, the fluid that is formed from the blood in the glomerulus and will eventually become urine.

Renal Tubule

The renal tubule continues from Bowman’s capsule and consists of the following parts: proximal convoluted tubule (in the renal cortex), loop of Henle (or loop of the nephron, in the renal medulla), and distal convoluted tubule (in the renal cortex). The distal convoluted tubules from several nephrons empty into a collecting tubule.

10Several collecting tubules then unite to form a papillary duct that empties urine into a calyx of the renal pelvis.

Cross-sections of the parts of the renal tubule. Notice how thin the walls of the tubule are, and also the microvillus in the proximal convoluted tubule. These anatomic characteristics provide for efficient exchanges of materials.

All parts of the renal tubule are surrounded by per tubular capillaries, which arises from the efferent arteriole. The peritubular capillaries will receive the materials reabsorbed by the renal tubules.

BLOOD VESSELS OF THE KIDNEY

The pathway of blood flow through kidney is an essential part of the process of urine formation. Blood from the abdominal aorta enters the renal artery, which branches extensively within the kidney into smaller arteries. The smallest arteries give rise to afferent arterioles in the renal cortex. From the afferent arterioles, blood flows into the glomeruli (capillaries, to efferent arterioles, to peritubular capillaries, to veins within the kidney, to the renal vein, and finally to the inferior vena cava. In this pathway there are two sets of capillaries, and recall that it is in the capillaries that exchanges take place between the blood and surrounding tissues. Therefore, in the kidneys there are two sites of exchange. The exchanges that take place between the nephrons and the capillaries of the kidneys will form urine from blood plasma.

OTHER FUNCTIONS OF THE KIDNEYS

In addition to the function describes thus far, the kidneys have other functions, some of which are not directly related to the formation of urine. These functions are secretion of renin (which does influence urine formation), production of erythropoietin, and activation of vitamin D.

1. Secretion of renin.When blood pressure decreases, the juxtaglomerular (juxt means “next

to”) cells in the walls of the afferent arterioles secrete the enzyme renin. Renin then initiates the renin-angiogenesis mechanism to raise blood pressure. The end product of this mechanism is angiotensin II, which causes vasoconstriction and increases the secretion of aldosterone, both of which help raise blood pressure.A normal blood pressure is essential to normal body functioning. Perhaps the most serious change is a sudden, drastic decrease in blood pressure, such as would follow a severe hemorrhage. In response to such a decreases, the kidneys will decreases filtration and urinary output and will initiate the formation of angiotensin II. In these ways the kidneys help ensure that the heart has enough blood to pump to maintain cardiac output and blood pressure.

2. Secretion of erythropoietin.

This hormone is secreted whenever the blood oxygen level decreases (a state of hypoxia). Erythropoietin stimulates the red bone marrow to increase the rate of RBC production. With more RCBs in circulation, the oxygen-carrying capacity of the blood is greater, and the hypoxic state may be corrected.

3. Activation of vitamin D.

This vitamin exists in several structural forms that are converted to calcitriol (D2) by the kidneys. Calcitriol is the most active form of vitamin D, which increases the absorption of calcium and phosphate in the small intestine.

11

DIFFERENCE BETWEEN A HEALHTY LIVER AND A CIRRRHOTIC LIVER

12

PATHOPHYSIOLOGY

13Narrative:

Cirrhosis is a chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver. There are three types of Cirrhosis or scarring

Modifiable/ Precipitating factors Heavy Alcoholic Beverage Drinker (40

years since 15 years old; approx. 5 bottles of tanduay daily

Exposure to toxic agents (plant chemicals) Environmental & work-related stressor

Non-modifiable/Predisposing factors

Family History of Leukamia (mother); Hypertension (father)

Age (55 years old)

Fluids accumulate in the peritoneal

cavity

Blood back flows into the GI tract

Obstruction in the hepatic portal circulation

Formation of scar tissues

Necrosis of hepatocytes

Damage to hepatic cells

Accumulation of fluids in

interstitialspaces particularly in the lower extremities

Impaired liver function

Easy fatigability

AnemiaRBC:2.84

Impaired GI function with impaired liver function

Esophageal varices

Caput medusae

Hemorrhoids

Distended blood

vessels

Ascite

Decreased colloid osmotic pressure

Decreased metabolism of protein

by the liver

Pitting edema on feet (grade 3)

of the liver (Biliary Cirrhosis, Alcoholic Cirrhosis, and Post necrotic Cirrhosis). The portion of the liver chiefly involved in cirrhosis consists of the portal and the periportal spaces, where the bile canaliculi of each lobule communicate to form the liver bile the bile ducts become the sites of the inflammation and the bile ducts become occluded with the inspissated bile and pus. The liver attempts to form new bile channels; hence, there is overgrowth of tissue made up largely of disconnected, newly formed bile ducts and surrounded by scar tissue.

Although several factors have been implicated in the etiology of cirrhosis, alcohol consumption is considered the major causative factor. Cirrhosis occurs with greatest frequency among people with alcoholism. Although nutritional deficiency with reduced protein intake contributes to liver destruction in cirrhosis, excessive alcohol intake is the major causative factor in fatty liver and its consequences. However, cirrhosis has also occurred in people who do not consume alcohol and in those who consume a normal diet and have a high alcohol intake.

Some people appear to be more susceptible than others to this disease, whether or not they have alcoholism or are malnourished. Other factors may play a role, including exposure to certain chemicals (carbon tetrachloride, chloride naphthalene, arsenic, or phosphorus).

Alcoholic cirrhosis is characterized by episodes of necrosis involving the liver cells, which sometimes occur repeatedly throughout the course of the disease. The destroyed liver cells are gradually replaced by scar tissue. Eventually, the amount of scar tissue exceeds that of the functioning liver tissue. Islands of residual normal tissue and regenerating liver tissue may project from the constricted areas giving the cirrhotic liver its characteristic hobnail appearance. The disease usually has an insidious onset and a protracted course, occasionally proceeding over a period of 30 or more years.

Clinical ManifestationsClinical manifestations include intermittent jaundice. Initially the liver is enlarged, hard, and

irregular, but eventually it atrophies. Signs and symptoms of cirrhosis increase in severity as the disease progresses. The severity of manifestations helps to categorize the disorder as compensated or decompensated cirrhosis. Compensated cirrhosis, with its less severe, often vague symptoms, may be discovered secondarily at a routine physical examination. The hallmarks of decompensated cirrhosis results from failure of the liver to synthesize proteins, clotting factors, and other substances and manifestations of hepatic portal hypertension.

Liver EnlargementThe liver tends to be large and the cells are loaded with fat. The liver is firm and has a sharp edge that is noticeable on palpation. Abdominal pain may be present because of recent, rapid

enlargement of the liver, which produces tension on the fibrous covering the liver. Later in the disease, the liver decreases in size as scar tissue contracts the liver tissue. The liver edge, if palpable, is nodular.

Portal obstruction and AscitesLate manifestations of cirrhosis are caused partly by chronic failure of liver function and partly

by obstruction of the portal circulation. Almost all of the blood from the digestive organs is collected in the portal veins and carried to the liver. Because a cirrhotic liver does not follow free blood passage, blood backs into the spleen and GI tract, and these organs become the seat of chronic passive congestion; that is, they are stagnant with blood and therefore cannot function properly. Fluid rich I protein may accumulate in the peritoneal cavity, producing ascites.

EdemaAnother late symptom of cirrhosis is edema, which is attributed to chronic liver failure. A

reduced plasma albumin conc. predisposes the patient to the formation of edema. Although edema is generalized, it often affects the lower extremities. Over production of aldosterone occurs, causing sodium and water retention and potassium excretion.

Vitamin deficiency and AnemiaBecause of inadequate formation, use, and storage of certain vitamins (notably vitamins A, C, K),

signs of deficiency are common, particularly hemorrhagic phenomena associated with vitamin K deficiency. Inadequate dietary intake and impaired liver function, account for the anemia that is often that is often associated with cirrhosis.

14

DOCTOR’S ORDER(COURSE IN THE HOSPITAL)

January 10, 2011

Please admit under the service of Dr.Padua(The patient is in need of medical attention)

TPR q 4° (To obtain baseline data of the patient and monitor any changes or unussualties in Vital signs)

DAT (To assure good and balance nutrition)

CBC, BT (To use as a basis in identifying patient’s problem)

SGPT, SGOT( To indicate any liver failure and problems)

PNSS @ KVO(To support the fluids and electrolytes in his body)

Ampicillin 1 gram IVTT q 6° ANST (used for treating bacterial infections)

Essentiale Forte 1 cup TID(Indicated for liver cirrhosis)

Furosemide 40mg IVTT now(To eliminate water and salt from the body)

For paracentesis(To take out fluid that has collected in the peritoneal cavity)

Ranitidine 50mg IVTT q8°(Short term treatment for gastric ulcer)

ECG(To measure the patient’s heart activity)

Creatinine(To assess kidney function)

U/A(To detect substances or cellular material in the urine)

Abdominal girth (To measure the intra-abdominal collection of fluid or monitor the ascites in the patient’s abdomen)

To follow PLR @ CA (To support the fluids and electrolytes in his body)

Aldactone 25mg 2 tabs TID(Causes increased amounts of Na & water to be excreted, while K is retained)

Furosemide 20mg ½ ampule IVTT q8° BP PREC(To excrete sodium, calcium, magnesium, chloride, water, and some potassium in the body)

January 11, 2011

NAHCO3 325mg 1tab TID(to relieve indigestion and neutralizes stomach acid)15

DETERMINATION ACTUAL VALUE

NORMAL VALUE

INTERPRETATION NURSING RESPONSIBILTY

CREATININE 313μmol/L. Male: 800-133μmol/L

Increase in creatinine indicates

Renal failure,renal calculi (related to

decreased renal excretion due to

obstruction)renal disease,

acute & chronic renal failure (related to decreased

urinary excretion)

Explain the purpose prior to the procedure.

Give client education. Drugs such as aminoglycosides (vancomycin, gentamicin) can cause kidney damage and so creatinine is monitored. Other drugs, such as cephalosprins (cefoxitin), may increase creatinine concentration without reflecting kidney damage.

Provide safety measures.

Observe for further complications.

16

DETERMINATION ACTUAL VALUE

NORMAL VALUE

INTERPRETATION NURSING RESPONSIBILTY

HEMATOLOGY:

Granulocytes

Hemoglobin

Red Blood Cell Count (RBC)

Hematocrit

Leukocyte Number Conc.

Lymphocytes

78

61

2.84

20.2

8.9

15.4

50.0-70.0%

Male: 120-160g/dL

4.0-5.50 x 1012/L

40.0-50%

4.0-11.0 x 10g/L

20 – 40%

-Increased indicates acute infection

-Decreased in various anemias

-Decreased RBC is usually seen in anemia of any cause with the

possible exception of thalassemia minor, where a

mild or borderline anemia is seen with a high or

borderline-high RBC.

-Decreased in severe anemia,

and low oxygen in the tissue

-Normal

-Decreased with aplastic anemia

Explain the procedure to the client.

Explain the importance or significance of having the procedure.

Health teaching about the diet and medication that may contribute to the result of the test.

Note for any abnormalities at findings.

Advise patient to eat nutritious foods.

17

GEN.NAME

BRAND NAME

CLASS MODE OF ACTION

INDICATION CONTRAINDICATION ACTUAL DOSE

USUAL DOSE

AMP

AMP

Anti-Ineffectives

Interferes with cell wall synthesis of

Treatment of respiratory tract & soft

Hypersensitivity to penicillins,

cephalosphorins or

1g IVTT q 6 hrs ANST

1g ampicillin

IV

LABORATORY STUDY #2

DRUG STUDY #1

ICILLIN

ICIN

susceptible organisms, preventing bacterial

multiplication, it also

renders the cell wall

osmotically unstable &

burst due to osmotic

pressure. Deactivated

by Beta-lactamase, an enzyme produced resistant bacteria.

tissue infections, bacterial

meningitis, septicemia

&gonococcal infections caused by

susceptible microorganis

m.

imipenem. Oral form not used to treat

severe pneumonia, emphysema, bacteremia,

pericarditis, & purulent or septic

arthritis during acute stage.

( )

18

GENERIC NAME

BRAND NAME

CLASSIFICATION MODE OF ACTION

INDICATION

CONTRAINDICATION

Essential phospholipids

Essentiale forte

Cholagogues, Cholelitholytics and Hepatic Protectors

Essentiale supports the vital

functions of the liver, especially

its antitoxic capacity. The

principal constituents of this preparation

are highly purified essential

phospholipids, the EPL

substance [active principle;

diglyceride esters of

cholinephosphor

Nutritional support in the management of damaged liver ( due to

chronic disease, liver

cirrhosis, fatty liver and

intoxication by hepatotoxic substances.

Essentiale Forte N should not be used in case of hypersensitivity to the medicine component.

DRUG STUDY #2

ic acid, of natural origin,

with excess

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GENERIC NAME

BRAND NAME


INDICATION CONTRAINDICATION USUAL DOSE

FUROSEMIDE

LASIX

Electrolytic and Water Balance

Agent; Loop Diuretic

Rapid-acting potent

sulfonamide “loop” diuretic

and anti-hypertensive

with pharmacologic

effects and uses almost identical to

those of ethacrynic

acid. Decreases

renal vascular resistance and

may increase renal

blood flow.

Treatment of edema

associated with cirrhosis of liver, and

kidney disease. May be used for

management of

hypertension, alone or in

combination with other

antihypertensive agents, and for treatment

of hypercalcemi

a.

Contraindicated in patients with

hypersensitivity to diuretics, patients with anuria, should be used with caution in patients

with preexisting electrolyte or water

balance abnormalities, impaired hepatic function (may precipitate hepatic

coma) and diabetes mellitus.

Furosemide20-40 mg IVTT

20

GENERIC NAME

BRAND NAME


INDICATION

CONTRAINDICATION

USUAL DOSE

ACTUAL DOSE

RA

ZA

Gastrointestinal agent;

Potent anti-ulcer drug

Short-term treatment of

Use cautiously with impaired renal or

I.V.: 20 mg

Ranitidine 50 mg IVTT

DRUG STUDY #3

DRUG STUDY #4

NITIDINE

NTAC

antisecretory (H2-receptor antagonist)Anti-ulcer agents

that competitively and reversibly inhibits histamine action at H2- receptor sites on parietal cells, thus blocking gastric acid secretion. Indirectly reduces pepsin secretion but appears to have minimal effect on fasting and postprandial serum gastrin concentrations or secretion of gastricintrinsic factorormucus.

activeduodenalulcer;maintenance therapy for duodenal ulcer patient after healing of acute ulcer; treatment of pathologic GI hypersecretory conditions

hepatic function. Ranitidine

tablets are contraindicated for patients known to

have hypersensitivity to the drug or any of

the ingredients

IV q8h

every 8 hours

21

GENERIC NAME

BRAND NAME

CLASS MODE OF ACTION INDICATION CONTRAINDICATION USUAL DOSE

DRUG STUDY #5

SPIRONOLACTONE

ALDACTONE

Diuretic Specificpharmacologicantagonist ofaldosterone,

acting primarilythrough competitive

binding ofreceptors at the

aldosterone-dependent Na-Kexchange site in

the distalconvoluted

renal tubule. Itcauses

increasedamounts of Na

and water to beexcreted, whileK is retained. Itacts both as adiuretic and as

anantihypertensive

drug by thismechanism.

Aldactone isindicated to

patients havingedema,

cirrhosis of the liver and

hypertension.

Aldactone is contraindicated for

patients with anuria,acute renal insufficiency,significant impairment of

renal excretory function, or hyperkalemia.

PO (adults):

25-400mg/day as a

single dose or

2-4 divided

dose

22

GEN. NAME

BRAND NAME


INDICATION CONTRAINDICATION USUAL DOSE

FUROSEMIDE

LASIX

Electrolytic and Water Balance

Agent; Loop Diuretic

Acts on theascending

loop ofHenle in the

kidney; inhibiting

reabsorption of

electrolytessodium and

chloride, causing

excretion ofsodium, calcium,

magnesium,chloride,

water andsome

potassium.

Indicated in acute

pulmonary edema, ascites,

and hepatic cirrhosis.

Hypersensitivity to sulfonamides , anuria,electrolyte depletion.

Furosemide

20-40mg IVTT

DRUG STUDY #6

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GENERIC NAME

BRAND NAME


INDICATION

CONTRAINDICATION

Sodium bicarbonate

Bell/ ans Urinary alkalinizer Increases plasma bicarbonate; buffers excesshydrogen ion concentration; raises blood ph; reverses the clinical manifestations of acidosis.

Oral: symptomatic relief of upset stomach from hyperacidity associated with peptic ulcer,gastritis, pepticesophagitis, gastric hyperacidity.

Contraindicated with allergy to components of preparations; metabolic and respiratory alkalosis; continuous GI suction; edematous or sodium-retaining states.

325 to 2000 mg orally 1 to 4 times a day. One gram provides 11.9 mEq (mmoL) each of sodium and bicarbonate.

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Name of Patient: Mr. TAP: Dr. Padua

Age: 55 years oldCC: Abdominal distention

HRP NURSING Dx.

AMB PATOPHYSIOLOGY CLIENT OUTCOME

INTERVENTION

DRUG STUDY #7

NURSING CARE PLAN #1

EXCHANGING

Fluid volumeexcess related

toaccumulation of fluids in the

peritoneal cavity

2° ascites

SUBJECTIVE:“Napansinkonalumalakiangtiyanko” asverbalized by the patient.

OBJECTIVE:· Anasarca· Altered electrolyte levels· Oliguria

Cirrhosis of the liver is a chronicdisease thatcauses cell destruction and fibrosis (scarring)of hepatic tissue.Fibrosis alters normal liver structure andvasculature, impairing blood and lymph flowand resulting in hepaticinsufficiency andhypertension in the portal vein. Complicationsinclude hyponatremia,water retention,bleeding, esophagealvarices. Coagulopathy,spontaneous bacterialperitonitis, and hepaticencephalopathy.

Within 6 hours ofNursing interventions,the patient willdemonstrate stabilized fluid volume anddecreased edema.

1.Measure intake andOutput.2. Assess respiratorystatus, noting increasedrespiratory rate, dyspnea.3.Monitor blood pressure.

4.Auscultate lungs, noting diminished/absent breath sounds and developing adventitious sounds. Assess degree of peripheral/dependent edema.5. Assess degree of peripheral/dependentedema. Measure abdominal girth.

6. Encourage bed restbecause ascites is present.7.Monitor electrolytes.

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HRP NSG. DX. AMB PATHOPHYSIOLOGY CLIENT OUTCOME

INTERVENTION

EXCHANGING

Imbalanced nutrition: less than body requirements, related to inability to digest nutrients

jaundice enlargement of

the abdomen edema on feet dry skin distended

jugular vein poor muscle

tone

Cirrhosis is a condition in which the liver slowly deteriorates and malfunctions due to chronic injury. Scar tissue replaces healthy liver tissue, partially blocking the flow of blood through the liver.Eating a nutritious diet is neededbecause malnutrition is common in people with cirrhosis, a healthy diet is important in all stages of the disease. If ascites develops, a sodium-restricted diet is recommended. A person with cirrhosis should not eat raw shellfish, which can contain a bacterium that causes serious infection.

Within the shift, the client will be able to verbalize and recognize foods to be eaten and avoided.

1. Encourage patient to eat nutritious food.

2. Encourage patient to eat supplementary feedings.

3. Encourage small frequent feedings.

4. Restrict intake of caffeine, spicy, cold and hot foods.

5. Encourage frequent mouth care.




26



HRP NURSING DX. AMB PATHOPHYSIOLOGY CLIENT OUTCOME

NSG. INTERVENTIONS

EXCHANGING

Risk for impaired skin integrity related to accumulation of bile salts in skin 2° liver cirrhosis

Jaundice, dry and scaly skin noted upon inspection;Pruritus.

.

Cirrhotic liver usually has a nodular consisting with bands of fibrosis and small areas of generating tissues leading to extensive destruction of hepatocytes. This alteration in the architecture of the liver alters the flow in the vascular and lymphatic system and bile duct channels. Periodic exacerbation is marked by bile stasis resulting to jaundice.

Within the shift, client will be able to identify techniques to prevent skin breakdown.

1. Assess the skin of the client.

2. Promote skin care by maintaining skin moisture.

3. Encourage client to have adequate intake of water and other fluids like fruit juices.

4. Educate client about proper skin care.

5. Provide clean environment.

6. Assess again for skin integrity.

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HRP

NURSING DIAGNOSI

S

AMB PATHOPHYSIOLOGY

CLIENT OUTCOM

E

NSG. INTERVENTI

ONS

RATIONALE EVALUATION



MOVING

Impaired physical mobility r/t presence of ascites and paracentesis.

Limited range of motion; limited ability to perform gross and fine motor skills; difficulty in turning noted.

Paracentesis was done to remove the fluids accumulated on the peritoneal cavity (ascites) causing enlargement of the abdomen, thereby limiting the client’s ability to move and do ADLs.

Within the shift, client will be able to demonstrate techniques to improve physical mobility and participate in ADLs.

1. Assist client in repositioning himself on a regular schedule as dictated by individual situation.

2. Encourage participation in self-care.

3. Identify energy conserving techniques forADLs.

4. Encourage adequate intake of fluids and nutritious foods.

5. Advise client to avoid strenuous activities.

6. Encourage client to verbalize feelings and concerns.

To support enhancement of client’s physical mobility.

To enhance self- concept and sense of independence.

To avoid fatigue and maximize participation.

Promotes well-being and maximize energy production.

To conserve energy.

To know what action should be taken and to identify priorities.

.Goal met. Client was able to perform ADLs independently.

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HRP NURSING DIAGNOSIS AMB PATHOPHYSIOLOGY CLIENT OUTCOME NSG. INTERVENTIONS

MOVING

Disturbed sleeping pattern related to exposure to unfavorable environment.

Subjective:“Putol-putolang tulog ko kasi naninibago ako sa paligid ko.”, as verbalized by the patient.

Objective:>body weakness noted>Frequentyawning noted

Treatment for cirrhosis depends on the cause of the disease and whether complications are present. The goals of treatment are to slow the progression of scar tissue in the liver and prevent or treat the complications of the disease. Hospitalization may be necessary for cirrhosis with complications.Cirrhosis is a complication of manyliver diseases that is characterized by abnormal structure and function of the liver. It leads to cirrhosis because they injure and kill liver cells and the inflammation and repair that is associated with the dying liver cells causes scar tissue to form.

Within the shift, the client will be able to verbalize adequate rest and sleep.

1. Place or position patient in a comfortable position.

2. Instruct client to do relaxation techniques and meditation.

3. Educate client to restrict caffeine from late afternoon or evening.

4. Assess sleep pattern disturbances that are associated with specific underlying illnesses.

5. Determine client’s expectations of adequate sleep

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CRITERIA GOOD POOR JUSTIFICATION

Sleep Pattern Mr. T is experiencing relapsing sleep.

Nutritional Status Mr.T eats the same kinds of food and does not drink water often.

Attitude towards treatment regimen

Mr.T participates with his treatment such in taking his medicines, laboratory exam and assessment.

Family support Family rarely visit and took care of him.

Financial support Mr. T supports himself with his

PROGNOSIS

http://www.medicinenet.com/script/main/art.asp?articlekey=110443

http://www.medicinenet.com/script/main/art.asp?articlekey=110443

savings and sometimes he need to ask money from his siblings.

Duration of Illness Mr. T experience signs and symptoms of liver cirrhosis since December 13,2010 upto 1 month.

Affect and Mood Mr. T is cooperative and participative.

GENERAL PROGNOSIS:

The cause of Mr. T’s condition is liver cirrhosis. He showed signs and symptoms such as jaundice, enlargement of abdomen and pitting edema. Treatment is still on going to treat the patient. Different factors of his life is affected and affecting his condition. Though client has difficulty financially, he still tried to meet his needs for his condition. Considering the factor cited above, the group concluded that Mr. T condition has poor prognosis.

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Medicationo Instruct client to follow and take the home medications prescribed by the physician.

R: Treatment regimen is important to have faster recovery.o Explain to the client the nature of the drugs so as the prescriptions.

R: Knowledge about the medications will make the client aware of what he is taking and may increase his cooperation.

Exerciseo Encourage client not to do strenuous activities and limit activities within own capacity as

possible.R: Activities that require great muscle strength should be avoided to prevent injury and muscle strain.

o Advise client to have adequate rest and sleep.R: To gain back the lost strength and be able to return to its normal state thus allow ample time for healing.

DISCHARGE SUMMARY PLAN

Treatmento Explain to the client and family the need for treatment and that it is a long process

depending on the compliance of the client to the therapeutic regimen.R: To make the client and family aware that the treatment does not end in the hospital and that their participation is a must in the continuation of care.

Hygieneo Advise client to observe proper hygiene like taking a bath everyday, hand washing before

and after performing activities especially when having meals and brushing of teeth every after meal.

R: Hygiene promotes comfort and cleanliness to the client and it also increases the sense of wellness.

Outpatient Visito Instruct client to visit physician on the dates given for follow-up check up.

R: Follow-up checkup is important for the physician to still monitor the progress of the therapeutic intervention availed by the client.

Dieto Educate client about the importance of taking proper diet.

R: Adequate information about the action will gain client’s cooperation.o Instruct client to take variety of nutritious foods such as fruits and vegetables once

ordered by the physician.R: To promote and maintain a healthy body.

Supporto Educate the family of the client about his condition.

R: Understanding the condition of the client will easily gain the cooperation of the family.

o Explain to the family of the client that physical, mental and emotional support are needed by the client in this time of his life and that it can help in the recovery of the client.

R: Proper support from the family will enhance client’s positive responses towards his recovery.

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To the patient and his family

Take medicines as prescribed by the physician to improve health. Family support is highly needed this time to lift patient’s hope and continue on fighting with his disease condition, and so that absolute care will be implemented to improve his over-all well-being. Patient must accept and thoroughly know what his condition is right now, in order for him to strictly follow the important interventions given and for him to also discipline himself in a good way.

To Notre Dame University-College of Health Sciences

Our group is honored to belong to such a prestigious university that values the importance of FIRES within every student, every college, and in different religions. We

RECOMMENDATION

recommend that the CHS will keep it up and still continue to find possible ways to improve and mold each nursing student, discover his/her skills and abilities, and continuously impose the virtues taught to us in this noble profession.

To the student nurses

Patient’s optimum care is our priority, and in order to implement ways for our patient’s recovery, we must know him well and must have adequate knowledge on his disease condition. Keen observation and assessment, application of the different nursing interventions, establishing rapport, thorough research and study are really needed to help make the patient become well. Data gathering skills and proper survey should be groomed for accurate presentation of cases. Never think that case studies are burdens in a student life, it is indeed one of the ways for a student to improve him/herself, and develop such attitudes and virtues within his/her realm. Teamwork and cooperation within the group should really be well applied in order to accomplish such case studies, for without it, everything else will go wrong. Patience, perseverance, prioritizing things and beginning with an end in mind should be honed within self to help achieve one’s task and goals.

To the readers

Our group recommends that the readers will still continue to research and read articles or readings other than our mini case study for there are a variety of sources that one can find to have a better understandingabout this and heighten one’s knowledge and awareness on the said disease. Liver cirrhosis is a serious and fatal disease but can be prevented only if a person starts taking care of his/her whole body earlier. Different ways could also be done to lower the chance for the development of such diseases. Hence, self-discipline and respect must be done. And institute good and effective patterns of one’s lifestyle, way of living, eating, drinking, and avoiding vices to prevent the occurrence of the different diseases.

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BOOKS:

Brunner and Suddarth’s Textbook of Medical-Surgical Nursing (Eleventh Edition) Volume 2

2007 Lippincott’s Nursing Drug Guide by Amy Karch

Nurses Pocket Guide edition 10 and 11

BIBLIOGRAPHY

Nursing Care Plan third edition by Gulanick, Klopp, Galanes, Gradishar, Puzas

Handbook of Diseases Third edition

Taber’s Cyclopedic Medical Dictionary.

WEB LINKS:

http://www.merckmanuals.com/professional/sec03/ch025/ch025a.html?qt=Liver%20Cirrhosis&alt=sh

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Documents

Mini Case Study