case liver cirrhosis

Liver Cirrhos

is

Objectives

General Objectives: After the presentation the participants will be able to understand the nursing care of Liver Cirrhosis.

Objectives

Specific Objectives: Present the demographic profile,

history of present illness, laboratory examination, and other pertinent assessment of the patient

Specific Objectives: Correlate the findings of assessment results to the pathophysiology of the disease

Objectives

Specific Objectives: Identify the drugs and mechanism of action used by the patient

Objectives

Specific Objectives: Derive the nursing

consideration in administering medication

Objectives

Specific Objectives: Identify the most effective

nursing care plan for the patient

Objectives

PATIENT’S PROFILESamar

61 y/o

Female

May 2, 2011

Mrs. X

November 14, 1949

SOCIAL/LIFESTYLE HISTORY

PAST MEDICAL HISTORY

Childhood Illness – Fever, cough and colds

Adult Illness –high blood pressure. Immunization –no longer remembered.

Previous Hospitalization Olphi Hospital – February 19, 2011 Jose Reyes Memorial Medical Center – May 2, 2011

Operation – Bilateral Tubal Ligation – 1981 Injuries – None Allergies – No known allergies on foods and

medications. Medication taken 2 days prior to confinement –

Paracetamol and Kremil-S tablets

PAST MEDICAL HISTORY

February 15, 2011 severe stomach ache, head ache, dizziness and loss of appetite. itchiness and easy fatigability. Paracetamol and Kremil-S tablets

HISTORY OF PRESENT ILLNESS

February 19, 2011, 12pm severe stomach ache Hematemesis loss of consciousness. to Olphi Hospital in Samar.

X-ray, ECG, UTZ confined for 4 days. 1 unit of PRBC monitored for blood glucose level.


February 23, 2011, discharge from the hospital Omeprazole and Metronidazole were prescribed.


One day prior to admission, nothing per orem in preparation for endoscopy.

Prior to admission severe stomach ache hematemesis loss of consciousness.


GENERAL APPEARANCEHEAD TO TOE ASSESSMENT

Physical Assessment

State of Awareness and level of consciousness: Conscious, alert and responsive to

questions and answers appropriately.

General Appearance

Apparent state of health chronically ill : progressive signs and

symptoms: enlargement of the abdomen (ascites), with

grade 2 pitting edema and yellowish discoloration of the skin (jaundice) and itchiness around skin (pruritus).

General Appearance

Signs of distress by verbalizing “nahihirapan na akong huminga at

kumilos”

General Appearance

Head to Toe AssessmentParts of the Body Actual Findings Interpretation

IntegumentColor

•Yellowish color of skin.

•Grade 2 pitting edema on feet.

•Thin and dryness appearance of skin

•decrease blood flow of bile to the intestine for

digestion. Therefore, there is marked accumulation

of bile together with bilirubin in the liver. Blood then reabsorb

bilirubin and distributes it to the systemic

circulation. This, yellowish discoloration is

present.

Parts of the Body Actual Findings Interpretation

Head• Face

•Eyes

•Ears

•With wrinkles,

•Pale-yellowish colored sclera and palpebral conjunctiva.

•Yellowish in color

•Wrinkles and sagged facial skin indicates muscle atrophy due to aging process.•Pale palpebral conjunctiva may be caused by decreased oxygen carrying capacity of the blood.•Marked accumulation of the bile together with the bilirubin in the liver. Blood then reabsorbs bilirubin and distributes to the systemic circulation. Thus, yellowish discoloration is present.

Head to Toe Assessment

Parts of the Body Actual Findings Interpretation

Head•Nose

•Mouth• Lips

•Gums

•Teeth

•Palates and Uvula

•Yellowish color, with flaring.

•Pale in appearance.

•Yellowish in color.

•Missing teeth (26 adult teeth only)•Yellowish color


Parts of the Body Actual FindingsThorax and Lungs• Posterior Thorax

•Anterior Thorax

Heart and Central Vessels•Jugular Veins

•Decreased chest expansion (<3cm)

•Decreased chest expansion (<3cm)

•Vein is visible

Head to Toe Assessment:

Parts of the Body Actual FindingsPeripheral Vascular System• Peripheral pulses

Abdomen

•Decreased or weak thread pulsation

•Yellowish discoloration• Dull sounds are heard•Liver cannot be assessed due to pain upon palpation with a pain scale of 8/10.


Parts of the Body • Actual FindingsExtremities• Upper and Lower •Peripheral grade 2 edema on

feet

• Decreased muscle mass

•Limited movement; patient cannot do full range of motion without assistance.


Gordon's Functional Health Patterns

HEALTH PERCEPTION-HEALTH MANAGEMENT PATTERN

The patient verbalized satisfaction on the current health situation compared to the pain and difficulties she experienced before she was admitted to JRMMC. Shows interest in improving health situation.


NUTRITIONAL-METABOLIC PATTERN She usually eats 3 cups of rice

per day with some fish, vegetables and meat. On nothing per orem for 2days due to gross hematemesis of 500ml. height= 5’2”, weight= 145lbs and BMI=26.5. Visible weight increase of 6lbs due to accumulation of fluids within the body. Notable drying of skin with pitting edema of grade 2 in both lower extreme ties


ELIMINATION PATTERN

Mrs. X usually has bowel movement of 1x/day before she was admitted to the hospital, but this changed during her stay in the hospital.1500cc, Output: 300cc with notable tea colored urine. No bowel movement for 3 days.


SLEEP REST PATTERN Mrs. X usually sleeps at 8:00 pm

and wakes up at 4:00 am. This pattern changed when she was admitted although she was able to sleep at night, whenever she wakes up she feels like she is not rested well. Dark circles around the eyes, frequent yawning during the interview. Observed to be sleeping most of the time during the day. Notable irritability when waken up.


COGNITIVE-PERCEPTUAL PATTERN The client has clear speech pattern. She had difficulty

of recalling recent information. She was oriented to time, place and person.


SELF-PERCEPTION AND SELF-CONCEPT PATTERN

The patient appears anxious on the outcome of her conditions. Her eyes appears teary. Mild anxiety is noted.


ROLE-RELATIONSHIP PATTERN

She noted that sometimes she had quarrels with her husband but it’s easily resolved. Noticeable excitement and smiles during our interview about her family.


SEXUALITY-REPRODUCTIVE PATTERN Lack of privacy to the environment was verbalized by

the client and was observed.


COPING-STRESS TOLERANCE PATTERN She mentioned that in the past when she feels

stressful the only thing she does is to go out, watch TV or sleep. Present signs of stress such as teary eyes, sudden movements of hands and quivering of voice are noted.


VALUE-BELIEF PATTERN Patient verbalized hope and belief in the support

system and health care team by.


COMPLETE BLOOD COUNT HEMATOLOGIC SECTION

LABORATORY EXAMINATIONS

Test Normal Values Result Interpretation

Hemoglobin 170-180 94.0

Decreased hemoglobin level indicates anemia from recent acute

bleedingHematocrit 0.40-0.54 0.30 Decreased;

indicates anemia, acute blood loss from bleeding

Red Blood Count 4.6-6.2 3.48 Decreased: indicates Anemia from recent acute

bleeding

COMPLETE BLOOD COUNT

Test Normal Values Result InterpretationMCHC 33-36 32 Decreased:

indicates Iron Deficiency

AnemiaWhite Blood Count 5-10 10.48 Increased:

indicates Infection,

Inflammation, Trauma

Neutrophils 55.0 84.8 Increased: indicates Acute

Stress Response, Acute infection



Lymphocytes 34.0 8.1 Decreased: indicates infection

Eosinophils 3.0 6.4 Increased: signs of Allergic reactions

Platelets 150-450 110 Decreased; indicates

decreased blood clotting factor



Prothrombin time

11.3-15.3 19.3 Increased: Indicates a

high chance of bleeding,

clotting factor depletion

HEMATOLOGIC SECTION

PATHOPHYSIOLOGY

alcoholism

Drugstoxinsvirussystemicinfections

Non-Modifiable

-Age (40-60 y/o)

Nutritional metabolism

Alteration in physiologic function

Fibrosis

Increase Portal Pressure

Process can be arrested

with adequate

liver regeneratio

n

Without adequate and proper

regeneration

Death

Nursing Care Plan• Fluid volume excess related to accumulation

of fluid in peritoneal cavity

• Imbalanced nutrition less than body requirements related to inadequate diet, discomfort and anorexia

• Altered comfort related to itchiness as evidenced by dryness of the skin

ASSESSMENT

Subjective: “Ang bigat ng tyan ko” as verbalized by the patient.

Objective: presence of edema in lower extremities DOB RR 32 cpm Abdominal girth 93cm Intake-1500cc Output-300 cc/ 8 hrs Weight: 148 lbs. Height- 5’2

NURSING DIAGNOSIS

Fluid volume excess related to accumulation of fluid in peritoneal cavity

PLANNING

Short Term:

After 8 hours of nursing intervention the client will able to improve fluid volume excretion as evidenced by:

decrease of 3cm in abdominal girth.

Long Term:

After 24 hours of nursing intervention the client will able to improve fluid volume excretion as evidenced by:

-Increased urine output -decreased ascites with decrease in weight

INTERVENTION

Independent: Measure and record abdominal girth and weight Monitor VS and I and O Explain rationale for Na and fluid restrictions

Dependent: Administer diuretics as ordered Instruct about restrictions of sodium and fluid

intake to less than 1 Liter/day

EVALUATION

Short Term:

After 8 hours of nursing intervention the client was able to improve fluid volume excretion as evidenced by:

decrease in abdominal girth.

Long Term:

After 24 hours of nursing intervention the client was able to improve fluid volume excretion as evidenced by:

Increased urine output decreased ascites with decrease in weight

ASSESSMENT

Subjective: “Nanghihina ako at laging nahihilo.” as verbalized by the patient.

Objective: Anorexia weight- 148 lbs height- 5’2” eats 3x a day, in small amount ½ cup of rice. poor appetite feeling of discomfort headache

NURSING DIAGNOSIS

Imbalanced nutrition less than body requirements related to inadequate diet, discomfort and anorexia

PLANNING

Short Term:

After 8 hours of nursing intervention the client will able to:

shows desire to eat each served

Long Term: After 3 days of my nursing intervention, the

client will able to demonstrate improvement of nutritional status as evidenced by increased food intake

INTERVENTION

Independent: encourage patient to eat, small frequent feeding encourage to eat high calorie and high in

carbohydrate diet. Encourage frequent mouth care, especially before

meals.

Dependent: Administer Vitamins, Zinc supplements as ordered

EVALUATION

Long Term: After 3 days of my nursing intervention, the

client was able to demonstrate improvement of nutritional status.

Short Term: After 8 hours of nursing intervention the client

showed desire to eat each serve meals

ASSESSMENT

Subjective: “Nangangati at pansin ko naninilaw and buo kung katawan” as

verbalized by the patient.

Objective: feeling of discomfort pruritus (itching) along with dryness of the skin irritability scratching of skin

NURSING DIAGNOSIS

Altered comfort related to itchiness as evidenced by scratching of the skin

PLANNING

Long Term: After 4-8 hours of nursing intervention the client will

have: maintenance of skin and mucous membrane integrity

Short Term: Within 3 hours of rendering nursing care, the client’s

itching will be controlled as evidenced by: client feels some relief. decreased dryness of skin decreased in scratching

INTERVENTION

Independent: Wash skin with warm water and mild soap Instruct to wear loose, soft clothing Keep linens dry and free of wrinkles. Soft bed linens and

change soiled linen as much as possible. Suggest clipping fingernails short

Dependent: -Administer medication

diphenhydramine (Benadryl), as ordered

EVALUATION

Long Term:

After 4-8 hours of nursing intervention the client was able to:

maintenance of skin and mucous membrane integrity

Short Term:

Within 3 hours of rendering nursing care, the client’s itching was controlled as evidenced by:

client feels some relief. decreased dryness of skin decreased in scratching

DRUG STUDY

Name of Drug Side Effect Nursing Consideration

Generic Name: Furosemide

Dosage:

40 mg

headache,paresthesis,weakness,hypotension,

- Monitor blood pressure before giving the drug.

- Monitor fluid intake and output

- Watch out for signs of hypokalemia

DRUG STUDY


Generic name:

Paracetamol

Dosage:

300 mg/iv

•A fever with chills or a sore throat •Sores, white spots in the mouth and lips, and oral ulcers •Skin rashes or hives •unusual bleeding or bruising has also been reported.

Monitor the temperature of the patient

Do not exceed to 10 doses within 24 hours as it may give strain to the liver.

Advice relative that drug is only for short term use.

DRUG STUDY


Generic Name:

Vitamin K

Dosage:

1 ampule

Pain, swelling, and tenderness at the

allergic sensitivity (i.e., rash, urticaria), including an anaphylactoid reaction

- Assess for any allergy to the drug.

- Check for medical history especially blood disorders, liver diseases

- Monitor for the Prothrombin time.

DRUG STUDY


Generic Name

Omeprazole

Dosage:

40 mg

HeadacheDiarrhea FatigueConstipationNauseaabdominal pain

Assess for any allergy to the drug

DRUG STUDY


Generic Name: Propanolol

Dose:

50mg

NauseaDiarrhea, Bronchospasm, DyspneaCold extremities

Monitor blood pressure of the patient

Watch out for side effects

THANK YOU!!!

case liver cirrhosis

Documents

past medical

marked accumulation

toe assessment

toe assessmentparts

systemic circulation

yellowish

general appearance

present illness