a case study on cirrhosis of liver
TRANSCRIPT
Objectives of Case study Objectives of Case study To gain in-depth knowledge about the study subject/disease To gain in-depth knowledge about the study subject/disease
condition. condition. To gain the confidence in handling such cases in future.To gain the confidence in handling such cases in future. To fulfill the partial course objective of M.N. curriculum.To fulfill the partial course objective of M.N. curriculum. To share experience and knowledge to friends, juniors and seniors.
Rational for the selection of case
Cirrhosis is ranked as the 9th leading cause of death in the united state and 4th leading cause of death in person between 35 and 45 years of life.
Excessive alcohol injection is the single most common cause of cirrhosis and alcoholism is common in Nepalese society, that’s why it is the interesting case for study so, I select this case.
A CASE STUDY ON CIRRHOSIS OF LIVER
Health History: A: Bio-graphical Data:
Patient’s Name : - Mrs. Thumi Sara Marsagni Age/ sex :-75 yrs/female
Marital status : - Married Education : - Literate Occupation : - Agriculture
Religion : - Hind Address :- Nawalparasi, Gaidakot ,1
Ward :- Female Medical Ward Bed No. : - 31 IP No. :- 45697 Date of admission :- 2068/07/13 Provisional Diagnosis:- Cirrhosis of Liver
Interview date :- 2068/07/14 Date of discharge :- 2068/07/18
Final Diagnosis :- Cirrhosis of Liver Attending physician :- Informants Obtained From :- Patient (self) & his son B : Chief complain
Abdominal distention since 15-16 days Bilateral pedal swelling since 10-12 days Moderate shortness of breathing since 5-7 days Loss of appetite since 15-16 days
C. Present Illness/ Health Status
1. Summary of Present illness;
Mrs . Thumisara was absolutely fine before 17monts back. Gradually she developed the problems of abdominal distension, swelling of lower legs and mild to moderate shortness of breathing, so her family members took her in medical shop near by her home and she was referred to hospital for further management . at that time she attained the medical OPD and cirrhosis of liver was diagnosed and advised to take oral medicines and stop of alcohol . Her condition was gradually improved.Thumisara again started to take alcohol since 6-7 months and the problem was relapsed again and she was admitted.
2. Investigation of symptom
symptoms onset character duration Alleviating factors
Aggravating factor
Abdominal distention
15-16days
moderate _ _ While taking more fluids and alcohol
Bilateral pedal swelling since
10-12 days
moderate _ _ _
shortness 5-7 Mild to _ Abdominal Resting in
of breathing
days moderate distention upright position
Loss of appetite
since 15-16 days
moderate _ _ _
D.Past Illness:
Childhood Illness Adult Illness
2)
Injuries and Accidents: My patient had no any history of external injuries and accidents.3) Hospitalization, Operations or Special Treatment: she had no history of previous hospitalization , but she had treated in OPD with same problem before 17 months.4) Allergies:-According to my patient she has not known allergies to any food, Drugs and others5) Medication Taken at Home :- She uses to takes some home remedy like Juwano, ginger , besar , marcha for some common health problem.6) Traditional Healer’s Prescription: According to my patient, sometimes she also used to take the Traditional Healer’s prescriptions for her and her family’s health problems.
Diseases yes No Disease Yes NoMeasles Hypertension Mumps Heart disease Whooping cough
Tuberculosis
Polio Diabetes Rheumatic Fever
Filariasis
Tuberculosis Malaria Malnutrition Cancer operation Asthma Others Accidents
Others
7) Medical Practioner’s prescription:- According to my patient, she takes medical practioner’s prescription for his health problem.8)Self prescription: My patient use to take some common medicines like , paracetamol, Decold , Diagen in her family members’ prescription whenever she has problem like headache ,fever , common cold , etc. but they doesn’t know the drug doses, it’s side effect ,indication and contraindications etc.
Family History1)
No. of children Age(year) Health StatusKrishna Bahadur
Marsagni48 years Healthy
Pashupati Marsangi 46 years HealthyDrupati Marsangi 42 years Healthy
Dol Kumari Marsangi 39 years HealthyBharat Marsangi 37 years Healthy
2) History of Any of the Disease below in Mother’s and Father’s Family
Disease Father’s Family Mother’sFamily
Remarks
yes No yes NoHypertension Diabetes Cancer Blood disorder Asthma Cardiovascular problems
Arthritis/Gout Tuberculosis Other specify
FAMILY TREE
F. Psychological:a) Client’s Reaction to illness: Mrs . Thumisara, has normal reaction to her illness .
b) Client’s Coping Pattern:she is using her past experiences of illness, other life experiences and support from the family, relatives as well as health person as coping pattern.
c) Client’s Value of Health:she thinks that health is very essential for young age but have to maintain for lifelong as we can.
d) Client’s Perception of the Care Giver:she thinks that all health care provider are very kind.
G. Sociological:a) Family Relationship: Client’s Position in the Family: she is the eldest person of the family.Person Living With Client (Support System) : Her Family Members (sons ,daughters granddaughter and grandsons.
75 years
42 yrs48 yrs 37 yrs
46 yrs 39 yrs
Recent Family Crisis or Changes: according to informant, they have difficult in managing the time for their sick mother because they have to go for work and study.B) Occupational History:Present Job: she is very old ,so she cannot do any work..
c) Educational Level: Highest Degree or Grade Attended: illiterateLevel of Learning: illiterate)
Cultural:
Ethnic Group: MagarClient’s Beliefs about Health and Illness: Her beliefs that the illness is caused by the unhappiness by god.Client’s Health Practice: According to she , she don’t have any idea for good health practice
Sources of Care(Modern /traditional): According to her and her informant , sometimes they goes to traditional healer , sometimes they goes to local medical shop and health post as well as Hospital for health seeking.
e) Leisure Time Activities: she spends her time with her grandsons and grand-daughtersf) Chemical Use (type, frequency, problems related to use)
Cigarettes: smoker. She takes 3-4 sticks /day Substances (e.g. Hashish, bidi, etc):- Non –userAlcohol: she takes alcohol every day about 800-1000ml.
H. Environmental History:a) Type of Drainage System: Openb) Types of Toilet Used: Water sealc) Sources of drinking Water: Tap water (unboiled water)
) Kitchen Style: Separate kitchen
e) Types of Fuel Used in Cooking: Fire-Wood
I. Significant Development Taska) Past if Relevant………………………………………………………… b)Current in Terms Of Appropriate Task For Age…………..………………………………………………………………………………….
Developmental tasks of older adulthood
S.N. According to book
According to patient
1 Adjusting to decreasing health and physical strength
My patient is adjusting her decreasing health and physical strength as she is depending on stick while walking .
As she is older she cannot do household work so she is depending to her family members for her activities of daily living
She is accepting her decrease health and physical strength as normal phenomena.
2 Adjusting to reduced or fixed income
My patient has no fixed income so she is economically fully depending to her family members .
3 Adjusting to death of spouse
Mrs. Thumisara has already lost her husband for 10 years so she is adjusting to death of spouse
4 Accepting oneself as an aging person
Mrs. Thumisara has full awareness that she is very old and she accepts oneself as an aging person so she handed over her kingship to her son and daughter- in law
5 Maintaining satisfactory living arrangements
Mrs. Thumisara has not maintained her own satisfactory living arrangement because she is non job
holder women however she is satisfied whatever she has now.
6 Redefining relationships with adult children.
My patient redefining relationship with adult children as she is still honorable in her family as a head of family so she gives her valuable advice and suggestion to her family as needed.
7 Finding meaning in life.
My patient is accepting the god’s natural phenomena towards the living creature and realizing that she fulfilled her female role sincerely.
Physical Examination
S.N Health History (Subjective Data)
Yes
No Physical Examination(objective Data)
1 GeneralCognation(Limitation/Restriction)Sensation(Limitation/Restriction)Communication(Limitation/Restriction
GeneralGait: Imbalanced Facial Expression (grimacing): undifferentiated Level of consciousness: ConsciousOrientation to time ,place and person: fully orientedMeasurementsHeight: 4feet 6 inchWeight :37 kgTemperature : 98°CPulse: 90 b/minRespiration :20 /minBlood pressure : 110/60 mm of hg
2 Problem related to Head and faceHeadacheInjuryPuffiness of face
Hair :black and grey in colourScalp: dirty, dandruff present, no injury, lumps and other lesions presentSkull: normal in shapeFace: uniform movement of side of face , slight edema ,no massesSinuses : No swelling , tenderness and depression
3 Problem Related to Eye/ Vision
Pain Swelling DischargeExcessive tears Difficulty Seeing at NightAny other problems……………………
Condition of Eyelids: No swelling, redness ,lesionsCondition of Conjunctiva: pale palpebral conjunctivas, Condition of cornea: transparentColour of Sclera: yellow scleraPupil Size Symmetry: uniform in size and shapeReaction to light : reactive to light Discharge from eyes : slightly white sticky discharge Visual Acuity: Sub- Normal Eye Glasses : Not used
4 Problem Related to Ear:PainTinnitusVertigoDizzinessOthers …………………..
Condition of External Ear:Normally Located external EarDrainage from Ear: No discharge of pus , blood ,slightly wax presentLumps or Lesions: Not found Ear Drum: Hearing Aid: Not used Rinne Test: AC>BCWeber Test: AC>BC
5 Problems Related to Nose
InjuryBleeding /DischargeBlockage
Location : centrally located Nasal Deviation : Not found Bleeding: NoPatency of the Nostrils: patented Any Discharge: Not foundSmell: No problem in smellingCondition of Nasal mucosa:Pale in colourFlaring Nostrils: Not presented.Inflammation: Not found.Nasal Polyps: Not found
6 Problems Related to MouthSore on LipsSore on TongueGum Bleeding Missing Teeth/ DenturesChange in TasteToothache
Lips: Dry Oral Cavity: Pale mucous membrane of oral cavity Teeth: Missing all teethTongue: slightly dry and coated tongueVocal cord, Uvula and Tonsils: Not enlarged and inflamed.
7 Problems Related to Speech Loss of ConsciousnessLoss of Memory Convulsion
Speech Disorders: Not presented.
8 Throat and NeckDifficulty n Swallowing
Location : centrally located, no tilting of headMovement : Full and smooth range of
Problems in TonsilNeck Rigidity
movement, no stiffness or tendernessJugular Vein : Not enlargedCondition of Thyroid: No enlargement of thyroid gland
10
Problem Related to Respiration :DyspnoeaCoughHoarseness of VoiceCyanosis Others………………………………..
Heart and Circulation : Chest painNumbness
Respiratory Rat:20 b/minDepth of respiration: Normal depthQuality of Respiration : dyspnoea in lying position
Chest Inspection- lateral diameter is wider than anterior
posterior diameter- sternum is located at the midline- Even expansion of the chest during
breathing No intercostals retraction
• Slight cough , but no productive sputum.
Chest Palpation- No tenderness, lump or depression along
the ribs.Percussion
- Deep resonant sound heard all over the lungs.Auscultation
- Breath sounds are heard in all areas of the lungs.
- Inspiration longer than expiration - No , rhonchi, wheezing sound was
presented
Pulse Rate: Radical: 88b/min Apical: 88 b/min
11
12
Palpitation Fever , chillsBleeding tendenciesOthers :…………………………………………………………………………………………
Nutrition / Hydration:
AnorexiaNausea/ VomitingUnusual thirst or hungerDiaphoresisNon VegetarianSpecial DietFood DislikesAbility to Chew or swallowResent change in Weight
Elimination and reproduction:Pain in UrinationChange in urine colourUrinary RetentionFrequency of UrinationIncontinence of UrineConstipation Diarrhea Passing worms, Mucous
Character of Pulse: Normal Blood Pressure: Right110/60mm of hg Left: 100/60 mm of hg
Peripheral Pulse: All presentCapillary Refill: 1 secondEdema ( e.g. puffy eye) : presentVaricosities: AbsentVisible External Jugular veins : AbsentSystolic or Diastolic Murmur : Absent
Body Build: AverageBody weight : 37 kgSkin Turgor/ Elasticity : NormalCondition of Buccal mucosa : intact
Appearance of Urine : yellowish (concentrated)Appearance of Stool: Normal Any Enlargement of Liver, spleen: moderately enlarged liver found.Any Masses in Abdomen: Not FoundAny tenderness in Above Ares: Tenderness in Rt. HypocardiumSize and shape of abdomen: distended abdomenShifting dullness: presentDistended abdominal veins : slightly Fluid thrill: present
13
Elimination and Reproduction:Appearance of Stool Bleeding from RectumFlatulenceHeart BurnAbdominal Pain Discharge from GenitaliaPain or Swelling of scrotumAny Unexpected vaginal bleedingAny menstrual DisorderUterine prolapsedKnowledge of family planning methodFamily Planning Device Used Bowel Habits: Regular/ IrregularPap Smear Test Done
Mobility :Difficulty with Ambulation Muscle cramping or WeaknessMuscle PainBack PainJoint Pain or SwellingLimited Joint MovementAbility to Do ADLS
Abdominal girth: 33 inchEnlarges Inguinal and femoral Nodes: Not found Bowel sounds: Present
Lesion or tumors of Rectal Area: Not foundAbnormalities of Genito-Urinary Area: Not foundFemale- Rectocele and Cystocele: not presentUterine prolapsed : not presentDischarge : Not presentOther………………………
………………….
Motor Strength and Mobility: slight reducedEnlargement and Stiffness of Joints: Not presentContractures: slightly Present( knee joint)Spinal Deformity: Not PresentRange of motion Exercise: Cannot move in full Range Of MotionCANE: use of stick Crutches : Not used Walker : Not used Prosthesis : Not Used
14
15
16
Comfort ,Sleep and Rest:
Pain Regular Sleep Pattern
Integumentary Hygiene :Non –healing soresChange in Mole ColourNail Changes Itching Of Skin SensationRegular bathing Habit
Reflexes
Location Of Pain : Rt. Hypochondrium tenderness
Discomfort due to abdominal distention Sleep disturb at night
Colour of skin, Texture, Turgor : Normal Pigmentation, Lesion, Tumors: Not foundSkin Inflammation : Not presentEdema: present (lower legs and abdomen)Rashes : Not presentAbnormal Nail Conditions: Not presentDistribution and Texture of Hair : equally distributed of scalp hair, no,any abnormally distribution in body hair , the texture of hair is soft Touch Sensation: Normally Presented all over the bodyEnlarged lymph Glands and nodes: Not found
Biceps Reflex: presentBrachilo radialis: presentTriceps Reflex: presentPatellar Reflex : presentAchilles Reflex: presentBabinski Reflex : present( negative)Kerning’s sign : Absent
UNIT II - INTRODUCTION TO DISEASE
Cirrhosis of liver
Introduction
• The term cirrhosis was first used by Rene Laennec (1781-1826) to describe the abnormal liver color of individuals with alcohol induced liver disease.
• Derived from Greek word Kirrhos means Yellowish – brown color.
Definition:
• Cirrhosis is a chronic progressive disease of the liver characterized by extensive degeneration and destruction of the liver parenchymal cells.
• Cirrhosis is a chronic disease characterized by replacement of normal liver tissue with diffuse fibrosis that disrupts the structure and function of the liver.
• The liver cells attempt to regenerate, but the regenerative process is disorganized, resulting in abnormal blood vessels and bile duct architecture.
• 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.
Scarring also impairs the liver's ability to:
• control infections
• remove bacteria and toxins from the blood
• process nutrients, hormones, and drugs
• make proteins that regulate blood clotting
• produce bile to help absorb fats—including cholesterol—and fat-soluble vitamins
Incidence:
• It is the twelfth leading cause of death, 27,000 deaths each year and affects men slightly more than women.
• It is the 10th leading cause of death in the US, with mortality rate of 9.2 deaths per 100,000 populations.
• Of those deaths, 45% were alcohol related. Men are more likely than women to have alcoholic cirrhosis.
• Worldwide, post necrotic cirrhosis is the most common in women. Mortality is higher from all types of cirrhosis in men and non whites.
CAUSES OF CIRRHOSIS Alcohol Chronic viral hepatitis (B or C) Non-alcoholic fatty liver disease Immune
o Primary sclerosing cholangitis o Autoimmune liver disease
Biliary o Primary biliary cirrhosis o Cystic fibrosis
Genetic o Haemochromatosis o α1-antitrypsin deficiency o Wilson's disease
Cryptogenic (unknown)
Etiology:
Alcohol.
• Heavy alcohol for several years can cause chronic injury to the liver and damages.
• For women, consuming two to three drinks—including beer and wine per day and for men, three to four drinks per day, can lead to liver damage and cirrhosis.
• A common problem in alcoholic is protein malnutrition.
Obesity:
WHO ,2008, estimated that more than 200 million men and close to 300 million women were obese, obesity is a common cause of chronic liver disease , 17% of liver cirrhosis is attributable to excess body weight.
Chronic hepatitis C.
Chronic hepatitis C causes inflammation and damage to the liver over time that can lead to cirrhosis and approximately 20% patient will develop cirrhosis.
Chronic hepatitis B and D.
• Hepatitis B and D is virus that infects the liver and can lead to cirrhosis, but it occurs only in people who already have hepatitis B. approximate 10%- 20% will develop cirrhosis.
Nonalcoholic fatty liver disease (NAFLD).
• This is associated with obesity, diabetes, protein malnutrition, coronary artery disease, and corticosteroid medications.
• Autoimmune hepatitis. It is caused by the body's immune system attacking liver cells and causing inflammation, damage, and eventually cirrhosis.
Genetic factors –
About 70 percent of those with autoimmune hepatitis are female.
Diseases that damage or destroy bile ducts.
• Several different diseases (cholangitis) can damage or destroy the ducts that carry bile from the liver, causing bile to back up in the liver and leading to cirrhosis.
Inherited diseases.
• Cystic fibrosis, alpha-1 antitrypsin deficiency, hemochromatosis, Wilson disease, galactosemia, and glycogen storage diseases are inherited diseases that interfere the liver function properly, Cirrhosis can result.
Drugs, toxins, and infections.
• Drug reactions( Acetaminophen, isonazide, methotrexate) prolonged exposure to toxic chemicals, parasitic infections, and repeated bouts of heart failure with liver congestion.
Types of cirrhosis :
Alcoholic (historically called Laennec’s cirrhosis) cirrhosis:
• Also called micro nodular or portal cirrhosis and usually associated with alcohol abuse.
• The first change in the liver from excessive intake is an accumulation of fat in the liver cells; uncomplicated fatty changes in the liver are potentially reversible if the person stops drinking alcohol.
If the alcohol abuse continues, widespread scar formation occurs throughout the liver.
Post necrotic cirrhosis( macro nodular):
• Most common worldwide, massive loss of liver cells with irregular patterns of regenerating cells due to complication of viral, toxic or
idiopathic (autoimmune) hepatitis.
Billiary cirrhosis: is associated with chronic billiary obstruction and infection. There is diffuse fibrosis of the liver with jaundice.
Cardiac cirrhosis: chronic liver disease results from long-standing, severe right side heart failure with corpulmonale, constrictive pericarditis, and tricuspid insufficiency.
Pathophysiology :
Liver insult, alcohol ingestion, viral hepatitis, exposure to toxin
Hepatocyte damage
Liver inflammation - ↑WBCs, nausea, vomiting, pain , fever, anorexia, fatigue
Alteration in blood and lymph flow
• Liver necrosis →liver fibrosis and scarring → portal hypertension
- ascities, edema,
- spleenomegaly(Anemia,
thrombocytopenia, leucopenia)
- Varices (esophageal varices, hemorrhoids.)
↓ billirubin metabolism – hyperbilirubinemia, jaundice
• ↓ bile in gastrointestinal tract – light colored stool• ↑ urobilinogen – Dark Urine• ↓ vit K absorption- bleeding tendency• ↓ metabolism of protein, carbohydrate, fats→ hypoglycemia, • ↓ plasma protein- ascites and edema
↓androgen and estrogen detoxification(↓ hormone metabolism)- ↑ estrogen and androgens hormone – Gynecomastia, loss of body hair, menstrual dysfunction, spider angioma, palmer erythema, testicular atrophy
• ↓ ADH and aldesterone detoxification so ↑ ADH levels - edema • Biochemical alteration - ↑ AST, ALT levels, ↑ bilirubin, low serum
albumin, prolong prothombin time, elevated alkaline phosphatase.• Liver failure• Hepatic encephalopathy• Hepatic coma• Death
Clinical manifestations:
Early manifestations –
No symptoms in the early stages of the disease. GI disturbances are more common , anorexia, dyspepsia, flatulence,
weakness, fatigue, nausea, vomiting, weight loss, abdominal pain and bloating, and change in bowel habit ( diarrhea, constipation).
Abdominal pain, dull and heavy feeling in right upper quadrant or epigastric due to swelling and stretching of the liver capsule, spasm of biliary duct.
Fever, lassitude, weight loss, enlargement of liver and spleen.
Later manifestations:
May be severe and result from liver failure and portal hypertension.
Jaundice, peripheral edema and ascities develop gradually. Other late symptoms include skin lesion, hematological disorders,
endocrine disturbances, and peripheral neuropathy. In the advanced stage the liver becomes small and nodular.
Jaundice : It results from the functional derangement of liver cells and
compression of bile duct by connective tissue overgrowth. Jaundice occurs as a result of decreased ability to conjugate and excrete
bilirubin. If obstruction of the biliary tract occurs, obstructive jaundice may also
occur and usually accompanied by pruritus.Skin lesion:
Spider angioma ( telangiectasia or spidernavi) are small dilated blood vessels with a bright red center point and spider like branches occurs in nose, cheeks, upper trunk, neck and shoulders.
Palmer erythema, a red area that blanches with pressure, is located on the palm of the hand.
Both lesions are due to increase estrogen in blood as a result of the damaged liver’s inability to metabolized steroid hormone.Hematologic problem:
Thrombocytopenia, leucopenia, anemia, due to spleenomegaly (back flow of blood from portal vein into the spleen.)
Anemia due to inadequate RBC production and survival, and due to poor diet, poor absorption and bleeding from varices.
Coagulation problems result from the liver’s inability to produce prothrombin and blood clotting and manifested by hemorrhagic phenomena or bleeding tendencies e.g. epistaxis, purpura, gingival bleeding, heavy menstrual flow.Endocrine problem :
In men, Gynecomastia, loss of axillary and pubic hair, testicular atrophy and impotence with loss of libido due to increased estrogen level.
In younger female, amenorrhea may occur and in older, bleeding may occur.
↑aldosterone hormone may cause sodium water retention and potassium loss.Peripheral neuropathy:
Probably due to dietary deficiency of thiamine, folic acid and
cobalamin.
Clinical manifestations:
According to bookAccording to patient
Compensated
• Intermittent mild fever• Vascular spiders• Palmar erythema (reddened
palms)• Unexplained epistaxis • Ankle edema• Vague morning indigestion• Flatulent dyspepsia• Abdominal pain• Firm, enlarged liver• Splenomegaly
Decompensate
• Ascites • Jaundice• Weakness• Muscle wasting• Weight loss• Continuous mild fever• Clubbing of fingers• Purpura (due to decreased
platelet count)• Spontaneous bruising
Hepatomegaly Jaundice (bilirubin total 2.2 mg /dl) Moderate Ascites Bilateral pedal edema Losses of appetite Abdominal pain dull and heavy feeling in right upper
quadrant weakness, fatigue, nausea, weight
loss Anemia (pale mucosa ,) Mild shortness of breathing
• Ascites • Jaundice• Weight loss
• Epistaxis • Hypotension• Sparse body hair• White nails• Gonadal atrophy
Diagnosis according to book
• Liver function test : ↑alkaline phosphate, ALT,AST and y – glutamyl transpeptidase ( GGT)
• Blood test: ↓ total protein, ↓ albumin, ↑ serum bilirubin and glubomin • Prothombin time is prolong• Liver cell biopsy to identify liver cell changes• Ascites fluid test• Liver ultrasound• CT Scan• Stool for occult blood
Endoscopy
InvestigationsThese are performed to assess the severity and type of liver disease.Severity■ Liver function. Serum albumin and prothrombin time are the best indicators of liver function: the outlook is poor with an albumin level below 28 g/L. The prothrombin time is prolonged commensurate with the severity of the liver disease .
■ Liver biochemistry. This can be normal, depending on the severity of cirrhosis. In most cases there is at least a slight elevation in the serum ALP and serum aminotransferases. In decompensated cirrhosis allbiochemistry is deranged.
■ Serum electrolytes. A low sodium indicates severe liver disease due to a defect in free water clearance or to excess
diuretic therapy.
■ Serum creatinine. An elevated concentration 130 mol/ L is a marker of worse prognosis.In addition, serum -fetoprotein if 200 ng/mL is strongly suggestive of the presence of a hepatocellular carcinoma.
Ultrasound examination. This can demonstrate changes in size and shape of the liver. Fatty change and fibrosis produce a diffuse increased echogenicity. Inestablished cirrhosis there may be marginal nodularity of the liver surface and distortion of the arterial vascular architecture. The patency of the portal and hepaticveins can be evaluated. It is useful in detecting hepatocellular carcinoma. Elastography is being used in diagnosis and follow-up to avoid liver biopsy.■ CT scan Arterial phase-contrast-enhanced scans are useful in the detection of hepatocellularcarcinoma.■ Endoscopy is performed for the detection and treatment of varices, and portal hypertensive gastropathy. Colonoscopy is occasionally performed forcolopathy.■ MRI scan. This is useful in the diagnosis of benign tumours such as haemangiomas. MR angiography can demonstrate the vascular anatomy and MR cholangiography the biliary tree.Liver biopsyThis is usually necessary to confirm the severity and type of liver disease. The core of liver often fragments and sampling errors may occur in macronodular cirrhosis. Special stains are required for iron and copper, and various immunocytochemical stains can identify viruses, bile ducts and angiogenic structures. Chemical measurement of iron and copper is necessary to confirm diagnosis of iron overload or Wilson’s disease. Adequate samples in terms of length and number of complete portal tracts are necessary for diagnosis and for staging/grading of chronic viral hepatitis.
Diagnostic Investigations in patient
According to Book According to Patient• Liver function test : Liver function test :
SGOT/ AST : 187 U/L
↑alkaline phosphate, ALT,AST and y – glutamyl transpeptidase ( GGT)
• Blood test: ↓ total protein, ↓ albumin, ↑ serum bilirubin and glubomin
• Prothombin time is prolong
• Liver cell biopsy to identify liver cell changes
• Ascites fluid test• Liver ultrasound• CT Scan•
SGPT/ ALT: 88.0 U/LAlkaline Phosphate: 124 IU/L
Total protein : 6.4 gm/dl Albumin : 3.4 gm/dl Prothombin time: 23.3 sec INR : 1.8 Bilirubin Total: 2.2mg/dl Creatinine : 2.0 mg /dl Haemoglobin: 7.8 gm/dl WBC : 11,600 Mm3 Platelets : 61,000 Mm3 USG: findings s/o cirrhosis of
Liver, Moderate Ascites
Others Investigations of patient
Date of investigation
According to my patient Normal range
2068/07/13 Hematology Hb : 7.8gm /dl WBC:11,600 mm3Platelets :61,000 mm3Prothombin Time (test): 23.3sec Prothombin Time (control): 14.0 secINR : 1.8Differential count Neutrophil- 90%Lymphocyte 10%Esinophil-00Basophil-00Biochemistry- report
HB% M-13-15 F-12-14 gm/dlWBC-400O-1100mm3 Platelets 1,50,000- 4,00,000 Prothombin Time (test) 14-16 sec
Neutrophil-40-70%Lymphocyte-30-35%Esinophil -1-2%Basophil-0-1%
2068/07/16
Blood sugar (R):129.0 mg/dlCreatinine: 2mg/dlSodium : 142.7mmol/lPotassium :3.45 mmol/l
Total Protein : 6.4 gm/dlAlbumin: 3.4 gm/dl
SGOT/AST : 187.0 U/LAGPT/ALT: 88.0 U/L
Alkaline phosphates: 124.0 IU /LBlood grouping:’’B’’ positive Bilirubin Total: 2.2 mg/dlBilirubin Total: 0.8 mg /dl
ECG : Normal Sinus rhythm, non specific T wave abnormality
Urine RE/MEColour- light yellowReaction –AcidicAlbumin- NilSugar-Nil transparency- Clear Pus Cell-2-4 /HPFRBCs: PlentyEpithelial cells- 3-4 /HPF
USG abdomen and pelvis: Finding S/O Cirrhosis of Liver Moderate Ascites
Creatinine: 1.7 mg/dl
Blood sugar (R): 60-180 mg/dlCreatinine: 0.4-1.4 mg/dlSodium : 135-150 mmol/LPotassium : 3.3-5.5 mmol/LTotal Protein :6-8 gm/dlAlbumin: 3.5-5.5 gm/dl
SGOT/AST : M ˂37 F ˂31 U/LAGPT/ALT ˂40.0 U/LAlkaline phosphates : M-64 -306 F: 84-306Up to 15 yrs: <644Up to 17 yrs : <483Bilirubin Total: 0.4-1.0 mg/dlBilirubin Total: 0.1-0.4
ECG : Sinus rhythm
Urine R/E:Acidic Appearance: ClearColor: P. yellowWBC:3-5/HPFEpithelial cell: 2-4/HPF
USG abdomen and pelvis: Normal scan
Creatinine: 0.4-1.4 mg/dl
068/07/17
Platelets :67,000 mm3
Hb : 10.2 gm /dlPlatelets :92,000 mm3
Platelets 1,50,000- 4,00,000 mm3
Management (According To Book)
Medical management
• Monitor for complications: Ascites, bleeding esophageal varices and hepatic encephalopathy and if occurs manage them accordingly.
• Many medicines have been studied, such as steroids, penicillamine (Cuprimine, Depen), and an anti-inflammatory agent (colchicine), but they have not been shown to prolong survival or improve survival rate.
• Researchers are studying various experimental treatments for cirrhosis.
Surgical management
• The only surgery that has been proven to improve the chances of long-term survival is liver transplantation.
• About 80-90 percent of people who undergo liver transplantation survive.
Maximize liver function:
• The diet should be adequate calories and protein (75- 100 gm/day) unless hepatic encephalopathy is present, in which case protein is limited.
• Restrict fluid and sodium if edema or fluid retention is present.• Diuretic, thiazide – potassium supplement. • The B vitamins and fat soluble vitamins (A, D, E, K).• Adequate rest is needed to maximize regeneration of liver cells. • Corticosteroids drugs to improve liver function in post necrotic
cirrhosis.
Treat underlying cause: if cirrhosis is from heavy alcohol use, the treatment is to completely stop
drinking alcohol. If cirrhosis is caused by hepatitis C, then the hepatitis C virus is treated
with medicine Prevent Infection:
by adequate rest, appropriate diet, avoidance of hepatotoxic substances.
Beta-blocker or nitrate
• For portal hypertension. Beta-blockers can lower the pressure in the varices and reduce the risk of bleeding. Gastrointestinal bleeding requires an immediate upper endoscopy to look for esophageal varices.
Complications
Portal hypertension :
• The nodules and scar tissue can compress hepatic veins within the liver. • This causes the blood pressure within the liver to be high, a condition
known as portal hypertension.• Portal venous pressure is more than 15mmHg or 20 cm of water.• Is characterized by ↑venous pressure in the portal circulation,
spleenomegaly, large collateral vein, ascites, systemic hypertension, and esophageal varices.
• The common area to form collateral channels are in the lower esophagus( the anastomosis of the left gastric vein and azygos vein), the parietal peritoneum, rectum.
• High pressures within blood vessels of the liver occur in 60% of people who have cirrhosis
Esophageal Varices:
• Esophageal Varices are a complex of tortuous veins at the lower end of the esophageal enlarged and swollen as a result of portal hypertension.
• 10-30% of UGI bleeding due to rupture of varices.• 80% bleeding due to esophageal Varices.• 20% due to gastric varices.
Peripheral edema and Ascites:
• Edema results from decreased colloidal oncotic pressure from impaired liver synthesis of albumin (hypoalbuminia)
• Ascites is the accumulation of serous fluid in the peritoneal cavity. • Protein move from the blood vessels via the larger pore of sinusoids into
the lymph space. • When the lymphatic system is unable to carry off the excess protein and
water, they leak through the liver capsule into the peritoneal cavity.
Hepatic encephalopathy :
• Hepatic encephalopathy is a neuropsychiatric manifestation of liver damage.
• It can occur in any condition in which liver damage causes ammonia to enter the systemic circulation without liver detoxification.
• Liver is unable to convert ammonia to urea. The ammonia crosses the blood brain barrier and produces neurologic toxic manifestations
• Clinical manifestations include changes in neurological and mental responsiveness, ranging from sleep disturbances to lethargy to deep coma.
• Grading systems are: early stage (stage 0 and 1) euphoria, depression, apathy, irritability, memory loss, confusion, drowsiness, insomnia.
• Lactulose , low-protein diet improves symptoms in 75 percent of cases.• Later stages( stage 2 and 3) include slow and slurred speech , impaired
judgment, hiccup slow and deep respiration, babinski reflex, stage 4 include disorientation to time , place, person.
Hepatorenal syndrome:
• Hepatorenal syndrome is a serious complication of cirrhosis characterized by functional renal failure with advancing azotemia, oliguria, and ascites.
MEDIAL MANAGEMENT IN PATIENT
Fluid restriction < 1000 ml /Day Low salt diet Egg white BD Monitor Daily Weight and abdominal girth Advice for Completely stop of alcohol Inj. Vitamin K 1 amp I/V OD x 3 Days Arrange and transfuse 2 pint of FFP Arrange and transfuse 1 pint whole blood. Inj. Optineurone 1 amp to be added in 5% dextrose
Others Supportive Managements
Inj .Taxim 1 gram TDS x 5 days Tab Lasilactone 1 tab Po OD x 5 days Tab Pantium 40 mg Po OD x 5days Tab Tone 100 PO BD x 5 days Tab Usoliv 300mg PO BD x 5days Inj. Optineurone 1 amp to be added in 5% dextrose x 3 days
Nursing management :
Assessment
Assess the client client closely for the presence of early manifestations such as :
Hepatomegaly Carefully check the laboratory data. As the disease progresses , assess the manifestations of
complications of cirrhosis such as ascites, portal hypertension or hepatic encephalopathy
History taking: past and present health history (alcohol intake, medication, infection etc) chief complain sign and symptoms of disease
Physical examination Psychosocial assessment
Nursing Diagnosis
• Ineffective tissue perfusion related to bleeding tendencies and varices that may hemorrhage
Goal
• Hemorrhage will be prevented as evidenced by absence of bleeding, normal vital sign and urine output of at least 0.5 ml/kg/hour
Interventions :
• Assess patient’s condition • Monitor for hemorrhage bleeding from gums, melena, hematuria,
hematemasis. • Assess vital sign for sign of shock• Monitor urine output • Protect patient from physical trauma to prevent hemorrhage • Avoid unnecessary injection and apply gentle pressure after injection.• Instruct the client to avoid vigorous nose blowing, straining with bowel
movement.• Provide stool softener to prevent straining with rupture of varices.
• Advice to use soft tooth brush to prevent gum bleeding.
Activity intolerance related to bed rest, fatigue, lack of energy, and altered respiratory function secondary to ascites.
Outcomes
The patient will maintain a balance between rest and activity as evidenced by the absence of fatigue
Interventions:
• Assess level of activity tolerance and degree of fatigue, lethargy, and malaise when performing routine ADLs.
• Assist with activities and hygiene when fatigued.• Encourage rest when fatigued or when abdominal pain or discomfort
occurs.• Assist with selection and pacing of desired activities and exercise.• Provide diet high in carbohydrates with protein intake consistent with
liver function.• Administer supplemental vitamins (A, B complex, C, and K).
Impaired skin integrity related to pruritus from jaundice and edema
Goal: ‘Decrease potential for pressure ulcer development; breaks in skin integrity’
Interventions:
• Assess degree of discomfort related to pruritus and edema.• Note and record degree of jaundice and extent of edema.• Keep patient’s fingernails short and smooth.• Provide frequent skin care; avoid use of soaps and alcohol-based
lotions.• Massage every 2 hours with emollients; turn every 2 hours
• Initiate use of alternating-pressure mattress or low air loss bed.• Recommend avoiding use of harsh detergents.• Assess skin integrity every 4–8 hours. Instruct patient and family in this
activity.• Restrict sodium as prescribed.• Perform range of motion exercises every 4 hours; elevate edematous
extremities whenever possible.
High risk for injury related to altered clotting mechanisms and altered level of consciousness
Intervention
• Assess level of consciousness and cognitive level.• Provide safe environment (pad side rails, remove obstacles in room,
prevent falls).• Provide frequent surveillance to orient patient and avoid use of
restraints.• Replace sharp objects (razors) with safer terms.• Observe each stool for color, consistency, and amount.• Be alert for symptoms of anxiety, epigastric fullness, weakness, and
restlessness.• Test each stool and emesis for occult blood.• Observe for hemorrhagic manifestations: ecchymosis, epistaxis
petechiae, and bleeding gums.• Record vital signs at frequent intervals, depending on patient acuity
(every 1–4 hours).• Keep patient quiet and limit activity.
Disturbed body image related to changes in appearance, and role function.
Goal: ‘Patient verbalizes feelings consistent with improvement of body image and self-esteem’
Intervention:
• Assess changes in appearance and the meaning these changes have for patient and family.
• Encourage patient to verbalize reactions and feelings about these
changes.• Assess patient’s and family’s previous coping strategies.• Assist patient in identifying short-term goals.• Encourage and assist patient in decision making about care.• Identify with patient resources to provide additional support
(counselor, spiritual advisor).• Assist patient in identifying previous practices that may have been
harmful to self (alcohol and drug abuse).
Fluid volume excess related to ascites and edema formation
Goal: Restoration of normal fluid volume
Intervention:
• Restrict sodium and fluid intake if prescribed.• Administer diuretics, potassium, and protein supplements as
prescribed.• Record intake and output every 1 to 8 hours depending on response to
intervention and on patient acuity.• Measure and record abdominal girth and weight daily.• Explain rationale for sodium and fluid restriction.• Prepare patient and assist with paracentesis
Risk for imbalanced body temperature: hyperthermia related to inflammatory process of cirrhosis or hepatitis
Goal: Maintenance of normal body temperature, free from infection
• Record temperature regularly (every4 hours).• Encourage fluid intake.• Apply cool sponges or icebag for elevated temperature.• Administer antibiotics as prescribed.• Avoid exposure to infections.• Keep patient at rest while temperature is elevated.• Assess for abdominal pain, tenderness
Ineffective breathing pattern related to ascites and restriction of thoracic excursion secondary to ascites, abdominal distention, and fluid in the thoracic
cavity.
Goal: Improved respiratory status
Intervention
Elevate head of bed to at least 30 degrees
Conserve patient’s strength by providing rest periods and assisting with activities.
Change position every 2 hours.
Assist with paracentesis or thoracentesis.
Explain procedure and its purpose to patient. Have patient void before paracentesis. Support and maintain position during procedure. Record both the amount and the character of fluid aspirated. Observe for evidence of coughing, increasing dyspnea, or pulse rate.
Application of Nursing Theory
Virginia Henderson’s independence theory
Henderson defined nursing as , “ the unique function of the nurse is to assist the individual, sick or well , in the performance of those activities contributing to health or its recovery ( or to peaceful death ) that he would perform unaided if he had the necessary strength, will or knowledge. And to do this in such a way as to help him gain independence of such assistance as soon as possible.
The 14 Basic components of Nursing Care
1. Breathe normally.2. Eat and drink adequately. 3. Eliminate body wastes. 4. Move and maintain desirable postures. 5. Sleep and rest.
6. Select suitable clothes-dress and undress. 7. Maintain body temperature within normal range by adjusting clothing
and modifying environment8. Keep the body clean and well groomed and protect the integument
9. Avoid dangers in the environment and avoid injuring others.10. Communicate with others in expressing emotions, needs, fears, or
opinions.11.Worship according to one’s faith. 12.Work in such a way that there is a sense of accomplishment. 13.Play or participate in various forms of recreation.14.Learn, discover, or satisfy the curiosity that leads to normal
development and health and use the available health facilities.
ASSESSMENT OF PATIENT ON THE BASIS OF 14 BASIS COMPONENTS
1 Breathe normally.
Patient has difficulty in breathing especially in supine position due to ascites
2 Eat and drink adequately.
Patient is taking so limited food She has loss of appetite She has restricted fluid intake
3 Eliminate body wastes.
Patient has no problem related to bladder and bowel empty but her serum creatinine level is high (2.0 gm/dl)
4 Sleep and rest
Patient has disturb sleep She has discomfort due to ascites
5 Select suitable clothes-dress and undress.
Patient has no significant problems in this area.
6 Maintain body temperature within normal range by adjusting clothing and modifying environment
Patient has sometimes mild fever
7 Keep the body clean and well groomed and protect the integument
Patient looks dirty She has risk for skin breakdown due to edema
8 Move and maintain desirable postures.
Patient has only imitated mobility
9. Avoid dangers in the environment and avoid injuring others.
patient has no significant problems in these areas as the environment is safe for patient
10. Communicate with others in expressing emotions, needs, fears, or opinions.
Patient is communicating limited to health team members because she has some language problem
11. Worship according to one’s faith.
Patient has some problem in this areas because she has no appropriate environment for worship according to own faith.
12. Work in such a way that there is a sense of accomplishment.
Patient has only limited involvement in activities of daily living
13. Play or participate in various forms of recreation.
she does not seems to interested in recreational activities like talking
to other patients , and staffs
14. Learn, discover, or satisfy the curiosity that leads to normal development and health and use the available health facilities
She is not interested to learn .She is not curious towards environment
NURSING CARE PLAN
NURSING DIAGNOSIS
Activity intolerance related to bed rest, fatigue, lack of energy, and altered respiratory function secondary to ascites.
GOAL
The patient will maintain a balance between rest and activity as evidenced by the absence of fatigue
PLANNING
Assess level of activity tolerance and degree of fatigue, lethargy, and malaise when performing routine ADLs.
Assist with activities and hygiene when fatigued. Encourage rest when fatigued or when abdominal pain or discomfort
occurs. Provide diet high in carbohydrates with protein intake consistent with
liver function. Administer supplemental vitamins (A, B complex, C, and K).
INTERVENTION
Assessed level of activity tolerance and degree of fatigue, lethargy, and malaise when performing routine ADLs.
Assisted with activities and hygiene when fatigued. Encouraged rest when fatigued or when abdominal pain or discomfort
occurs. Encouraged to take diet high in carbohydrates. Encouraged to take egg white BD Administered supplemental vitamins B complex, (inj. neurobion in 5%
dextrose) as prescribed Administered vit. K as prescribed
Evaluation:
My goal was partially met as patient was complained of less fatigue than before.
NURSING DIAGNOSIS
Fluid volume excess related to ascites and edema formation
Goal
Restoration of normal fluid volume
PLANNING
Restrict sodium and fluid intake if prescribed. Administer diuretics, potassium, and protein supplements as
prescribed. Record intake and output every 1 to 8 hours depending on response to
intervention and on patient acuity. Measure and record abdominal girth and weight daily. Prepare patient and assist with paracentesis if needed.
INTERVENTION
Restricted sodium as prescribed Restricted fluid intake up to 1000ml/day as prescribed. Administered diuretics (tab lasilactone 1 tab OD) as prescribed. Recorded intake and output strictly. Measured and recorded abdominal girth and weight daily.
EVALUATION
My goal was not fulfilled as patient’s edema and ascites was increased than before
NURSING DIAGNOSIS
Ineffective breathing pattern related to ascites and restriction of thoracic excursion secondary to ascites
GOAL
Improved respiratory status
PLANNING
Elevate head of bed to at least 30 degrees Conserve patient’s strength by providing rest periods and assisting
with activities. Change position every 2 hours. Administer oxygen as needed
INTERVENTIONS
Elevated head of bed (semi fowler’s position) Conserved patient’s strength by providing rest periods and assisting
with activities. Changed position every 2 hours. Encouraged for deep breathing and coughing exercise
Evaluation
My goal was partially met, as patient reported the improved breathing comfort than before
NURSING DIAGNOSIS
Risk for impaired skin integrity related to pruritus from jaundice and edema
GOAL
Decrease potential for pressure ulcer development; breaks in skin integrity
INTERVENTION
Assessed the degree of discomfort related to pruritus and edema. Kept the patient’s fingernails short and smooth. Provided frequent skin care by changing the daily clothes and
encouraged to apply powder especially in-between the fingers and toes.
Changed the patient’s position in every 2 hours Assessed skin integrity in every 4–8 hours. Instruct patient and family
in this activity. Restricted sodium as prescribed. Encouraged to Perform range of motion exercises every 4 hours; Elevated edematous extremities.
EVALUATION
My goal was fully met, as patient did not developed pressure sore and any other skin lesion during hospitalization
NURSING DIAGNOSIS
High risk for injury / bleeding related to altered clotting mechanisms.
GOAL
Bleeding tendency will be minimized
PLANNING
Observe for hemorrhagic manifestations:such as ecchymosis, epistaxis ,petechiae, and bleeding gums.
Observe each stool for color, consistency, and amount. Be alert for symptoms of anxiety, epigastric fullness, weakness, and
restlessness. Test each stool and emesis for occult blood. Record vital signs at frequent intervals, depending on patient acuity
(every 1–4 hours). Administer vit K as prescribed
Transfuse fresh frozen plasma as prescribed.
INTERVENTION
Observed for hemorrhagic manifestations: such as ecchymosis, epistaxis ,petechiae, and bleeding gums.
Observed each stool for color, consistency, and amount. Closely observed the symptoms of internal hemorrhage such as anxiety,
epigastric fullness, weakness, and restlessness. Recorded vital signs at frequent intervals, Administered vit K as prescribed Transfused fresh frozen plasma as prescribed.
EVALUATION
My goal was fully met as the patient did not developed the sign of haemorrhage during hospitalization.
DAILY PROGRESS NOTE OF PATIENT
Date :- 2068/07/ 13Admission day
A patient was admitted in male medical ward from OPD with history of abdominal distention , bilateral pedal edema , mild shortness of breathing and loss of appetite .
On admission patient’s vitals sign were: B.P=110/60 mm of hg, R.R=22/min, Pulse=98/min, Temp.=98ºf weight: 37kg
Patient’s general condition was ill looking. Mild to moderate shortness of breathing was noticed.
USG abdomen and all base line investigation was ordered
MAJOR NURSING INTERVENTION
Admission procedure carried out Vein open done and stat medication given All the ordered investigation send Monitored vital sing Maintained intake and output chart Frequently assessed the patient’s condition Monitored Weight
1 nd day of admission( 2068/07/14) Patient’s general condition was not improved than yesterday. Injection vit k added Dose of tablet lasilactone changed from ½ tab to one tab Fluid restriction <1000ml /day Low salt diet and egg white BD ordered Arrange and transfuse 1 pint of FFP
B.P=100/60 mm of hg, R.R=22/min, Pulse=96/min, Temp.=98ºf weight: 37kg abdominal girth = 31”Intake=1050ml output= 1000ml
MAJOR NURSING INTERVENTION
Assessed in all morning care Monitored of vital sign regularly Attended doctor’s round. Hair comb done Nail care given I/V site changed Daily weight and abdominal girth taken and recorded . Detail history was done.
2 nd day of admission( 2068/07/15) Patient’s general condition was as same as yesterday. Serum creatinine and platelet test order for tomorrow. Fluid restriction <1000ml /day Low salt diet and egg white BD ordered Arrange and transfuse 1 fresh whole blood.
B.P=120/70 mm of hg, R.R=20/min, Pulse=96/min, Temp.=98.8ºf weight: 37.5kg abdominal girth = 32”Intake=1050ml output= 9050ml
MAJOR NURSING INTERVENTION
Assessed in all morning care Monitored of vital sign regularly Attended doctor’s round. Hair comb done Daily weight and abdominal girth taken and recorded . Encouraged for intake of food Head to toe physical examination was done.
3 nd day of admission( 2068/07/16) Patient’s general condition was worse than yesterday. Complain of shortness of breathing and abdominal discomfort . Serum creatinine and platelet test was send and report collected (creatinine
=1.7mg/dl , platelet 67,000 mm3) 1pint fresh whole blood was transfused.
B.P=140/90 mm of hg, R.R=22/min, Pulse=96/min, Temp.=97ºf weight: 37.5kg abdominal girth = 33.2”Intake=800ml output= 700ml Sp02 =92% without o2.
MAJOR NURSING INTERVENTION
Assessed in all morning care Monitored of vital sign regularly
Attended doctor’s round. Hair comb done Daily weight and abdominal girth taken and recorded . Encouraged for intake of food High fowlers’ position was maintained
4 nd day of admission( 2068/07/16) Patient’s general condition was worse than yesterday. Complain of shortness of breathing and abdominal discomfort more severe
than yesterday. Patient was drowsy and lethargic Nothing was taken from yesterday evening Patient party asked for discharge Patient was discharged on request.
B.P=130/90 mm of hg, R.R=22/min, Pulse=100/min, Temp.=99ºf weight: 38kg abdominal girth = 34”Intake=600ml output= 500ml Sp02 =90% without o2.
MAJOR NURSING INTERVENTIONS
Assessed in all morning care Attended doctor round . Removed the i/v cannula Performed all discharge procedureProvided discharge teaching on the following topics:
Medication Diet Follow up Rest and sleep Regular check up Prevention of recurrence of disease etc.
SPECIAL GAGETS USED IN MY PATIENT
Sphygmomanometer Stethoscope ECG monitoring
U.S G machine. Knee hammer. Thermometer Pulse oxymeter.
Discharge medication
Tab Lasilactone 1 tab Po OD x 7 days Tab Pantium 40 mg Po OD x 10 days Tab Tone 100 PO BD x 7 days Tab Usoliv 300mg PO BD x 7 days Inj. Vitamin K 1 amp I/V OD x 3 Days Fluid restriction < 1000 ml /Day Low salt diet Egg white BD
Follow up after 1 week and sos.
Learned from the Experience
◦ Identified the complete health need of old age . ◦ Provide comprehensive nursing care to the patient having
cirrhosis of liver ◦ Provide the opportunity for in-depth study of disease condition ◦ Develop competency in handling such disease condition ◦ Provide the opportunity to o apply the Nursing theory in real
situation. ◦ Identified the evaluate the educational need of the patient and
patient family.
SIGNIFICANCE FINDINGS AND SUMMARY
chief complain on Admission (2068/07/13)
Abdominal distention since 15-16 days Bilateral pedal swelling since 10-12 days Moderate shortness of breathing since 5-7 days
Loss of appetite since 15-16 days
On Physical examinations
Abdominal distention +
Fluid thrill +
Swelling of face +
Hepatomegaly +
Icterus +
Significant Investigations
SGOT/AST : 187.0 U/L AGPT/ALT: 88.0 U/L(˂40.0 U/L) Albumin : 3.4 gm/dl (3.5-5.5 gm/dl) Bilirubin Total: 2.2mg/dl (0.4-1.0 md/dl) Prothombin time: 23.3 sec( 14-16 sec) INR : 1.8 ( o.8-1.2) Creatinine : 2.0 mg /dl Haemoglobin: 7.8 gm/dl WBC : 11,600 Mm3 Platelets : 61,000 Mm3
Liver ultrasound
impression: s/o cirrhosis of Liver, Moderate Ascites
Medical Management
: fluid restriction Transfusion of 2 pint FFP Vit K and inj. polybion supplementary diuretic drugs (lasilaction) Daily weight and abdominal girth monitoring
Prognosis of patient
initially improved than detoriation of condition Discharged on request on 2068/07/17
PATHOPHYSIOLOGY OF CIRRHOSIS OF LIVER
Liver insult, Alcohol ingestion, viral hepatitis, exposure to toxin,
Hepatocyte damage
Liver inflammation
WBC, fever, anorexia,
Pain, , nausea, vomiting fatigue,
Alteration in blood and lymph flow
Liver necrosis Liver fibrosis and scarring
Portal hypertension
Acites, Edema, spleenomegaly
Anaemia, thrombocytopenia, leukopenia
Varices
Esophageal varices, superficial abdominal vertices (caput medusa)
Hemorrhoids
Decreased bilirubin metabolism/biliary tree damage/obstruction
Hyperbilirubinemia Jaundice Decreased bile in
gastrointestinal tract Light colored stool Increased urobilinogen Dark urine Decreased vit. K
absorption Bleeding tendency
Hormone metabolism
Androgen &estrogen
Gynaecomastia Loss of body
hair Menstrual
dysfunction Spider angioma Palmar
erythemia
ADH & Aldestrone
Edema
Metabolism of protein
Decreased Plasma protein Ascites ,edema
Carbohydrate & Fat metabolism
Hypoglycemia Malnutrition
Liver failure
Inability to metabolize ammonia to urea
Hepatic encephalopathy
Hepatic coma
Death
Increased serum ammonia, alteration in sleep, asterixis, respiratory acidosis, foul breath