Liver Cirrhosis Case Presentation 4r423w

ACKNOWLEDGEMENT

The group would like to express their heartfelt gratitude, sincere appreciation and profound regards to the following people who, in one way or another, gave guidance, strength, and encouragement in making this case presentation possible. First of all, to Almighty God the Father, who granted us the knowledge and skills, Who send forth the gift of Holy spirit that aided them in completing this study. Without Him, none of these things would be possible. To their family, friends, and classmates, for their consideration and unending , emotionally, spiritually and financially. To their clinical instructor, Mrs. Jocelyn Ferraren, RN, for guiding us in the course of making this case presentation and giving them tips on how to have a good presentation. To all medical personnel and staff of DMC, MED- ward, for the warm accommodation during their clinical exposure and for giving them inspiration to keep the spirit of caring burning. To the of the group, for sharing ideas, cooperating and giving full effort in making the case presentation successful.

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Lastly, to our client and his family for their acceptance and willingness to share time, effort and giving us the essential information needed for this case presentation.

INTRODUCTION The liver is one of the largest and most complex organs in the body. It stores vital energy and nutrients, manufactures proteins and enzymes necessary for good health, protects the body from disease, and breaks down (or metabolizes) and helps remove harmful toxins, like alcohol, from the body. It is one of the most important organs in the body since it has many significant functions. A lack or failure to provide proper care of it may lead to an abnormality or disorder. One of the severe forms that may happen is Liver Cirrhosis. Liver Cirrhosis is derived from Greek word kirrhos, meaning "tawny" (the orange-yellow colour of the diseased liver).It is a chronic disease that causes cell destruction and fibrosis (scarring) of hepatic tissue. Fibrosis alters normal liver structure and vasculature, impairing blood and lymph flow and resulting in hepatic insufficiency and hypertension in the portal vein. Cirrhosis is most commonly caused by alcoholism, hepatitis B and C and fatty liver disease but has many other possible causes. Some cases are idiopathic, i.e., of unknown cause. It may be classified by the structural changes that take place or by the cause of the disorder. Internationally, liver cirrhosis is the 8thth most common cause of death. It is most common among people ages 45 – 75, killing more than 25,000 people each year, 50% of which are alcohol related. In the Philippines and other underdeveloped countries,

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however, the incidence of liver cancer is rather high. Liver cancer is relatively common in our country primarily because many Filipinos suffer from cirrhosis of the liver, a major risk factor for liver cancer. Cirrhosis of the liver precedes 80 percent of all liver cancers; thus, any condition that predisposes to cirrhosis indirectly causes liver cancer. The usual cause of liver cirrhosis among Filipinos is chronic hepatitis B, a major public health problem in the country. Chronic hepatitis B afflicts between 10 and 12 percent of all Filipinos (i.e., more than 8 million Filipinos). Other less significant causes of cirrhosis are hepatitis C infection and alcoholism. The latest DOH advisory shows that liver cancer is the third most common form of cancer among Filipinos—in men, it is the second most common, while in women, it is the ninth most common. Locally, liver cirrhosis is the 17th leading cause of death here in Davao. In connection with it, last February 11, 2010, the Group 3 of section 3H was assigned on duty at the Davao Medical Center- Communicable Pavilion where they met their patient Mr. Cute who was diagnosed of having Liver Cirrhosis. They were motivated to learn more and study the disorder since it was their first time to encounter such case. Also, the group was more encouraged to choose the patient for their case presentation in order to acquire better understanding and to gain more knowledge and use it for the future.

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OBJECTIVES To have a course of direction, organization and to recognize the essence of this study, we have set the following objectives:

GENERAL OBJECTIVES

After rendering effective nursing care for three days at the Davao Medical Center, MED- Ward, we aim: • To provide an extensive study about Community acquired pneumonia ascites

secondary to liver cirrhosis for us to gain better understanding about the disease and be equipped with competence in dealing with related situations in the future; • To improve our skills in doing relevant interventions which promote wellness to

persons having the disease; •

Not only to understand the situation of the client and their families who are confronted with the disease but also to empathize with them.

SPECIFIC OBJECTIVES 

Find a case in the DMC, MED- ward within the three-day duty;

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

Establish a good interpersonal relationship with our chosen client as well as to his significant others;



Acquire necessary data of our client which are relevant to our case study;



Trace the patient’s family lineage and present remarkable familial disease;



Trace the health history of the client and the family by collecting information both from the past and present illnesses;



Evaluate the client’s development guided by Erik Erikson, Robert Havighurst and Jean Piaget’s Theory;



Define the complete diagnosis of our client guided by three different sources;



Perform cephalocaudal assessment to the client thoroughly;



Discuss the systems involved in the development of the disease in the human anatomy and physiology;



Present the etiology and symptomatology of the disease process with each of its rationales and identify which are present on the client’s case;



Trace the pathophysiology of the disease as experienced by our client and

Sends thesignal to the medulla oblongata to presentcough Crackles and Wheezes

it through a schematic diagram; 

Present and analyze the doctor’s order in chronological manner;



Explain and interpret both actual and possible diagnostic studies including indication, result, and their implications;

The mucosal lining nerves detects the excessive the secretions

Exudates production and Edema Cilia try to propels the mucous out of the 5 system Stimulates mucous

large quantities



Discuss the different drugs taken by the patient with corresponding intervention;



Identify different nursing theories made by

Florence Nightingale,

Chemical mediators irritate the goblet cells of the bronchial nursing lining Stimulates Diapedesis and positive Virginia chemotaxis of Leukocytes

Henderson and Lydia Hall and relate it on the patient’s conditions; 

Inflammation of the Parenchyma

Formulate specific, measurable, attainable, realistic, and time-bounded nursing care plans with corresponding rationales for each of the nursing interventions;

 

Evaluate the client’s progress with our continuous care; Render health teachings or appropriate nursing interventions necessary client and family as well;



Present a discharge plan for the patient

Fever

Obstruction of the airway

Cilia fail to sweep the mucous to the because of thickness Histamine causes vasodilation Prostaglandin and Leukotrienes causes blood vessels to be more permeable



Present and justify the prognosis of our patient



Provide recommendations for the better management of patient with the same disease in the future endeavor;



Accomplish our case presentation.

Damage of the cells release Histamine, Prostaglandins and Leukotrienes Blood vessels leak. Damage on the blood vessels is scant Predisposing factors: Age- elderly adults (age above 70)

Precipitating factors: Smoking Alcoholism

6 Hematemesis and

GI bleeding If treated: MGT: Transplantatio n Paracentesis Medications

PATIENT’S DATA

Name: Mr. Cutie Age: 72 years old Sex: Male Date of birth: May 23, 1937 Place of birth: Igacos, Davao City Current address: Manablay Callawa, Buhangin Davao City Occupation: Farmer Nationality: Filipino Religion: Christianity (Roman Catholic) Civil Status: Married

plasmaphorese s If not treated Progressive liver destruction, systemic counsel Hepatic encephalopath y Toxic substance production Mental retardation Hepatic coma

DEATH

Date of ission: February 6, 2010

- Destruction of cell membranes causes red blood cells to burst

Time of ission: 04:09PM

Nursing Resp:

CLINICAL DATA

Mode of ission: Ambulatory Chief complaint: malaise, loss of appetite, nausea, and black tarry stool

-Give supplements containing Vit.E

Nursing Resp: 7 -Give Vit.D fortified milk

-Give supplementati on

Ward: MED - itting physician: Dr. Emerson R. Taghoy Vital signs upon ission: Temp: 36.6 C BP: 90/60 mmHG PR: 65 bpm RR: 28 m Final diagnosis: CAP MR Ascites 2’ Liver Cirrhosis Source: Significant others and patient's chart

Varices and hemorrhoids May rupture and bleed Vitamin D Decrease absorption of calcium and Phosphorus from the GI tract Vitamin E Decrease against oxidative damage caused by free radicals Nursing Resp:

- Monitor urine output - Elevate edematous extremities -Reposition every 2 hours if patient - ister diuretics as prescribed - Tell patient to use antiembolic stockings or bandage 8 Nursing Resp: -Give

-prevent injury -decrease risk for infection

Development of tissues, and resistance to infections

GENOGRAM Lola-har

Lolo-har

Grandmade r

Body malaise

Titahar

PAPA-HAR 

Manong

Decreased source of MAMA-HARenergy  Auntie  Decreased glucose in the body

Tito 

Kol 

Decreased vitamin K Gwaping 

Boylet 

Gwafa 

Keks 

Pefa  A Vitamin

Cutie●

Vitamin deficiency Nursing Resp: -Encourage intake of Vit.K rich foods

LEGEND: MALE FEMALE

 DECEASED  TB  HYPERTENSION ●

LIVER CIRRHOSIS

Nursing Resp: Nursing Resp: -Assess pain scale -Monitor VS -ister analgesic as ordered

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Absence of bilirubin in the feces

FAMILY BACKGROUND AND HEALTH HISTORY Family History

Bile unable to reach Gi tract Clay colored stool ASCITES

Most of the significant details gathered on the interview we had came from

Third spacing occurs Mr.Cutie’s wife and daughter since he was not able to verbalize due to his condition. JAUNDICE

Upon the interview, we found out that no one in the family had any of the sickness that the patient had namely Liver Cirrhosis and Community Acquired Pneumonia.

Speeds up destruction of RBCs

Cutie is a married man with three children. He is the main decision maker in the

Chronic ive family as evidenced by his wife verbalizing,” siya man gyud ng gabuot ug unsay maayo congestion

para sa amoa”. In regards to their health, several of their family specifically the Spleen patient, his wife and his daughter have hypertension which was all diagnosed by GI the tract physician, whom they usually consult in Polyclinic Health Center where their neighbor Stomach pain works as a nurse. However they were not able to recall the name of the physicianAltered they bowel function

consulted, but they were able to the month and year that their condition was

Blood regurgitation diagnosed: on August of the year 2009. In reference to the diagnosis that was given by to the spleen , tract the physician, maintenance medication was given to the three of them howeverGIthey Prominent forgot since they only used the said the medication for about two weeks. Finances were a

distended factor since they were not able to comply the medication prescribed by the physician.blood vessels in the stomach Bleeding The family does not seek medical advice until the condition they have worsens as tendencies

stated by Cutie’s wife. All of them had experienced fever, flu, cough, colds, stomach

Shunting of pains, etc. but again they don’t seek medical attention until condition becomes worse.blood from portal vessels to vessels with lower pressure Decrease in osmotic pressure 10 KIDNEYS

Signal for aldosterone release

Lifestyle

Na+ absorption/ H2O retention

As verbalized by the patient’s wife, the patient at his young age was a typicalK+ excretion

adolescent who goes with friends and often explores things around. As stated, the patient

EDEMA

was curious at all things and because of that he was inclined to a number of vices which

No free blood age may actually have affected his health status. He was smoking badly as he was able to Backflow of bile

consume 1-2 packs of cigarette a day and drinks enormously as he was able to drink 1

long neck of Tanduay on his own. At times, he goes beyond 1 long neck and even drinks Bile goes to the blood

half a gallon of “Tuba” when he is not yet drunk. As stated by his wife, his husband doesstream

not stop drinking unless he becomes drunk. As the normal things go as stated by his Formation of collateral

wife, the patient and his drinking colleagues use same glass whenever they drink. All of vessels blood these had been the lifestyle of the client since then.

in the GI system Accumulation of ammonia

When he reached his adulthood, he worked as a farmer and still continued to

drink and smoke whenever he has time. He often sleeps at 10:00pm and wakes Unable up at to convert ammonia to urea

5:00am then takes his breakfast and goes to his work. He takes his break from 11:30am up to 12:30pm and thus eats his lunch. He goes to work and ends at 5:00pm. What he

Decreased

normally does is clean the plantation and get rid of unwanted growth of grasses allglucogenesis over the place that may alter the good growth of the trees that were present. Whenever he has Decrease in albumin

spare time such as weekends which is his rest day from work, he stays at home, watches production TV or talks with his children or goes to his neighbor and drinks. He had such routine Obstruction until of portal

last year, 2009, when he finally had stopped doing his usual things when he was circulation diagnosed of having hypertension. He drinks rarely and smokes only about 2-4 sticks aPortal day compared before when he was not yet diagnosed with hypertension.

hypertension Liver Decreased RBC 11 Body malaise, pallor

Change to Fowler’s position, assess CRT

Decreased erythropoietin

Diet

Hepatic fibrosis

The patient’s wife was able to notice that his husband was fond of eating fatty Impaired hepatocyte

foods such as “taba sa baboy.” Whenever they have this kind of viand, she reported that function

her husband would really eat a lot of these when available. She also mentioned that her changes Matrix husband liked eating salty foods such as dried fish and ginamos almost every day. It Extracellular has matrix

been said by the patient’s wife that these viands are the usual part of every meal.components In Predisposing addition to that, they often take canned goods. As the patient’s wife verbalized “Syempre Factors:

dong ana man gyud na sa pobre”. Moreover, drinking coffee every morning has always Male

been the routine of his husband, still reported by his wife.

Age (45-75 yrs old) Race

History of past illness Race: Asian

Other than ordinary fever, cough, and flu, which they treat only through over-thePathophysiology counter drugs and no consultations, the patient didn’t have any serious illness. This was of Liver Cirrhosis the case, however, until he reached the old age when different signs and symptoms started to manifest, increased blood pressure arise. He then sought medical advice since Precipitating factors:

there were other manifestations of hypertension such as dizziness, nausea and pain on his

nape. Then he found out that he has hypertension as diagnosed. Only through daily BP Chronic alcoholism

taking at Santo Tomas Clinic, a clinic just around the area, did they found out about this Diet

gradual increase in blood pressure. It was treated and taken cared of through unrecalled Smoking

medications that were prescribed to him by the said clinic. sMOK Portal obstruction Grandfader 12

History Of Present Illness For the past years, the patient did not have any serious illness related to his present condition. But on January 23, 2010, 2 weeks prior to the patient’s ission, he had headache, chest pain, dull abdominal pain, felt nauseated and dizzy. The patient and even his wife had never thought that it was a manifestation of an underlying problem and so they did not take it seriously. They did not seek medical attention; instead his wife gave him over-the-counter medication such as Paracetamol for his headache which he took four times during that day and one Diatabs for his stomach pain which is actually not appropriate since the medication itself was wrong and that the underlying condition was not taken into consideration. The condition however did not last long since it was relieved one day after it occurred. The patient and his wife were relieved and thought that it was just a “Panuhot and Kabuhi”. One week prior to patient’s ission to the hospital, his wife noticed that his husband had abdominal distention which she abruptly noticed as evidenced by her verbalization, “Dili man kaayo na siya dako ug tiyan sa una. Murag ning kalit ra man. Atong mga last week sa January ra pud nako nabantayan”. On the 2nd day of February, 2010, four days prior to ission to the hospital the patient sought consultation at the Emergency Room since the patient felt loss of appetite, stomach pain which radiated to the patient’s back and prandial vomiting. Despite the manifestations seen on the client, he was discharged and was requested to have an ultrasound of the abdomen. Aside from that, it was again diagnosed that he has hypertension so antihypertensive medications were prescribed. Days had gone and on the

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6th of February 2010, the patient experienced body malaise, loss of appetite, nausea, and black tarry stool which were his chief complaint that resulted to his ission to Davao Medical Center.

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DEVELOPMENTAL DATA

Erik Erikson’s Psychosocial Theory of Development Theory

Stage

Result and Justification

Erik Erikson, in his

Integrity versus Despair

The patient has fully

Psychosocial Theory of

(65 years old and above)

achieved integrity.

development, believed that

This stage focuses on

According to his wife,

personality develops in a

reflecting back on life.

Cutie is already contented

series of stages. Erikson's

Integrity means feeling at

with his life. His wife

theory proposes that life is a

peace with oneself and the

verbalized "Kamao ka

sequence of developmental

world. No regrets or

dong, miskan ana ra na

stages or levels of

recriminations. Despair

akong bana, wala gyud na

achievement. He described

and/or 'Disgust' represent the

siya nagmahay ug taman-

eight stages of development

opposite disposition: feelings

taman sa mga

and in each stage signals a

of wasted opportunities,

nangahitabo sa among

task that must be

regrets, wishing to be able to

kinabuhi. Simple ra nga

accomplished. Our progress

turn back the clock and have

panginabuhi ra ang

through each stage is in part

a second chance. Those who

among panginabuhi pero

determined by our success,

are unsuccessful during this

wala gyud na siya nag

or lack of success, in all the

phase will feel that their life

dahum na mudato.

previous stages. Erikson

has been wasted and will

Kontento na siya sa amo.

also believed that the more

experience many regrets. The Okay na sa iya kay

success an individual has at

individual will be left with

napadako niya ug maayo

each developmental stage,

feelings of bitterness and

among mga anak,

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the healthier the personality

despair. Those who feel

makahikahos mi sa pang

of an individual is.

proud of their

adlaw-adlaw." Despite of

accomplishments will feel a

it, the patient was not able

sense of integrity.

to send his three children

Successfully completing this

in college. Moreover, the

phase means looking back

patient has been alcoholic

with few regrets and a

for almost 60 years and

general feeling of

been smoking since his

satisfaction. These

teenage years. These

individuals will attain

habits are wasted

wisdom, even when

opportunity and Mr. cutie

confronting death.

has not attained the wisdom since he was not able to decipher that his vices would affect his health in the long run.

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Robert Havighurst’s Developmental Task Theory Theory

Stage

Result and Justification

Havighurst believes that in

Later Maturity (60 and

The patient has not fully

every developmental stage,

above)

achieved this stage since

certain tasks are needed to be accomplished for one’s progression. In his theory, he proposes that growth and

This stage in a person’s life is concerned with the achievement of the following

each associated with six to ten tasks to be learned. Havighurst identified Six

accomplished. He has his circle of friends whose age is almost same with

tasks:

development is occurring during six stages in life,

some tasks are not

his. They drink and play 1. Adjusting to decreasing physical strength and health. 2. Adjusting to

cards together. But according to his wife, he is not still used to his deteriorating strength. We

Major Stages in human life

retirement and

always wanted to work or

covering birth to old age.

reduced income.

at least to keep his self

Infancy & early childhood (Birth till 6 years old),

3. Adjusting to death of a spouse.

Middle childhood (6-13 years old), Adolescence (13-

busy, same as the thing he has been doing when he was still younger, but his

4. Establishing an

strength is limiting him

18 years old), Early

explicit affiliation

already. Therefore, he was

Adulthood (19-30 years

with one’s age group.

not able to adjust from his

old), Middle Age (3060years old), and Later

5. Meeting civic and social

physical limitation due to aging.

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maturity (60 years old and over). From there, Havighurst recognized that each human has three

responsibilities. 6. Establishing satisfactory physical living arrangements.

sources for developmental tasks. They are: * Tasks that arise from physical maturation: Learning to walk, talk, control of bowel and urine, behaving in an acceptable manner to opposite sex, adjusting to menopause. * Tasks that arise from personal values: Choosing an occupation, figuring out ones philosophical outlook. * Tasks that have their source in the pressures of society: Learning to read, learning to be responsible citizen. A developmental

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task is “a task which arises at or about a certain period in the life of an individual, successful achievement of which leads to his happiness and to success with later tasks, while failure leads to unhappiness in the individual, disapproval by society, and difficulty with later tasks”.

JEAN PIAGET’S THEORY OF COGNITIVE DEVELOPMENT Theory

Stage

Result and Justification 19

Jean Piaget proposed a sequence of cognitive development that emphasized the relationship between action and thought. Each phase in his theory is characterized by the ways in which the person interprets and uses the environment. The individual learns by

Formal Operations This stage is characterized by formal reasoning. It is in this stage that a person’s acquisition of the ability to think abstractly, reason logically and draw conclusions from the information available is measured.

The patient did not achieve this cognitive stage. The patient is a chronic alcohol drinker and a smoker. From that alone, he must have thought that this will have a bad effect on his health. He was not able to reason out logically and did not

interacting with the

able to see the bigger

environment through

picture that can be brought

assimilation,

about by his vices that

accommodation and

these will result to illness.

adaptation.

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DEFINITION OF COMPLETE DIAGNOSIS CAP MR Ascites 2’ Liver Cirrhosis

Community-Acquired Pneumonia Community-acquired pneumonia (CAP) is one of the most common infectious diseases addressed by clinicians. CAP is an important cause of mortality and morbidity worldwide. CAP is usually acquired via inhalation or aspiration of pulmonary pathogenic organisms into a lung segment or lobe. Less commonly, CAP results from secondary bacteremia from a distant source, such as Escherichia coli urinary tract infection and/or bacteremia. CAP due to aspiration of oropharyngeal contents is the only form of CAP involving multiple pathogens. Source: Handbook of Medical-Surgical Nursing 3rd Edition by Springhouse, 2006

Community-Acquired Pneumonia Community-acquired pneumonia (CAP) is a disease in which individuals who have not recently been hospitalized develop an infection of the lungs (pneumonia). CAP is a common illness and can affect people of all ages. CAP often causes problems like difficulty in breathing, fever, chest pains, and a cough. CAP occurs because the areas of

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the lung which absorb oxygen (alveoli) from the atmosphere become filled with fluid and cannot work effectively. Patients at moderate risk (class IV of the Pneumonia Severity Index) and high risk (class V) should be hospitalized, given their much higher rates of death and complications. In general, most such patients are elderly and have two or more additional poor prognostic factors, such as serious coexisting conditions, abnormal vital signs, and abnormal laboratory values. Source: Medical-Surgical Nursing: A Psychophysiologic Approach by Luckmann and Sorensen, 2003

Community-Acquired Pneumonia Patients with community-acquired pneumonia often present with cough, fever, chills, fatigue, dyspnea, rigors, and pleuritic chest pain. When a patient presents with suspected community-acquired pneumonia, the physician should first assess the need for hospitalization using a mortality prediction tool, such as the Pneumonia Severity Index, combined with clinical judgment. Pneumonia Severity Index

Patient Characteristics

Points

Demographics Male Female

Age (years) Age (years) – 10 22

Patient Characteristics

Points

Nursing home resident Comorbid illness

+ 10

Neoplastic disease Liver disease Congestive heart failure Cerebrovascular disease Renal disease Physical examination findings

+ 30 + 20 + 10 + 10 + 10

Altered mental status Respiratory rate >30 breaths per minute Systolic blood pressure < 90 mm Hg Temperature < 35°C (95°F) or >40°C (104°F) Pulse rate >125 beats per minute Laboratory and radiographic findings

+ 20 + 20 + 20 + 15 + 10

Arterial pH < 7.35 Blood urea nitrogen >64 mg per dL (22.85 mmol per L) Sodium < 130 mEq per L (130 mmol per L) Glucose >250 mg per dL (13.87 mmol per L) Hematocrit < 30 percent Partial pressure of arterial oxygen < 60 mm Hg or oxygen percent

+ 30 + 20 + 20 + 10 + 10 + 10

saturation < 90 percent Pleural effusion Total points:

+ 10 _______ Mortality % (No. of

Recommended site of

Point total

Risk

Risk class patients)

care

No

Low

I

0.1 (3,034)

Outpatient

predictors ≤ 70 71 to 90 91 to 130 >130

Low Low Moderate High

II III IV V

0.6 (5,778) 2.8 (6,790) 8.2 (13,104) 29.2 (9,333)

Outpatient Inpatient (briefly) Inpatient Inpatient

Source: Stephanie Wessel Reyburn, M.D., M.P.H., Mayo School Of Graduate Medical Education, Rochester, Minnesota - Http://Www.Aafp.Org/Afp/2006/0201/P442.Html Accessed On February 21, 2010

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Ascites Ascites is an accumulation of serous fluid in the abdominal cavity. The fluid accumulates primarily because of low production of albumin by the failing liver. An insufficient amount of protein in the capillaries causes plasma to seep into the abdominal cavity. The accumulated fluid causes a markedly enlarged abdomen. The fluid may cause severe respiratory distress as a result of elevation of the diaphragm. Source: Understanding Medical Surgical Nursing by Williams and Hopper, 2007

Ascites Ascites is the accumulation of fluid (usually serous fluid which is a pale yellow and clear fluid) in the abdominal (peritoneal) cavity. The abdominal cavity is located below the chest cavity, separated from it by the diaphragm. Ascitic fluid can have many sources such as liver disease, cancers, congestive heart failure, or kidney failure. Source: Medical-Surgical Nursing: A Psychophysiologic Approach by Luckmann and Sorensen, 2003

Ascites

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Ascites is diagnosed by inspection of the fluid-filled abdomen, percussion for dullness and tapping of massive ascites to produce fluid waves. When these signs are accompanied by other manifestations of disease associated with ascites, usually cirrhosis, identification of the problem is validated.

Source: Handbook of Medical-Surgical Nursing 3rd Edition by Springhouse, 2006

Liver Cirrhosis Liver cirrhosis is the final stage of many types of liver injury. The cirrhotic liver varies in appearance, but a nodular consistency with hands of fibrosis (scar tissue) is prominent. The cirrhosis patient frequently presents with problems such as ascites, gastrointestinal bleeding and encephalopathy. The disease often progresses quietly until such as emergency occurs. Hepatomegaly (enlarged liver), splenomegaly (enlarged spleen), vascular changes, or abnormal laboratory tests may be the first indicator in the patient who is

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Source: Medical-Surgical Nursing: A Psychophysiologic Approach by Luckmann and Sorensen, 2003

Liver Cirrhosis A chronic hepatic disease, cirrhosis is characterized by diffuse destruction and fibrotic regeneration of hepatic cells. As necrotic tissue yields to fibrosis, this disease alters liver structure and normal vasculature, impairs blood and lymph flow, and ultimately causes hepatic insufficiency.

Source: Handbook of Medical-Surgical Nursing 3rd Edition by Springhouse, 2006

Liver Cirrhosis Cirrhosis is a consequence of chronic liver disease characterized by replacement of liver tissue by fibrous scar tissue as well as regenerative nodules (lumps that occur as a result of a process in which damaged tissue is regenerated) leading to progressive loss of liver function.

Source: Blackwell’s Dictionary of Nursing 5th Edition, 2004

26

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PHYSICAL ASSESSMENT

Date and Time Performed: February 11, 2010 at 5:00 pm Personal Data Cutie is a male patient itted to the Med of Davao Medical Center. He is 72 years old and was born on May 23, 1937. He was born in IGACOS, Davao City and is currently living at Buhangin, Davao City. He is Filipino and a Christian (Roman Catholic) in religion. He is married. The reason for his ission is malaise, loss of appetite, nausea, and black stools experienced on the 6th of February, 2010. Health History The patient claimed that he never had any past illnesses that lead him to an ission to a hospital. It was just a number of feverish experiences, cough, colds and flu which he had. It was stated by his wife upon our interview that he was diagnosed with hypertension a year ago and had maintenance medications. And just a month ago, he then had chest pain, dizziness, nausea, and body malaise. General Survey Received lying on bed unconscious as evidenced by the patient not responding to verbal and pain stimuli. Patient had an IVF of D5NaCl at 80cc/hr infusing well at left metacarpal vein; with endotracheal tube with O2 at 5-7 L/min connected to a bag valve; with Foley catheter connected to a Urobag draining 100 cc of dark yellow colored urine. He was untidy as the patient was with dirty feet and untrimmed and dirty nails. 28

Vital Signs: BP- 110/70mmhg

Temperature- 38.3

PR- 96bpm

RR- 24

Skin The patient had jaundice with uniform skin color all throughout the body except under his axillae, which is darker. His skin folds and axillae were moist. Skin temperature was uniform in all extremities when touched. Senile skin was noted. Hair Upon inspection, hair was short and white in color. His hair was thin and evenly distributed as evidenced by the absence of areas of alopecia along the scalp. No infection or infestations were noted upon inspection and palpation of the patient’s hairline and scalp. Dandruff was noted on patient’s scalp however there were no lesions, lumps, or masses upon palpation. Nails Clubbing of nails was noted on patient. Upon palpation, nail base was firm and fingernails had a rough texture. Epidermis surrounding the nails was intact and no lesions were noted. Nails were long, dirty and untrimmed. Toenail surface was slightly curved and rough.

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Skull and Face Skull was rounded and normocephalic. Symmetry in anatomy of face was noted. Eyes and Vision Hair of eyebrows was evenly distributed and periorbital skin was intact without swelling or inflammation. Eyebrows were symmetrically aligned. Upon inspection, skin of eyelids was intact and no discharges and discolorations were present. Icteric sclera was noted. Iris were black in color, and had a round, smooth border. Pupillary response to illumination was sluggish and equal on both eyes as evidenced by constricting of both illuminated and non-illuminated pupils upon illumination. Patient does not wear glasses: visual acuity when he was still conscious and awake was grossly normal as stated by his wife. Ears and Hearing Upon inspection, auricles were of the same color with facial skin, were symmetrically aligned with each other, and were aligned with the outer canthus of each eye. Cerumen was present but was not impacted or excessive in amount. Upon palpation, auricles were firm, and not tender as evidenced by the auricle being pulled upward, downward, and backward without resistance, and the pinna being folded forward without resistance and recoiling after folding. Patient was unresponsive since he is in comatose.

30

Nose Upon inspection, external nose was symmetrical. No abnormal discharges or flaring were noted. Also, the nose was with uniform color with facial skin. Nasal septum was intact and in midline. Patient was with NGT on his right nares. Mouth Upon inspection, endotracheal tube with O2 at 5-7 L/min connected to bag valve was noted. Outer lips were brownish pink and were dry. Teeth were shiny and yellow in color. Neck Upon inspection, neck veins were not distended or visible. Shoulder muscles were of anatomically symmetrical. Thorax and Lungs The skin over the posterior thorax was intact and uniform in color with the rest of the body. Also, chest expansion was symmetrical when air is istered through the endotracheal tube with O2 at 5-7 L/min connected to a bag valve. Crackles were noted upon auscultation. Cardiovascular and Peripheral Vascular Peripheral pulses were regular and present on all four extremities. Slow capillary refill time of 4-5 seconds gathered upon three checks was noted.

31

Chest No masses, lesions or any unusuality noted on patient’s chest. Abdomen Upon inspection, distended abdomen and ascites was noted. Abdomen was supple when palpated. Size of abdomen was observed to be not appropriate for patient’s body. Abdominal girth of 39 inches was taken. Caput medusae noted on the skin of the abdomen. Genito-urinary Upon inspection, no swelling, lesion or mass noted on the genitals of the patient. Patient is with Foley catheter which is connected to a Urobag draining 100 cc of dark yellow colored urine. Back and Extremities Patient was not able to manifest movements on the upper body and lower body since the patient was not conscious during the assessment. Bones appear to have no deformities. Elbows have no deformities. However a grade 1 pitting edema was noted on all four extremities as skin does not immediately (approximately 4 seconds) go back to its normal state when pressure is applied.

32

ANATOMY AND PHYSIOLOGY

Liver The liver is the largest internal organ in the body, and weighs about 3 pounds in an adult. The liver is located in the right upper quadrant of the abdomen, just below the diaphragm. A thick capsule of connective tissue called Glisson's capsule covers the entire surface of the liver. The liver is divided into a large right lobe and a smaller left lobe. The falciform ligament divides the two lobes of the liver. Each lobe is further divided into lobules that are approximately 2 mm high and 1 mm in circumference. These hepatic lobules are the functioning units of the liver. Each of the approximately 1 million lobules consists of a hexagonal row of hepatic cells called hepatocytes. The hepatocytes secrete bile into the bile channels and also perform a variety of metabolic functions. Between each row of hepatocytes are small cavities called sinusoids. Each sinusoid is lined with Kupffer cells, phagocytic cells that remove amino acids, nutrients, sugar, old red blood cells, bacteria and debris from the blood that flows through the sinusoids. The main functions of the sinusoids are to destroy old or defective red blood cells, to remove bacteria and foreign particles from the blood, and to detoxify toxins and other harmful substances. Approximately 1500 ml of blood enters the liver each minute, making it one of the most vascular organs in the body. Seventy-five percent 33

of the blood flowing to the liver comes through the portal vein; the remaining 25% is oxygenated blood that is carried by the hepatic artery. The hepatic portal system begins in the capillaries of the digestive organs and ends in the portal vein. Consequently, portal blood contains substances absorbed by the stomach and intestines. Portal blood is ed through the hepatic lobules where nutrients and toxins are absorbed, excreted or converted. Restriction of outflow through the hepatic portal system can lead to portal hypertension. Portal hypertension is most often associated with cirrhosis. Patients usually present with splenomegaly, ascites, GI bleeding and/or portal systemic encephalopathy. The consequences of portal hypertension are due to portal systemic anastomosis formed by the body as an attempt to by the obstructed liver circulation. These collateral vessels form along the falciform ligament, diaphragm, spleen, stomach and peritoneum. The collaterals find their way to the renal vein where blood drained from the digestive organs is let into the systemic circulation. The liver is responsible for important functions, including: •

Bile production and excretion

•

Excretion of bilirubin, cholesterol, hormones, and drugs

•

Metabolism of fats, proteins, and carbohydrates

•

Enzyme activation

34

•

Storage of glycogen, vitamins, and minerals

•

Synthesis of plasma proteins, such as albumin and globulin, and clotting factors

•

Blood detoxification and purification

The liver synthesizes and transports bile pigments and bile salts that are needed for fat digestion. Bile is a combination of water, bile acids, bile pigments, cholesterol, bilirubin, phospholipids, potassium, sodium, and chloride. Primary bile acids are produced from cholesterol. When bile acids are converted or "conjugated" in the liver, they become bile salts. Bilirubin is the main bile pigment that is formed from the breakdown of heme in red blood cells. The broken-down heme travels to the liver, where is it secreted into the bile by the liver. Bilirubin production and excretion follow a specific pathway. When the reticuloendothelial system breaks down old red blood cells, bilirubin is one of the waste products. This "free bilirubin" is a lipid soluble form that must be made water-soluble to be excreted. The conjugation process in the liver converts the bilirubin from a fat-soluble to a water-soluble form. The liver also plays a major role in excreting cholesterol, hormones, and drugs from the body. The liver plays an important role in metabolizing nutrients such as carbohydrates, proteins, and fats. The liver helps metabolize carbohydrates in three ways: •

Through the process of glycogenesis, glucose, fructose, and galactose are converted to glycogen and stored in the liver.

35

•

Through the process of glycogenolysis, the liver breaks down stored glycogen to maintain blood glucose levels when there is a decrease in carbohydrate intake.

•

Through the process of gluconeogenesis, the liver synthesizes glucose from proteins or fats to maintain blood glucose levels.

The liver synthesizes about 50 grams of protein each day, primarily in the form of albumin. Liver cells also chemically convert amino acids to produce ketoacids and ammonia, from which urea is formed and excreted in the urine. Digested fat is converted in the intestine to triglycerides, cholesterol, phospholipids, and lipoproteins. These substances are converted in the liver into glycerol and fatty acids, through a process known as ketogenesis. Prothrombin and fibrinogen, substances needed to help blood coagulate, are both produced by the liver. The liver also produces the anticoagulant heparin and releases vasopressor substances after hemorrhage. Liver cells protect the body from toxic injury by detoxifying potentially harmful substances. By making toxic substances more water soluble, they can be excreted from the body in the urine. The liver also has an important role in vitamin storage. High concentrations of riboflavin or Vitamin B1 are found in the liver. 95% of the body's vitamin A stores are concentrated in the liver. The liver also contains small amounts of Vitamin C, most of the body's Vitamin D stores, and Vitamins E and K.

36

Biliary tract The biliary tract (or biliary tree) is the common anatomy term for the path by which bile is secreted by the liver on its way to the duodenum, or small intestine, of most of the mammal family. It is referred to as a tree because it begins with many small branches which end in the common bile duct, sometimes referred to as the trunk of the biliary tree. The duct is present along with the branches of the hepatic artery and the portal vein forming the central axis of the portal triad. Bile flows in opposite direction to that of the blood present in the other two channels. The liver is usually excluded, but sometimes included. Pressure inside in the biliary tree can give rise to gall stone and lead to cirrhosis of the liver. Blockage can cause jaundice. The biliary tract can also serve as a reservoir for intestinal tract infections. Since biliary tract is an internal organ, it has no somatic nerve supply,and,therefore,colicky pain due to infection and inflammation of the biliary tract is not a somatic pain but it may be caused by luminal distension which causes stretching of the wall (the same mechanism of pain in intestinal colic in intestinal obstruction in which intestine also do not have somatic nerve supply)

37

The path is as follows: •

Bile canaliculi >> Canals of Hering >> bile ductules (in portal tracts) >> intrahepatic bile ducts >> left and right hepatic ducts >>

•

merge to form >> common hepatic duct >>

•

exits liver and s >> cystic duct (from gall bladder) >>

•

forming >> common bile duct >> s with >> pancreatic duct >>

•

forming >> ampulla of Vater >> enters duodenum The anatomy of the biliary tree is a little complicated, but it is important to

understand. The liver's cells (hepatocytes) excrete bile into canaliculi, which are intercellular spaces between the liver cells. These drain into the right and left hepatic ducts, after which bile travels via the common hepatic and cystic ducts to the gallbladder. The gallbladder, which has a capacity of 50 milliliters (about 5 tablespoons), concentrates the bile 10 fold by removing water and stores it until a person eats. At this time, bile is discharged from the gallbladder via the cystic duct into the common bile duct and then into the duodenum (the first part of the small intestine), where it begins to dissolve the fat in ingested food. The liver excretes approximately 500 to 1000 milliliters (50 to 100 tablespoons) of bile each day. Most (95%) of the bile that has entered the intestines is resorbed in the last part of the small intestine (known as the terminal ileum), and returned to the liver for reuse.

38

The many functions of bile are best understood by knowing the composition of bile: 1. Bile Salts (cholates, chenodeoxycholate, deoxycholate): these are produced by the liver's breakdown of cholesterol. They function in bile as detergents that dissolve dietary fat and allow it to be absorbed. Hence, disruption of bile excretion disrupts the normal absorption of fat, a process called malabsorption. Patients develop diarrhea because the fat is not absorbed (steatorrhea) , and develop deficiencies of the fat-soluble vitamins (A, D, E, and K). 2. Cholesterol and phospholipids-while only 4% of bile is cholesterol, the secretion of cholesterol and its metabolites (bile salts) into bile is the body's major route of elimination of cholesterol. Phospholipids, which are components of cell membranes, enhance

the

cholesterol

solubilizing

properties of bile salts. Inefficient excretion of cholesterol can cause an increased serum cholesterol. This predisposes to vascular disease (heart attacks, strokes, etc.) 3. Bilirubin-while this comprises only 0.3% of bile, it is responsible for bile's yellow color. Bilirubin is a product of the body's metabolism of hemoglobin, the carrier of oxygen in red blood cells. Disruption of the excretion of this component of bile leads to a yellow discoloration of the eyes and skin (jaundice). 4. Protein and miscellaneous components

39

Bile production and recirculation is the main excretory function of the liver. Tumors that obstruct the flow of bile from the liver can also impair other liver functions. Therefore, it is necessary to understand these other functions to understand the symptoms that these tumors can cause. These include: Metabolic functions, such as the maintenance of glucose (blood sugar) levels Synthetic functions, such as the synthesis of serum proteins such as albumin, blood clotting (coagulation) factors, and complement (a mediator of inflammatory responses) Storage functions, such as the storage of sugar (glycogen), fat (triglycerides), iron, copper, and fat soluble vitamins (A, D, E, and K) Catabolic functions, such as the detoxification of drugs Circulation of the blood in blood vessels There are two circulatory routes of blood as it flows through the blood vessels: the systemic and the pulmonary circulation. In systemic circulation, blood flows from the left ventricle of the heart through blood vessels to all parts of the body (except gas exchange tissues of lungs) and back to the atrium. In pulmonary circulation on the other hand, venous blood moves from the right atrium to right 40

ventricle to pulmonary artery to lung arterioles and capillaries where gases exchanged; oxygenated blood returns to the left atrium via pulmonary veins; from left atrium, blood enters the left ventricle.

Hepatic Portal Circulation The veins of the hepatic portal digestive

circulation organs,

drain

the

spleen,

and

pancreas and deliver this blood to the liver through the hepatic portal vein. When you have just eaten, the hepatic portal blood contains large amounts of nutrients. Since the liver is a key body organ involve in maintaining the proper glucose, fat and protein concentrations in the blood, this system “takes a detour “to ensure that the liver processes these substances before they enter the systemic circulation. As blood flows slowly through the liver, some of the nutrients are removed to be stored or processed in various ways for later release to the blood. The liver is drained by the hepatic veins that enter the inferior vena cava. Like the portal circulation that links the hypothalamus of the brain and the anterior pituitary gland, the hepatic portal circulation is

41

a unique and unusual circulation. Normally, arteries feed capillary beds, which in turn drain into veins. Here we see veins feeding the liver circulation. The inferior mesenteric vein, draining the terminal part of the large intestine, drains into the splenic vein, which itself drains the spleen, pancreas and the left side of the stomach. The splenic vein and superior mesenteric vein (which drains the small intestine and the first part of the colon) to form the hepatic portal vein. The L. Gastric vein, which drains the right side of the stomach, drains directly into the hepatic portal vein.

42

ETIOLOGY

43

Basic Etiology Predisposing

Present/

Rationale

Actual

Absent

Factors Male



Liver Cirrhosis occurs

The patient is male.

mostly in men. http://www.cancer.org/docr oot/cri/content/cri_2_2_2x_ what_causes_liver_cancer_ 25.asp Ages 45-75



Liver Cirrhosis is most

The patient is 72 years old.

common among people ages Race: Asian



45-75 years old. In Asia and Africa, cirrhosis

The patient is an Asian since

is also common but more

he was born from Filipino

likely to be associated with

parents, and he was born in

hepatitis.

IGACOS, Davao City, and currently resides here in

http://esynopsis.uchc.edu/e

Buhangin, Davao City.

Atlas/GI/1210.htm

Biliary atresia

X

Infants can be born without

The patient has no record or

bile ducts (biliary atresia)

history of Biliary atresia.

and ultimately develop cirrhosis. The bile ducts carry bile formed in the liver to the intestines, where the bile helps in the digestion of fat. So, when the bile ducts are blocked, bile is trapped in the liver, http://www.medicinenet.co m/cirrhosis/page3.htm

44

Basic Etiology Precipitating

Present/

Rationale

Actual

Absent

Factors Chronic



alcoholism

Chronic high levels of alcohol

As stated by the

consumption injure liver cells.

patient’s wife, the

Alcohol seems to injure the liver

patient at his young age

by blocking the normal

was able to drink 1 long

metabolism of protein, fats, and

neck (750 ml) of

carbohydrates. Alcohol can

Tanduay on his own. At

poison all living cells, causing

times, he goes beyond 1

liver cells to become inflamed

long neck and even

and die. Thirty percent of

drinks half a gallon of

individuals who drink daily at

“Tuba” when he is not

least eight to sixteen ounces of

yet drunk. As stated by

hard liquor or the equivalent for

his wife, his husband

fifteen or more years will develop

does not stop drinking

cirrhosis.

unless he becomes drunk. When he reached

http://www.emedicinehealth.com/ cirrhosis/page2_em.htm#Cirrhosi s%20Causes

his adulthood, he continues to drink and smoke when he finds time to do them.

Chronic viral

X

Condition where hepatitis B or

The patient had no

hepatitis

hepatitis C virus infects the liver

medical record of

(types B, C,

for years. some patients infected

acquiring hepatitis B, C,

and D).

with hepatitis B virus and most

or D.

patients infected with hepatitis C virus develop chronic hepatitis, which, in turn, causes progressive

45

liver damage and leads to cirrhosis, and, sometimes, liver cancers. Hepatitis B causes liver inflammation and injury that over several decades can lead to cirrhosis. Hepatitis D is dependant on the presence of hepatitis B, but accelerates cirrhosis in co-infection The hepatitis C virus ranks with alcohol as a major cause of chronic liver disease and cirrhosis. Infection with this virus causes inflammation of and low grade damage to the liver that over several decades can lead to cirrhosis. http://www.spiritustemporis.com/cirrhosis/causes.ht ml

46

Smoking



Research reveals that smoking

The patient smokes 1-2

damages the liver. Smoking

packs of cigarette a day,

activates chemical materials

and he started smoking

within the body. These chemicals

when he was a teenager.

that are manufactured by smoking At the same time, he also provoke oxidative stress

also drinks Tanduay

which is linked with lipid

(750mL) 2-3 times a

peroxidation. When this occurs,

week since he was a

the condition fibrosis is

teenager. He only

developed.

stopped smoking when

Smoking increases the manufacturing of pro-

he was diagnosed with hypertension last 2009.

inflammatory cytokines which is related to liver cell damage. Smoking also contributes the continued succession of chronic alcoholic-hepatitis as well as to the progression of cirrhosis.

Http://www.ehow.com/howdoes_4577854_effects-smokingdrinking-liver.html

47

Malnutrition, especially

X

Fat builds up in the liver and

There is no scientific

eventually causes cirrhosis.

basis that the patient has

high fat intake

an increase fat in the Fat (triglycerides) accumulates throughout the hepatocytes for the following reasons: •

Export of fat from the

blood or increased level of cholesterol in the blood (LDL-bad cholesterol)

liver is decreased because hepatic fatty acid oxidation and lipoprotein production decrease. •

Input of fat is increased because the decrease in hepatic fat export increases peripheral lipolysis and triglyceride synthesis, resulting in hyperlipidemia.

http://digestive.niddk.nih.gov/ddi seases/pubs/cirrhosis/

48

SYMPTOMATOLOGY

SYMPTOMS

Present/

Rationale

Actual

absent Anorexia



Increased brain tryptophan (TRP)

This is present

availability for serotonin synthesis

with the patient,

play a role in the pathogenesis of

since this is one

anorexia. Since in chronic liver

of the reasons he

failure, increased plasma and

consulted the

cerebrospinal fluid TRP

emergency room.

concentrations are characteristically

The wife stated

reported, that also in liver cirrhosis,

that the patient

increased brain TRP availability

had no appetite to

constitute the pathogenic mechanism

eat

of anorexia.

http://www3.interscience.wiley.com/j ournal/49716/abstract? CRETRV=1&SRETRY=0 Nausea and vomiting



The malabsorption of fats may lead

Two weeks prior

to deficit of fatsoluble vitamins,

to ission, the

hemorrhoids, intolerance to fatty

patient started

foods, nausea and vomiting attacks,

feeling nauseous,

and abdominal bloating. Since the

and four days

liver has already decreased in

prior to

function, its function to produce bile

ission, he had

which emulsifies fats is also

prandial vomiting

decreased, thus these symptoms

which is one of

persists.

the reasons he

49

www.enwikipedia.org/wiki/Liver_dis

sought

ease#Symptoms_of_a_diseased_liver

consultation at the emergency room.

Body malaise



This is due to the decreased in liver

The patient

function of the liver because of the

experienced body

hepatic fibrosis. Therefore, the

malaise, and was

patient has also decreased

one of his chief

erythropoietin which then results to

complaint that

the decrease of red blood cells

resulted to his

circulating in the blood, and there

ission at

will be decreased hemoglobin. All of

DMC.

this in return will cause the patient to have body malaise. Bleeding



tendencies

Bleeding tendencies such as

The patient had

nosebleeds, easy bruising, and

bleeding as

bleeding gums may result from

evidenced by him

thrombocytopenia secondary to

having black

splenomegaly, decreased vitamin K

stools, which is

absorption and decreased production

also known as

of coagulation factors and

melena, indicative

regurgitation of blood to the spleen

of bleeding in the

and gastrointestinal tract.

upper gastrointestinal tract.

Suddarth, Doris Smith. The Lippincott Manual of Nursing Practice. 5th edition. 1991. Pages 514515.

Portal



Portal hypertension occurs because of The patient has

50

hypertension

the obstruction of portal circulation

ascites which is a

brought about by the portal

complication of

obstruction caused by the hepatic

portal

scarring.

hypertension.

http://www.emedicinehealth.com/cirr hosis/page2_em.htm#Cirrhosis %20Causes

This is an evidence that he indeed has portal hypertension. In addition, the patient was diagnosed to have hypertension on the year 2009.

Ascites

This

happened

because

of

the The patient has

decrease of albumin in the blood ascites as plasma. Albumin is responsible for evidenced by his maintaining the oncotic pressure in distended the blood volume. A decrease in abdominal cavity. albumin will mean a decrease in oncotic pressure, which will result to a more permeable membrane which results to fluid leaking through the vasculature

into

the

abdominal

cavity. Suddarth, Doris Smith. The Lippincott Manual of Nursing Practice. 5th edition. 1991. Pages 514515. Jaundice



Jaundice is the buildup of bile

The patient was

pigment that is ed by the liver

noted to have 51

into the intestine. Due to the portal

yellowish skin

obstruction, the bile going to the GI

color on all four

tract will have a backflow to the

extremities

liver. The bile then goes to the blood

including the

stream, and this causes the yellowing

palms. The

of the skin, due to the presence of bi

patient also had icteric sclera

(http://www.healthscout.com/ency/68

when inspected.

/292/main.html)

edema on the



extremities

Plasma albumin is reduced, leading One week prior to to edema.

ission, the wife of the patient

Suddarth, Doris Smith. The

noticed the

Lippincott Manual of Nursing

obvious

Practice. 5th edition. 1991. Pages 514- abdominal 515.

distention of the patient’s abdomen. Upon physical assessment, the patient was noted to have ascites and edema on all four extremities.

Caput medusae



Portal hypertension results from the

The patient was

abnormal blood flow pattern in liver

noted to have

created by cirrhosis. The increased

large, dilated, and

pressure is transmitted to collateral

distended veins

venous channels. Sometimes these

on the abdomen

venous collaterals are dilated. Caput

area when

52

medusa consists of dilated veins seen

inspected

on the abdomen of a patient with cirrhosis of the liver.

Coma



This is a progressive symptom, The patient is on a secondary to the loss of ammonia to comatose state. urea

conversion

and

consequent

delivery of toxic ammonia to the brain. Deterioration of mental function from lethargy to coma and eventual death

PATHOPHYSIOLOGY

53

PATHOPHYSIOLOGY

54

DOCTOR’S ORDERS DATE

DOCTOR'S

RATIONALE

REMARKS

ORDER Feb. 6,

Please it patient ission in the hospital is required

2010

under blue service – for optimum medical and nursing care;

ITTED

55

Level II Pavillion and to receive medications, undergo tests, and perform procedures which can only be done in the hospital setting. The blue service accommodates patients with gastro, endo and immunologic problems. VSq4 and record

Vital signs are taken to provide

TAKEN

please

baseline data and to watch-out for any

AND

unusualities.

RECORDED

Start venoclysis with Helps expand intravascular volume, PNSS 1L @

corrects an underlying imbalance in

120cc/hr

fluids and electrolytes and compensates

STARTED

the loss in the body. Moreover, it serves as a route for medication. Labs:

CBC (complete blood count and

CBC PC

platelet count) is a basic screening test WITH and is one of the most frequently

DONE

RESULTS

ordered laboratory procedures. The findings in the CBC PC give valuable diagnostic information about the hematologic and other body systems, prognosis, response to treatment and recovery. CXR-PA

A chest radiograph is used to diagnose DONE BUT

56

conditions affecting the chest, its

NO

contents, and nearby structures. Chest

IMPRESSIO

radiographs are among the most

N MADE

common films taken, being diagnostic of many conditions. A chest x-ray may be ordered when a person's symptoms include a persistent cough, coughing up blood, chest pain, a chest injury, or difficulty in breathing. ECG

ECG is a non-invasive test used to

NOT DONE

assess the heart function. It is a graphic produced by an electrocardiograph, which records the electrical activity of the heart over time. B1 B2

Elevation of serum bilirubin levels is

DONE

related to hemolysis of RBCs and

WITH

subsequent re-absorption of

RESULTS

unconjugated bilirubin from the small intestines. The condition may be benign or may place the patient at risk for multiple complications/untoward effects.

57

BUN

The BUN test is primarily used, along DONE with the creatinine test, to evaluate

WITH

kidney function in a wide range of

RESULTS

circumstances, to help diagnose kidney disease, and to monitor patients with acute or chronic kidney dysfunction or failure. Increased BUN levels suggest impaired kidney function. This may be due to acute or chronic kidney, damage, or failure. S. Na, S. K

Serum sodium and serum potassium

NOT DONE

levels are checked to determine fluid and electrolyte balance. Crea

A disorder in the kidney function

NOT DONE

reduces excretion of creatinine, resulting in increased blood creatinine levels. This test diagnoses impaired renal functions. SGPT and SGOT

Elevations of SGPT, an enzyme found DONE within the liver cells, indicate that the WITH liver cells are either leaky (internal

RESULTS

contents are entering the blood) or damaged.

58

Meds:

Inhibits reabsorption of sodium and

Furosemide 40 mg

chloride at proximal and distal tubule

tab OD

and in the loop of Henle

Spironolactone

Spironolactone inhibits the action of

25mg tab OD

aldosterone thereby causing the kidneys

GIVEN

GIVEN

to excrete salt and fluid in the urine while retaining potassium. Essentiale Forte

Increase functional status of the liver,

CAP BID

improvement in the lipids metabolism

GIVEN

caused by accelerated synthesis of lipoproteins in the liver, activation of the phospholipid-depending ferments, increased synthesis of glycogen in the liver, decreased the fatty infiltration of the hepatocytes I&O q shift

Intake & output monitoring is done to

RECORDED

assess the fluid retention status of the patient and to prevent cardiac overload. Watch out for any

To ensure that immediate nursing

WATCHED

unsualities

interventions can be rendered in cases

OUT

of deviances from the normal health status so complications can be prevented Refer accordingly

Referral is done to correct unusualities

REFERRED

as soon as possible and to inform the

59

attending physician of the patient's condition. February Labs: CBC PC,

These tests were not yet done and so

7, 2010

ECG, B1 B2, S. Na, the doctor ordered again and made

@ 4:00

K, Crea, SGPT,

AM

SGOT

NOT DONE

requests for these tests for analysis.

Follow up chest X-

This is to inform the patient or

FOLLOWED

ray reading

significant other to have the copy of the UP result from the laboratory.

Additional labs: 1.

Transabdominal USD is ordered to for NOT DONE

Transabdominal

visualization of the abdomen which

USD

helps in diagnosing the patient’s condition.

2. Serum albumin

A serum albumin test measures the

DONE

amount of this protein in the clear

WITH

liquid portion of the blood. This test

RESULTS

can help determine if a patient has liver disease or kidney disease, or if the body is not absorbing enough protein. 3. HBS-Ag

The hepatitis B surface antibody (anti- NOT DONE HBs) is the most common test. Its presence indicates previous exposure to HBV, but the virus is no longer present and the person cannot on

60

the virus to others. 4. Anti-HAV IgM

This test is used to help diagnose a

NOT DONE

liver infection due to the hepatitis A virus (HAV). This test may also be used to determine if you have produced antibodies and developed immunity in response to a hepatitis A vaccine or a previous hepatitis A infection. 6. Anti-HCV

To determine if you have contracted

NOT DONE

the hepatitis C virus (HCV) and to monitor treatment of the infection 7. PT/PTT

Since the Prothrombin time (PT)

NOT DONE

evaluates the ability of blood to clot properly, it can be used to help diagnose bleeding. When used in this instance, it is often used in conjunction with the PTT to evaluate the function of all coagulation factors. Occasionally, the test may be used to screen patients for any previously undetected bleeding problems prior to surgical procedures.

61

Furosemide 40mg

Inhibits reabsorption of sodium and

IVTT now, then

chloride at proximal and distal tubule

GIVEN

Furosemide 40mg 1 and in the loop of Henle tab BID Spironolactone

Spironolactone inhibits the action of

100mg BID

aldosterone thereby causing the kidneys

GIVEN

to excrete salt and fluid in the urine while retaining potassium. Essentiale Forte 1

Increase functional status of the liver,

cap TID

improvement in the lipids metabolism

GIVEN

caused by accelerated synthesis of lipoproteins in the liver, activation of the phospholipid-depending ferments, increased synthesis of glycogen in the liver, decreased the fatty infiltration of the hepatocyte Lactulose 30cc @

Produces osmotic effect in colon.

bedtime

Resulting distention promotes

GIVEN

peristalsis. Decrease blood ammonia build- up causes hepatic encephalopathy, probably ass result of bacterial degradation which lowers pH of colon contents. Ceftriaxone 1gm

This antimicrobial agent inhibits

GIVEN

62

IVTTq12, ANST

bacterial cell wall synthesis by binding to one or more of the penicillinbinding proteins (PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested.

Please monitor I&0

Intake & output monitoring is done to

MONITORE

q shift and record

assess the fluid retention status of the

D

patient and to prevent cardiac overload. Refer if UO < 30

A decrease in urine output may indicate REFERRED

cc/hr

a serious, even life-threatening condition. It may be caused by dehydration du, diarrhea, lack of adequate fluid intake or total urinary tract obstruction.

CBG q6 (6AM-

The capillary blood glucose test is

11AM- 6PM –

ordered to measure the amount of

11PM)

glucose in the blood right at the time

NOT DONE

of sample collection. It is used to

63

detect both hyperglycemia and hypoglycemia , to help diagnose diabetes, and to monitor glucose levels. Refer if CBG ≥

High levels of glucose most frequently REFERRED

180mg/dL, <

indicate diabetes, but many other

80mg/dL

diseases and conditions can also cause elevated glucose such as chronic renal failure and hyperthyroidism. Low blood glucose levels are seen in patients with drinking alcohol and extensive liver disease.

Refer

Referral is done to correct unusualities

REFERRED

as soon as possible and to inform the attending physician of the patient's condition. February Please do gastric

Gastric lavage is done to address

7, 2010

lavage now until

gastrointestinal bleeding.

@ 8:10

water is clear

AM

DONE

Please insert FBC

To monitor the intake and output of the INSERTED

F16 and attach to

patient. This may also avoid bladder

urobag

distention.

64

Strict I&O

Intake & output monitoring is done to

MONITORE

monitoring and

assess the fluid retention status of the

D AND

record please

patient and to prevent cardiac overload. RECORDED

NPO Temporarily

For better visualization of the abdomen DONE during the ultrasound

Shift IVF to D5NSS D5NSS restores sodium chloride deficit SHIFTED 1L @ 80cc/hr

and extra cellular fluid volume.

For USD of the

Abdominal ultrasound is an imaging

whole abdomen,

procedure used to examine the

KUB, Pancreas

presence of abnormalities in the

NOT DONE

structure of the organs intraabdominally. Continue other meds All medications previously ordered by attending physician should be

CONTINUE D

continued to hasten patient's recovery. Please attach all labs For monitoring and analysis of the requested

ATTACHED

patient’s condition through the results of the tests done

Feb. 8,

Start omeprazole

Suppress gastric acid secretion by

2010 @

40mg IVTTq12, 1st

inhibiting the partial cell H+/K+ ATP

6:20 AM done once available

STARTED

pump

*coffeeground output / NGT 65

Feb. 9,

Repeat CBC,

These tests were not yet done and so

2010 @

protime, USD of the the doctor ordered again and made

11:00

liver, Pancreas,

AM

serum albumin,

NOT DONE

requests for these tests for analysis.

BUN Lactulose 30cc TID, Produces osmotic effect in colon. to make 4-5 bowl

Resulting distention promotes

mvt/day

peristalsis. Decrease blood ammonia

GIVEN

build- up the causes hepatic encephalopathy, probably ass result of bacterial degradation which lowers pH of colon contents. Furosemide 40 mg

Inhibits reabsorption of sodium and

IVTT, OD

chloride at proximal and distal tubule

GIVEN

and in the loop of Henle Omeprazole 40mg

Suppress gastric acid secretion by

IVTT q12

inhibiting the partial cell H+/K+ ATP

GIVEN

pump Vit. K 1 amp IVTT

It is given to prevent bleeding.

GIVEN

OD Essential Forte 1 cap Increase functional status of the liver, TID

GIVEN

improvement in the lipids metabolism caused by accelerated synthesis of lipoproteins in the liver, activation of the phospholipid-depending ferments,

66

increased synthesis of glycogen in the liver, decreased the fatty infiltration of the hepatocytes Metronidazole

Disrupts DNA and protein synthesis

500mg 1 TAB q6

susceptible organisms. Therapeutic

GIVEN

effects: Bactericidal, trichomonacidal or amebicidal action. Spectrum: Most notable for avtivity against anaerobic bacteria including: Bacteroides, clostridium. In addition is active against: Trichomonas vaginalis, entamoeba histolytica, giardia lamdia, H. pylori and clostridium difficile. Hold all PO Meds

Holding all PO meds is done as

DONE

preparation for the gastric lavage. Giving medications would just be drawn out of the patient’s stomach during the procedure. Pls. do gastric lavage Gastric lavage is done to address

DONE

until gastric aspirate gastrointestinal bleeding. goes out clear NPO temporarily

For better visualization of the abdomen DONE during the ultrasound

CBG Monitoring q6 The capillary blood glucose test is ordered to measure the amount of

NOT MONITORE

67

glucose in the blood right at the time

D

of sample collection. It is used to detect both hyperglycemia and hypoglycemia , to help diagnose diabetes, and to monitor glucose levels. Refer for persistent ↓ To notify the physician regarding the in sensorium

REFERRED

changes of the patient’s health status and to prevent further complications

Feb. 9,

Restrain if necessary Patient may be restless or

2010 @ (per watcher’s

uncomfortable with the equipment

12:05

attached to him needing a restraint to

request)

PM

RESTRAINE D

keep them in place and prevent dislodging causing harm.

Feb. 10, Repeat CBC Plt Ct,

These tests were not yet done and so

2010 @

Protime with INR,

the doctor ordered again and made

1PM

Serum Na, K, Crea,

requests for these tests for analysis.

ABG

Blood gases are a measurement of

NOT DONE

DONE

how much oxygen and carbon dioxide is in your blood. It also determines the acidity (pH) of your blood. The test is used to evaluate respiratory diseases and conditions that affect the lungs. It helps determine the effectiveness of

68

oxygen therapy. The test also provides information about the body's acid/base balance, which can reveal important clues about lung and kidney function and the body's general metabolic state. Please facilitate

To conduct ultrasound testing to the

FACILITAT

transport on USD

patient which may be helpful in

ED

test today

determining other problems in the patient’s health status

NPO temporarily

For better visualization of the abdomen DONE during the ultrasound

Give tranexamic

Inhibits activation of plasminogen,

GIVEN

acid 100mg IVTT q8 thereby preventing the conversion of plasminogen to plasmin Give Vit. K 1 amp

It is given to prevent bleeding.

GIVEN

now, OD For gastric lavage

This is to ensure that the patient would DONE

today without fail

undergo the gastric lavage as it is needed by the patient immediately on the same day as per doctor’s request

NPO except meds

Restrictions for any intake per orem

DONE

except the medications is given for better visualization of the abdomen during the ultrasound and for patient’s

69

recovery through the therapeutic effects of medicine. Start albumin 25%

To compensate for the decreased

50 cc q12

albumin levels which is responsible for

STARTED

maintaining osmotic pressure inside the blood vessels BP monitoring qh

To monitor changes in the blood

MONITORE

until stable

pressure which is significant in

D

determining the patient’s status Continue meds

All medications previously ordered by

CONTINUE

attending physician should be

D

continued to hasten patient's recovery. Refer

Referral is done to correct unusualities

REFERRED

as soon as possible and to inform the attending physician of the patient's condition. Feb, 10, Referred for ↓

Glasgow Coma Scale or GCS, is

2010

sensorium, (E1 V3

neurological scale which aims to give

M5) GCS 9

a reliable, objective way of recording

CR – 90

the conscious state of a person, for

RR – 22

initial as well as subsequent

T- 39

assessment. (E1 – does not open eyes,

REFERRED

V3- Utters inappropriate words, M5 Localizes painful stimuli) Moderate Brain Injury, GCS 9 – 12

70

Do ABG now

Blood gases are a measurement of

DONE

how much oxygen and carbon dioxide is in your blood. It also determines the acidity (pH) of your blood. The test is used to evaluate respiratory diseases and conditions that affect the lungs. It helps determine the effectiveness of oxygen therapy. The test also provides information about the body's acid/base balance, which can reveal important clues about lung and kidney function and the body's general metabolic state. Do CBG now

The capillary blood glucose test is

NOT DONE

ordered to measure the amount of glucose in the blood right at the time of sample collection. It is used to detect both hyperglycemia and hypoglycemia , to help diagnose diabetes, and to monitor glucose levels. O2 inhalation @ 5-7 O2 inhalation is indicated for patients

DONE

L/min via face mask that lack oxygen supply and need assistance in maintain the desired

71

oxygen supply Monitor VS qh and

The patient is for close monitoring and MONITORE

record

needs further assessment to monitor to D address if there’s any unusualities

Refer

Referral is done to correct unusualities

REFERRED

as soon as possible and to inform the attending physician of the patient's condition. Feb. 11, Follow-up requested For monitoring and analysis of the

FOLLOWED

2010

-UP

labs

patient’s condition through the results of the tests done

For gastric lavage

Gastric lavage is done to address

DONE

gastrointestinal bleeding. Cold water is used to prevent any bleeding in the gastrointestinal tract. IVF of PNSS 1L @

Helps expand intravascular volume,

80cc/hr

corrects an underlying imbalance in

DONE

fluids and electrolytes and compensates the loss in the body. Moreover, it serves as a route for medication

PNSS is isotonic with the blood and tissue fluid, used as a solvent for drugs that are to be istered parenterally

72

like blood to replace body fluids. It is used as a prime once on blood transfusion. Refer

Referral is done to correct unusualities

REFERRED

as soon as possible and to inform the attending physician of the patient's condition. Feb. 11, Referred due to dec. Glasgow Coma Scale or GCS, is 2010

sensorium GCS5 (E1 neurological scale which aims to give

(+)

V1 M3) & dyspnea

REFERRED

a reliable, objective way of recording

active

the conscious state of a person, for

bleeding

initial as well as subsequent

per orem

assessment. E1- Does not open eyes, V1 - Makes no sounds, M3 -

(+) gross

Abnormal flexion to painful stimuli

hematuri

(decorticate response), GCS of 5 –

a on FC

Severe Brain Injury Intubate pt. now

The ET tube is inserted into a

with ET size 75 level patient's trachea in order to ensure that 21

INTUBATE D

the airway is not closed off and that air is able to reach the lungs. The endotracheal tube is regarded as the most reliable available method for protecting a patient's airway.It is

73

indicated when the oxygenation with noninvasive methods is inadequate CAB while awaiting This is to provide the patient with

DONE

mech. vent. adequate oxygen supply through continues bag valving until the mechanical ventilation is available. MV Set-up

To assist the patient in his breathing

PO2 = 100%

pattern since he is not able to

RR 16

his own required oxygen levels.

DONE

TV 500cc Insert NGT French

Nasogastric intubation is a medical

INSERTED

16 and open to drain process involving the insertion of a plastic tube (nasogastric tube, NG tube) through the nose, past the throat, and down into the stomach. The main use of a nasogastric tube is for feeding and for istering drugs and other oral agents. NPO Temp

For better visualization of the abdomen DONE during the ultrasound

Give tranexamic

Inhibits activation of plasminogen,

acid 500mg IVTT

thereby preventing the conversion of

GIVEN

plasminogen to plasmin

74

Vit. K 1amp IVTT

It is given to prevent bleeding.

GIVEN

Suction catheter –

To remove retained secretion in the

SUCTIONE

PRN

catheter to clear obstructed airway

D

Turn to sides q2

Turning the patient to sides prevents

DONE

now – hold

the patient from developing decubitus ulcer. Continue meds

All medications previously ordered by

CONTINUE

attending physician should be

D

continued to hasten patient's recovery. Refer

Referral is done to correct unusualities

REFERRED

as soon as possible and to inform the attending physician of the patient's condition. Feb. 11, Transfer to 6 or 9 To provide better care and monitoring

TRANSFER

2010 @

awaiting for ICU

to the patient while awaiting for room

RED

12NN

vacancy

vacancy in the ICU

For referral to

For co-management and thorough

consultant c/o Dr.

analysis of the patient’s condition.

INFORMED

Honcoda today To receive 2U PRBC In order to increase the number of red

TRANSFUS

and transfuse once

blood cells in the blood

ED

To secure 6U FFP

For the treatment of deficiencies of

SECURED

and transfuse once

coagulation proteins for which specific

available

factor concentrates are unavailable or

available

75

undesirable. Give tranexamic

Inhibits activation of plasminogen,

acid 500mg IVTT

thereby preventing the conversion of

q8, 1 dose now

plasminogen to plasmin

For gastric lavage

Gastric lavage is done to address

with cold water

gastrointestinal bleeding. Cold water

GIVEN

DONE

is used to prevent any bleeding in the gastrointestinal tract. Referral to Dr.

For co-management and thorough

Pilapil

analysis of the patient’s condition.

For HBS-AG, Anti-

These tests were not yet done and so

HBC IgM, Anti-

the doctor ordered again and made

HCV

requests for these tests for analysis.

For USD of the

Abdominal ultrasound is an imaging

whole ABD

procedure used to examine the

REFERRED

NOT DONE

NOT DONE

presence of abnormalities in the structure of the organs intraabdominally. Pls. facilitate transfer To provide better care to the patient in

FACILITAT

to IMCU/ICU

ED

a setting where he will monitored thoroughly.

Feb. 11, Paracetamol 300mg

Inhibits the synthesis of prostaglandins GIVEN

2010 @

that may serve as mediators of pain and

12:45P

IVTT now

fever, primarily in the CNS.

76

M

Refer

Referral is done to correct unusualities

REFFERED

as soon as possible and to inform the T – 38.2

attending physician of the patient's condition.

Feb. 12, Dx: HBS-Ag, Anti-

These tests were not yet done and so

2010 @

the doctor ordered again and made

HBC, Anti-HCV

11:45 AM

DONE

requests for these tests for analysis. Still for mech. vent.

To provide the patient with adequate



amount of oxygen

Follow up

For compatibility testing.

FOLLOWED

crossmatching of

Crossmatching is important to detect

-UP

blood and transfuse

agglutination of donor RBC’s caused

once available

by antibodies in patient's serum.

For compliance to

Continuation of medication ensure INFORMED

medication

spontaneous condition

treatment

and

of

compliance

DONE

patients to

the

medical regimen, revealing the desired outcomes Refer

Referral is done to correct unusualities

REFERRED

as soon as possible and to inform the attending physician of the patient's condition.

77

DIAGNOSTIC EXAMS Arterial Blood Gas Arterial Blood Gas Test is done to determine an imbalance in the amount of oxygen gas (O2) or carbon dioxide gas (CO2) in your blood or an acid-base imbalance, which may indicate a respiratory (lung/breathing), metabolic, or kidney disorder. Blood gas tests are ordered when there are symptoms of an O2/CO2 or pH imbalance, such as difficulty breathing or shortness of breath. Date ordered: February10, 2010

pH

Value

Normal Range

Unit

7.510

7.35-7.45

mmHg

Clinical Significance

Increase in pH is brought about by the increase in bilirubin in the blood which is alkalinic.

pC02

21.3

35-45

mmHg

Decreased pC02 is caused by hypoxia due to the accumulated fluid in the abdominal cavity creating pressure in the diaphragm. Thus, affecting the respiratory status of the patient.

PO2

82.0

80-100

mmHg

PO2 level is at normal range.

78

HC03

16.6

22.0-27.0

mmol/L

When bicarbonate levels are lower than normal, it suggests that the body is having trouble maintaining its acid-base balance. Bicarbonate concentrations in the serum may fall due to consumption by combining with protons (H+) from acids such as lactic acid, keto-acids etc; or by loss from the body from gastro-intestinal or renal sources. Renal loss of bicarbonate may be due to compensatory mechanisms for a respiratory alkalosis.

02Sat

97.2%

80-100

%

02 Saturation is at normal range.

Partially Compensated Respiratory alkalosis Respiratory alkalosis is a medical condition in which increased respiration (hyperventilation) elevates the blood pH (a condition generally called alkalosis). Respiratory alkalosis is due to the dyspnea caused by the pressure exerted by the ascites to the diaphragm, leading to respiratory rate which is lower than normal. Moreover, respiratory alkalosis could result from a ventilatory rate or tidal volume that is too high or from the patient triggering excessive additional breaths.

79

Nursing Responsibilities when withdrawing blood o

order and patient identity

o Explain to the patient the purpose of the hematology or blood test. o

Gather equipment and wear clean gloves

o Inform the patient that the blood sample will be drawn from his antecubital vein in either of the arms. o Apply hot or cold compress to injection site if swelling occurs. o Inform the patient that a total of 5cc of blood will be extracted from him. o Label the sample and maintain chain of custody and deliver or send sample to the lab o Properly dispose of used equipment

80

Hematology

Hematology is the study of blood and its disorders. Hematologists, board-certified internists, look specifically at blood components such as blood count, and blood and bone marrow cells. Hematology tests can help diagnose anemia, hemophilia, blood-clotting disorders, and leukemia. Date ordered: February 6, 2010

81

TEST

RATIONALE

REFERENCE RESULT

N/H/L CLINICAL SIGNIFICANCE

RANGE CBC+PLT Hgb

Hemoglobin is the protein molecule

115-175 g/L

104

L

Low hemoglobin is referred to

in red blood cells that carries oxygen

as anemia which may by the

from the lungs to the body's tissues

decreased erythropoietin caused by

and returns carbon dioxide from the

cirrhosis of the liver.

tissues to the lungs. Hemoglobin also plays an important role in maintaining Hct

RBC count

the shape of the red blood cells. Hematocrit is a measure of how much

0.36-0.52

0.29

L

Because of the decrease in the RBC

space red blood cells take up in the

in the blood, hematocrit as well

blood.

would decrease.

RBC count is the number of red blood 4.20-6.10 cells per volume of blood, and is

2.94

L

x106 /uL

A decreased number of RBCs results from the decrease erythropoietin

reported in either millions in a

production of the liver.

microliter or millions in a liter of blood. WBC count

Measures the amount of white blood

5.0-10.0 x103

cells. These immune cells form in

/uL

9.65

N

WBC is in normal range.

the bone marrow to help fight infection DIFFERENTIAL COUNT

82

83

TEST

RATIONALE

REFERENCE RESULT

N/H/L CLINICAL SIGNIFICANCE

RANGE CBC+PLT Hgb

Hemoglobin is the protein molecule

115-175 g/L

107.0

L

Low hemoglobin is referred to

in red blood cells that carries oxygen

as anemia which may by the

from the lungs to the body's tissues

decreased erythropoietin caused by

and returns carbon dioxide from the

cirrhosis of the liver.

tissues to the lungs. Hemoglobin also plays an important role in maintaining Hct

RBC count

the shape of the red blood cells. Hematocrit is a measure of how much

0.36-0.52

0.31

L

Because of the decrease in the RBC

space red blood cells take up in the

in the blood, hematocrit as well

blood.

would decrease.

RBC count is the number of red blood 4.20-6.10 cells per volume of blood, and is

3.08

L

x106 /uL

A decreased number of RBCs results from the decrease erythropoietin

reported in either millions in a

production of the liver.

microliter or millions in a liter of blood. WBC count

Measures the amount of white blood

5.0-10.0 x103

cells. These immune cells form in

/uL

12.78

H

High levels indicate presence of bacterial infection.

the bone marrow to help fight infection DIFFERENTIAL COUNT

84

Date ordered: February 9, 2010

85

Blood Chemistry Blood chemistry is the chemical composition of the blood. The levels of various substances in the blood can provide clues to a patient's condition, ranging from the presence of a liver disorder to a pregnancy. Routine bloodwork to check blood chemistry is often a part of a diagnostic workup, with the blood being analyzed to check for specific elements which could contribute clues to the diagnosis. Doctors rely on information about normal ranges of things like proteins and lipids to read the blood analysis. Date ordered: February 9, 2010 TEST

RESULT

UNIT

NORMAL

L/N/H

CLINICAL SIGNIFICANCE

L

Low total protein levels can

RANGE TOTAL PROTEIN

59.40

g/L

63 - 82

suggest a liver disorder. In Total protein measurements can reflect

patients with liver problems,

nutritional status and may be used to

there is a decrease in total

screen for and help diagnose kidney

protein levels because of the

disease, liver disease, and many other

decrease in production of

conditions

albumin, a protein which is

86

exclusively produced in the liver. GLOBULIN

40.70

g/L

23 - 35

H

An elevation in the level of serum globulin can indicate the

Globulins are proteins that include

presence of cirrhosis of the liver

gamma globulins (antibodies) and a

and bacterial infection.

variety of enzymes and carrier/transport proteins. They are a diverse group of proteins in the blood, and together represent the second most common proteins in the bloodstream. ALBUMIN

18.70

g/L

35 - 50

L

There is a decrease of albumin in the blood plasma because of

Albumin is the most abundant protein

the decrease in its production

found in blood plasma, representing 40

due to problems in the liver.

to 60% of the total protein. A/G RATIO

0.5

-

1.5 – 2.5

L

A decrease in Albumin

87

Globulin Ratio is an indicative The ratio of the concentrations of

of a problem in liver functions.

albumin to globulin in blood serum.

88

Blood Chemistry Date ordered: February 6, 2010

89

SGPT

Result

Unit

Reference Ranges

L/N/H

Clinical Significance

84.0

U/L

30.0-65.0

H

An increase in SGPT level is due to impaired liver function caused by liver cirrhosis. It can be

ALT (SGPT) is, by caused by hepatic inflammation (including contrast, normally found infectious mononucleosis, pancreatitis, alcohol, largely in the liver. This viral hepatitis) is not to say that it is exclusively located in liver but that is where it is most concentrated. It is released into the bloodstream as the result of liver injury. It therefore serves as a fairly specific indicator of liver status. SGOT

182.0

U/L

15.0-37.0

H

An increase in SGPT level is due to impaired liver function caused by liver cirrhosis. It can be

AST (SGOT) is normally

caused by hepatic inflammation (including

found in a diversity of

infectious mononucleosis, pancreatitis, alcohol,

tissues including liver,

viral hepatitis)

heart, muscle, kidney, and brain. It is released

90

91

DRUG STUDY

Deneric Name

Brand Name Classification

Furosemide Furoside, Lasix Myrosemide, Uritol, Diumide-K® (functional) Loop diuretic

(chemical) Sulfonamide derivative Dosage and Route 40 mg tab OD Mechanism of Inhibits reabsorption of sodium and chloride at proximal and distal tubule Action and in the loop of Henle Indication Pulmonary edema, hypertension, third spacing Contraindication Hypersensitivity to sulfonamides, anuria, hypovolemia, infants, lactation and electrolyte depletion Drug Interaction >increased toxicity with lithium, non-depolarizing skeletal muscle relaxant >increased hypotensive action with antihypertensives and nitrates Side/Adverse Effects

>increased ototoxicity with aminoglycosides, cisplatin, vancomycin CNS: headache, fatigue, weakness, vertigo CV: orthostatic hypotension, chest pain, ECG changes circulatory collapse EENT: loss of hearing, ear pain, tinnitus and blurred vision ELECT: hypokalemia, hypochloremic alkalosis, hypocalcemia, matabolic alkalosis

GI: nausea, diarrhea, dry mouth, abdominal cramps, gastric irritaions GU: polyuria, renal failure, glycosuria HEMA: thrombocytopenia, agranulocytosis, anemia Nursing

INTEG: rash, pruritus, purpura, diaphoresis >assess for drowsiness and restlessness for it may indicate metabolic

Responsibilities alkalosis >monitor for signs of hypokalemia; postural hypotension, malaise, fatigue, tachycardia, leg cramps and weakness >observe hearing problems including tinnitus and hearing loss >monitor I & O qd to determine fluid loss. >monitor vital signs; rate, depth, and rhythm of respiration >ister in AM to avoid interference with sleep if using drug as diuretic > Use sterile equipment and apply principles of asepsis. > Ensure correct identification of the patient prior to the procedure. >Decontaminate hands prior to the procedure. >The cannula insertion site should be inspected for complications, i.e. infiltration, infection. >instruct patient to increase fluid intake 2-3 L/day unless contraindicated >tell the patient to rise slowly from lying or sitting position because orthostatic hypotension may occur >evaluate for therapeutic response

Generic Name Brand Name Photo

Omeprazole Losec and Prilosec

Classification Gastric acid secretion, proton-pump inhibitor Dosage and Route 40mg IVTTq12 Mechanism of Suppress gastric acid secretion by inhibiting the partial cell H+/K+ Action Indication Contraindication Drug Interaction

ATP pump To prevent ulceration in patients under NPO Known hypersensitivity to omeprazole decreased effect: decreased ketoconazole; decreased itriconazole increased toxicity: diazepam increase half-life; increased digoxin,

increased phenytoin, increased warfarin Side/Adverse EffectsCNS: headache, dizziness Neuromascular & Skeletal: weakness, back pain GI: nausea, diarrhea, vomiting, abdominal pain, constipation, taste perversion Nursing Responsibilities

Respiratory: upper respiratory infection, cough  Ensure ten rights of medication istration  Instruct patient not to chew, crush or open capsule  Instruct patient to take before eating, capsule should be swallowed whole

 Warn patients that Zegerid contains 460 mg sodium bicarbonate per dose. Those following a sodium-restricted diet should be cautious.  Tell patient to empty contents of Zegerid packet into a small cup containing 2 tablespoons of water.  Instruct patient to take drugs 30 minutes before meals.  Caution patient to avoid hazardous activities if he gets dizzy.  Inform patient that prilosec OTC may take 1-4 days for full effect.

Generic Name Brand Name Photo Classification

Spironolactone Aldactone Electrolyte and water balance agent; potassium sparing diuretic

Dosage and Route PO – (25, 50, 100) mg tablets

DOSING: Edema – 25 – 200 mg/d in divided doses, continued for atleast 5 daysd

Mechanism of

One of the main functions of the kidneys is to retain salt (sodium

Action

chloride) and water in the body. In patients with heart failure and cirrhosis, increased levels of a hormone produced by the adrenal glands, called aldosterone, causes salt and fluid to be retained by the kidneys. (At the same time, it also causes the kidneys to eliminate potassium.) The body becomes overloaded with salt and water, and this worsens the heart failure. Spironolactone inhibits the action of aldosterone thereby causing the kidneys to excrete salt and fluid in the urine while retaining potassium. Therefore, spironolactone is classified as a potassium-sparing diuretic, a drug that promotes the output of urine (diuretic) while allowing the kidneys to hold onto

Indication

potassium. clinical conditions associated with augmented aldosterone production, as in essential hypertension, refractory edema due to CHF, hepatic cirrhosis, nephritic syndrome and idiopathic edema

Contraindication Patients

with

anuria,

acute

renal

insufficiency,

significant

impairment of renal excretory function, or hyperkalemia. Drug Interaction Spironolactone can lower blood sodium levels while raising blood potassium levels. Excessively high blood potassium levels can lead to potentially life-threatening abnormalities in the rhythm of the heart. Therefore, spironolactone usually is not istered with

Generic Name

Ceftriaxone

Photo

Brand Name

Rocephin

Classification

cephalosporin antibiotic

Dosage and Route

1gm IVTTq12

Mechanism of

This antimicrobial agent inhibits bacterial cell wall synthesis by

Action

binding to one or more of the penicillin-binding proteins (PBPs) which in turn inhibits the final transpeptidation step of peptidoglycan synthesis in bacterial cell walls, thus inhibiting cell wall biosynthesis. Bacteria eventually lyse due to ongoing activity of cell wall autolytic enzymes (autolysins and murein hydrolases) while cell wall assembly is arrested.

Indication

Respiratory tract and intraabdominal infections

Contraindication

Cephalosporin hypersensitivity.

Drug Interaction

Warfarin (Coumadin, Jantoven) If you are taking ceftriaxone and warfarin, your body may metabolize the drugs differently than intended. You healthcare provider may choose to monitor your INR and prothrombin time more frequently and adjust accordingly. INR and prothrombin time are tests used to measure how well your blood clots.

Probenecid (Benemid, Probalan) If you are taking both ceftriaxone and probenecid, your body may metabolize the drugs differently than intended and significantly increase the amount of ceftriaxone in your system. Your healthcare provider may choose to monitor your progress

Generic Name

metronidazole

Photo

Brand Name

Flagyl

Classification

Anti-infectives, antiprotozoals, antiulcer agents

Dosage and Route Mechanism of Action

500mg 1 TAB q6 Disrupts DNA and protein synthesis susceptible organisms. Therapeutic effects: Bactericidal, trichomonacidal or amebicidal action. Spectrum: Most notable for activity against anaerobic bacteria including: Bacteroides, clostridium. In addition is active against: Trichomonas vaginalis, entamoeba histolytica, giardia lamdia, H. pylori and clostridium difficile.

Indication

PO: Amebecide in the management of amebic dysentery, amebic liver abscess and trichomoniasis: treatment of peptic ulcer disease caused by Helicobacter pylori.

Contraindication

Hypersensitivity. Use cautiously in: history in blood dyscrasias, History of seizures or neurologic problems and severe hepatic impairement.

Drug Interaction

Drug-drug: Cimetidine may decrease metabolism of metronidazole. Phenobarbital and rifampin increases metabolism and may decrease effectiveness. Metronidazole increases the effects of phenytoin, lithium, and warfarin. Disulfiram-like reaction may occur with alcohol ingestion. May cause acute psychosis and confusion with disulfiram. Increased risk of leucopenia with fluorourousel or azathioprine.

Side/Adverse Effects CNS: Seizures, dizziness, headache.

Generic Name

Lactulose

Photo

Brand Name

Contulose

Classification

Laxative

Dosage and Route

30cc @ bedtime

Mechanism of

Produces osmotic effect in colon. Resulting distention promotes

Action

peristalsis. Decrease blood ammonia build- up the causes hepatic encephalopathy, probably ass result of bacterial degradation which lowers pH of colon contents. Relieves constipation, decreases ammonia concentration.

Indication

- constipation - To prevent and treat hepatic encephalopathy, including hepatic precoma and coma I patients with severe hepatic disease. - to restore bowel movements after hemorrhoidectomy.

Contraindication

Contraindicated in patients on low- galactose diet

Drug Interaction

Drug-drug. - Should not be used with other laxatives in the treatment of hepatic encephalopathy - Anti- infectives may diminish effectiveness in treatment of hepatic encephalopathy

Side/Adverse Effects GI: belching, cramps, distention, flatulence, diarrhea ENDO: Hyperglycemia Nursing

Generic Name

Essentiale Forte

Photo

Brand Name

Essential Forte

Classification

Cholagogues, Cholelitholytics & Hepatic Protectors

Dosage and Route

1 cap TID

Mechanism of

Increase functional status of the liver, improvement in the lipids

Action

metabolism caused by accelerated synthesis of lipoproteins in the liver, activation of the phospholipid-depending ferments, increased synthesis of glycogen in the liver, decreased the fatty infiltration of the hepatocytes

Indication

- cirrhosis - Hepatic steatosis (also in cases of diabetes) - Acute and chronic hepatitis - Necrosis of the liver cells - Hepatic coma and precoma - Toxic liver damage (including pregnancy toxicosis)

Contraindication

- Contraindicated in patients hypersensitive to drug -in newborn children -in pregnant women

Drug Interaction

Not indicated

Side/Adverse Effects In very rare cases it can cause :abdominal pain, nausea, diarrhea and allergic reaction(skin rash). Nursing Responsibilities

1. Instruct patient on proper use of the drug

Generic Name

Phytonadione

Photo

Brand Name

Aqua-Mephyton, Vitamin K

Classification

Vitamin ( fat soluble)

Dosage and Route Mechanism of Action

1 amp now, OD -Required for hepatic synthesis of blood coagulation factors II (prothrombin), VII, IX, and X. - prevention of bleeding due to hypoprothrombinemia

Indication

•

Anticoagulant-induced prothrombin deficiency caused by coumarin or indanedione derivatives;

•

Prophylaxis and therapy of hemorrhagic disease of the newborn;

•

hypoprothrombinemia due to anti-bacterial therapy;

•

hypoprothrombinemia secondary to factors limiting absorption or synthesis of vitamin K, e.g., obstructive jaundice, biliary fistula, sprue, ulcerative coilitis, celiac disease, intestinal resection, cystic fibrosis of the pancreas, and regional enteritis;

•

Contraindication Drug Interaction

other drug-induced hypoprothrombinemia.

Hypersensitivity to any component of this medication. -Large doses will counteract the effect of warfarin - large doses of salicylates or broad-spectrum

Generic name

paracetamol

Photo

Brand name

Aeknin

Classification

Therapeutic: antipyretics, non-opiod analgesics

Ordered Dosage and

300mg IVTT now

Frequency Mode of Action

Inhibits the synthesis of prostaglandins that may serve as mediators of pain and fever, primarily in the CNS. Has no a significant anti-inflammatory property or GI toxicity. Therapeutic Effects: analgesia, antipyresis.

Indication

Mild pain, Fever

Contraindication

Contraindicated in: Previous hypersensitivity. Products containing alcohol, aspartame, saccharin, sugar, or tartrazine should be avoided in patients who have hypersensitivity or intolerance to these compounds. Used cautiously in: Hepatic disease/renal disease; chronic alcohol use/abuse; Malnutrition

Drug Interactions

Drug-drug: Chronic high-dose acetaminophen may increase the risk of bleeding with warfarin. Hepatoxicity is additive with other hapatotoxic substances, including alcohol.

Adverse Reactions/ Side Effects

GI: Hepatic failure, hepatoxicity (overdose) GU: renal failure(high doses/chronic use) Hemat: neutropenia, pancytopenia, leukopenia

Generic name

Tranexemic acid

Photo

Brand name

Cyclokapron

Classification

Hemostatic agent, antifibronolytic agent

Ordered Dosage and

100mg IVTT q8

Frequency Mode of Action

Inhibits activation of plasminogen, thereby preventing the conversion of plasminogen to plasmin

Indication

Prevention of hemorrhage

Contraindication

Hypersensitivity, active intravascular clotting

Drug Interactions

Concurrent use of clotting factor, complexes may increase the risk of thrombotic complications. risk of thrombosis may be increased by estrogens. Drug will antagonize the effects of thrombolytic agents.

Adverse Reactions/ Side Effects

CNS: visual abnormalities CV: hypotension, thrombosis, thromboembolism GI: nausea, vomiting, diarrhea

Nursing

i.

Responsibilities

observe the 10 rights of medication istration of medication

ii.

check for hypersensitivity to drug

iii.

observe for bleeding

iv.

instruct patient ot take tranexamic acid as directed

NURSING THEORIES

Theorist: Dorothea Orem Theory: Self-care Deficit Theory Orem’s theory states that each person has a need for self care in order to maintain optimal health and wellness. Each person possesses the ability and responsibility to care for themselves and dependants. The theory is separated into three conceptual theories which include: self-care, self-care deficit, and nursing system. Self care is the ability to perform activities and meet personal needs with the goal of maintaining health and wellness of mind, body and spirit. Self-care is a learned behavior influenced by the metaparadigm of person, environment, health and nursing. There are three components of this theory: universal self-care needs, developmental self-care needs, and health deviation. Universal theory includes activities which are essential to health and vitality. Developmental self-care need include the interventions and teachings designed to return to a person to or sustain a level of optimal health and well-being. Health Deviation selfcare encomes the variation of meeting self-care which may occur as a result of disability, illness or injury. Orem created three areas of how care can be istrated to a client depending on the physical and mental capabilities of the client: the wholly compensatory, partly compensatory and the ive-educative role. The wholly compensatory system accomplishes the client’s therapeutic self-care, compensates for the client’s inability to participate in their self-care, provides and protects the client. The partly compensatory is a give and take system between the client and the nurse. The nurse performs, compensates and assists the client as needed while the client participates,

regulates and accepts care and assistance form the nurse. Lastly, the ive-educative role indicates that the client is participating in most of their self-care, and the nurse’s role is simply to monitor and regulate the client’s self-care.

Application to client: The client’s environment failed to provide adequate warmth and ventilation. It has a limited space and is not quiet enough for the client to take adequate rest. These factors contributed to the client’s present condition as well as his ability to cope and recover. The nurse’s role is to help client achieve optimal health and wellness by acting as an advocate, redirector, person and teacher and to provide an environment conducive to therapeutic development. One example of this theory is by creating nursing care plans which was made by the student nurses. The theory applies to the assessment and evaluation of the nursing process. Since patient is in a comatose state, we have applied the wholly compensatory system. Since patient is unable to do the self-care activities, the nurse together with the medical team assisted the client’s needs by providing adequate care to the patient through helping the client achieve good hygiene, preventing bed sore by turning the patient to sides, preventing injury and promoting rest and comfort to the patient. Also, nurses were able to create nursing care plans which became their guide on how to render care to the patient. Also, important health teachings were provided to the family of the patient.

Theorist: Lydia Hall Theory: Core, Care and Cure Theory Hall's theory emphasizes the importance of individuals as unique, capable of growth and learning, and requiring a total person approach. Her definition of health can be inferred to a state of self-awareness with conscious selection of behaviors that are optimal for that individual. Hall stresses the need to help the person explore the meaning of his or her behavior to identify and overcome problems through developing self-identity and maturity. The concept of society or environment is dealt with in relation to the individual. Hall's theory of nursing involves three interlocking circles, each one of it represents one aspect of nursing. The same aspect represents intimate bodily care of the patient. The core aspect deals with the innermost feeling and motivations of the patient and family through the medical aspects of care. Care is the sole function of nurses, where as core and cure are shared with other of the health care team. The major purpose of care is to achieve interpersonal relationship with the individual. The nurse plans and prepares a series of independent nursing interventions that can aid from its condition. These interventions are designed to provide good and conducive atmosphere, istering drugs to the right patient, right drug and right time. The nurse also provides health teachings to the client’s family on medication management and independent actions such as advising the client to have complete bed rest.

Theorist: Faye Glenn Abdellah Theory: Twenty-one Nusring Problems Abdellah’s theory would state that nursing is the use of the problem solving approach with key nursing problems related to health needs of people. Such a statement maintains problem solving as the vehicle for the nursing problems as the client is moved toward health – the outcome. Faye Abdellah formulated the twenty-one Nursing Problems and categorizes them into three: the Physical, sociological, and emotional needs of clients, the types of interpersonal relationships between the nurse and patient and the common elements of client care. The 21 Nursing Problems were divided into four care needs: Basic to all patients, Sustenal care needs, Remedial care needs and Restorative care needs. The Nursing problem presented by a client is a condition faced by the client or client’s family that the nurse through the performance of professional functions can assist them to meet. An overt nursing problem is an apparent condition faced by the patient or family, which the nurse can assist him or them to meet through the performance of her professional functions. The covert nursing problem is a concealed or hidden condition faced, by the patient or family, which the nurse can assist him or them to meet through

the performance of her professional functions. According to Abdellah, nursing is a helping profession.

Application to Client: Since our patient is suffering from his condition, the student nurses have identified nursing problems which made them choose the theory of Abdellah. The patient was in a state of coma and so he was not able to perform certain activities which he needs. Thus, student nurses provided care and assisted the client and his family. Some of the nursing interventions done to address the problems identified by the student nurses which falls under the 21 nursing problems theory were: maintained good hygiene and physical comfort, promoted rest and sleep, promoted safety through the prevention of accidents, injury, or other trauma and through the prevention of the spread of infection, maintained good body mechanics and prevent and correct deformity, To facilitate the maintenance of a supply of oxygen to all body cells, facilitated the maintenance of elimination, recognize the physiological responses of the body to disease conditions, created and / or maintained a therapeutic environment. The student nurses focused their interventions to the needs of the patient which helps in the promotion of recovery to the patient.

NURSING CARE PLANS Date / Time

Cues

February

Objective:

A

- crackles

C

11, 2010 at 4pm

heard on lung field upon ausculatation -with bag valve connected to endotracheal tube

Needs

T I

Nursing Diagnosis

Ineffective airway

At the end of

clearance related to

7 hours span

accumulation of

of care, the

secretions secondary

patient will

to Community

have

Acquired Pneumonia

effective

V I T Y E X E

Objective of Care

airway as evidenced by R: Pneumonia, which

absence of

is an acute infection

crackles.

of the lungs, causes inflammation in lung tissues which leads to

Nursing Intervention

1. Provide suctioning. R: to clear airway from accumulated

Evaluation

February 11, 2010; 11pm

secretions.

GOAL UNMET

2. Elevate head of bed.

After rendering

R: Gravity decreases pressure on the diaphragm 3. Turn patient to sides every 2 hours R: repositiong enhances drainage and promotes ventilation to different lung segments.

nursing interventions within the 7hours span of care, the patient has still ineffective airway clearance

damage on mucous

4. Assist in providing respiratory

as evidenced by

and alveolar

through ambu bagging.

presence of

membranes. This damage results in secretion of exudates and mucous as the

R: mechanical ventilation maintains adequate airways and improve respiratory functions.

crackles on lung field.

R C I S

system tries to get rid with the infection. This secretions cause obstruction in the airway.

A T T E R N

R: to maintain anatomic position of the tongue and provide natural airway 6. Re-ausculate lung sound R: to note for progress, if crackles are

E P

5. Insert mouth guard.

Williams, L.S &

still present.

Hoppers, P.D. (2007).

7. Provide oxygen with appropriate

Understanding

humidifier, as ordered.

medical-surgical nursing,3rd ed. Philadelphia: F.A. Davis Company.

R: to facilitate oxygenation and liquefy secretion for easy suctioning. 8. Monitor oxygen saturation. R: to rule out presence of gas exchange impairement. 9. Carry out diagnostic orders made by the physician such as ABG or AFB and secure result. R: to determine the degree of respiratory impairment such as

presence of hypoxemia.

Date

Cues

Needs

Nursing. Diagnosis

F

Objective cues:

N

Bleeding related to altered

E B R

-

Melena

noted Decreas

U

-

A

ed platelet

R

count of 115

Y

x103 /uL (Normal:

11,

150-400

2010

x103 /uL)

@ 5:00 PM

-

Gastric

lavage ordered

U T R I T I O N A L

Intervention

Evaluation

Within the 8

1. Monitor patient’s vital

February 11, 2010

clotting mechanism:

hours span of

signs, especially the

decreased prothrombin and

care, the patient

blood pressure

thrombin production

will be able to:

secondary to liver cirrhosis

M E

® To obtain baseline

maintain normal

data and prevent

® One of the functions of

hemodynamic

hypotension

liver is the production of

status as

prothrombin and thrombin

evidenced by a

which are substances

normal intake

needed to help blood

and output

2. Assess patient’s level of consciousness ® A change in the level

coagulate. In patients with

of consciousness

liver cirrhosis, they are at

indicates a decrease in

higher instances of

circulating blood volume

bleeding because of the decreased coagulation factors.

-

Objective

3. Monitor intake and output ® To determine fluid balance and prevent dehydration 4. Regulate intravenous

T

fluids appropriately

A

® To prevent

B

dehydration and correct the normal

O

hemodynamic status

L

5. Monitor hematocrit and

@ 10:30 PM Goal Met Within the 8 hours span of care, the patient was able to maintain normal hemodynamic status as evidenced by a normal intake and output

Date /Time February

Cues Objective Cue:

Nursing Diagnosis

Objective/Goal

Intervention

N

Hyperthermia related to the

Within my 1-3 hour

1.

U

release of endogenous

span of care, my

signs.

- Increased

T

pyrogen secondary to

patient’s body

® serves as baseline data

body

R

presence of CAP and liver

temperature will

temperature of

I

cirrhosis

decrease from 38.1°C

2.

38.3

T

to 36.5-37.5°C.

developmental age of client.

11, 2010 5:00pm

Needs

Monitor patient’s vital

@ Note chronological and

R: Hyperthermia is the

® Elderly or impaired

O

elevation of body temperature

individuals ay not be able to

is warm to

N

above normal range. Most

recognize and/or act on

touch

A

often, it results from infection

symptoms of hyperthermia

L

somewhere i the body, but it

-

Skin

Increa

sed

diagnos

is of CAP

GOAL MET Patient’s body temperature

3.

conditions (cancer, allergic

bath

from 38.1 ° C

reactions, and CNS injuries).

® promotes heat loss by

to 36.7° C

M

Macrophages, white blood

evaporation and conduction

E

cells, and injured cells release

T

chemical substances called

4.

A

pyrogens that act directly on

lightweight, loose-fitting

B

the hypothalamus, causing its

clothes.

O

thermostat to be set to a

® encourages heat loss by

respiratory

-

8:00pm

may be caused by other -

rate of 24

February 11, 2010

I -

Evaluation

Provide tepid sponge

Limit clothing in

decreased

-

ascites

L

higher temperature.

radiation and conduction.

Reference:

5.

Nurse’s Pocket Guide 10th

with air-conditioning or fans.

Edition by Doenges, et al.

® promotes heat loss by

I C P A

Cool the environment

convection

T T

6.

Keep clothing and linens

E

dry.

R

® to reduce shivering

N 7.

ister replacement

fluids and electrolytes ® to replace fluids lost through perspiration and respiration. 8.

Maintain bedrest

® to reduce metabolic demands 9. Discuss importance of adequate fluid intake

® To prevent dehydration INTERDEPENDENT 10.

Collaborate with

dietician in providing patient with high-calorie diet, or parenteral nutrition ® to meet increased metabolic demands 11.

Notify physician if

pharmacologic regimen is inadequate to meet hyperthermia control goal. ® to determine if there is a need to increase dosage, change medication or use a stepped program (e.g., switching from injection to oral route, or lengthening time interval between doses).

DEPENDENT 12.

ister antipyretics,

orally or rectally, as ordered. ® to aid in reducing the body temperature 13.

Provide supplemental

oxygen as ordered. ® to offset increased oxygen demands and consumption. 14.

ister replacement

IV fluids and electrolytes as ordered. ® to circulating volume and tissue perfusion and to aid in hydration

DATE/ CUES

NEE

NURSING

OBJECTIVES OF

D

DIAGNOSIS

CARE

TIME F

Objective:

E B R U A

N - ascites -dry, scaly and shiny -edema

R Y

U T R I T

-dyspnea

I O

1

N

1

A

,

L -

Fluid

Within 8 hours span

Volume

of care, the client

Excess in the

will be able to :

NURSING INTERVENTIONS

1.

® To obtain baseline date and

space related to liver organ

a. Stabilize

failure as

fluid volume as

evidenced by

evidenced by

2.

ascites

balanced I/O,

dependent venous pooling or

with liver failure, there is a decreased

Vital signs within normal limits

venostasis. ® To determine causative factors 3.

Thus,

environment, limiting external

osmotic

Provide quiet

stimuli. ® To promote adequate rest

2

M

pressure in

0

E

the

and comfort for faster

intravascular

recovery

1

T

spaces. This

0

A

leads to the

4.

Monitor intake and output

accumulation @

B

of fluid in the

Goal Unmet

Assess for evidence of

albumin.

decrease in

11:00 pm

to note any unusualities

production of

resulting to

February 11, 2010

Measure vital signs

@

interstitial

®In patients

EVALUATION

® To determine elimination o

Patient was unable to: o

stabilize fluid volume as evidenced by imbalance intake and output

Date / Time

Cues

February

Objective:

N

-

U

11, 2010 at

Needs

Nursing Diagnosis w/ Rationale

4pm

Jaundice noted in the skin upon inspection .

-

+4 pitting edema noted on all four extremitie

T R I T I O N

s -

(+) body malaise

A

Risk for impaired

Within my

skin integrity related

seven hours

to prolonged bed rest

span of care,

R: When edema and jaundice are present, the skin is placed at more risk of being

the patient will maintain undamaged physical

impaired because of

Skin integrity

the bilirubin present

by not

on the blood.

manifesting

Moreover, prolonged bed rest can form decubitus ulcers at the patient’s back.

L

Vital Signs: BP- 110/70

Objective of Care

signs of decubitus ulcer.

Nursing Intervention w/ Rationale 1. Monitor patient’s vital signs. ® serves as baseline data

February 11, 2010; 10pm

2.) Assess for any changes in skin. ® to be able to determine the causative factors 3.) Note and record degree of jaundice of skin and sclera and scratches on the body. ® to be able to assess skin integrity 4.) Maintain strict skin hygiene.

Goal Met: After seven hours span of care, the patient still maintained intact skin integrity as evidenced by absence of

® to prevent the spread of bacteria

decubitus ulcer

and prevent infection

at the patient’s

5.) Provide adequate clothing/covers. Reference :

Evaluation

®to prevent vasoconstriction

back.

mmHg

M

PR- 96 bpm

E

RR- 24 cycles

T

per minute TEMP. – 38.3 °C

Nurse’s Pocket Guide

6.) Observe for reddened/blanched

11th Edition by

areas and institute treatment

Doenges, et al.

immediately. ®: Reduces likelihood of progression

A

to skin breakdown.

B

7.) Change patient’s position every

O L I C

two hours. ®: To relieve the pressure on the patient’s back. 8.) Drain urine bag every two hours. To monitor output of patient in order to determine fluid and electrolyte

P A T T E

intake and loses 9.) Encourage frequent skin care to significant other. Also, perform morning care to patient by performing complete bed bath and apply lotion afterwards. ®: To promote hygiene and skin

R N

integrity. To promote skin moisture, and prevent roughness on skin. 10.) Emphasize importance of adequate nutritional/fluid intake to significant others. (through NGT feeding) ®: to maintain general good health and skin turgor. 11.) ister medications as ordered. ® to treat any underlying cause

POST-MORTEM 

Ask permission to the family before doing the post-mortem care.

R: The family is in grieving stage and so nurses should be sensitive enough in dong responsibilities 

Ask permission to the patient before removing tubing from his body

R: It is to convey respect and value to the patient’s body 

Use caution when removing tape from the body to avoid skin breakdown.

R: The body temperature decreases with a resultant lack of skin elasticity 

Elevate the head to prevent discoloration from the pooling of blood.

R: a physiological change will happen in which a bluish purple discoloration that is a by-product of red blood cell destruction occurs in the dependent areas in the body. 

The nurse should close the eyelids, insert dentures, close the mouth and position the body in a natural position as soon as possible after death.

R: To prevent the body from stiffening caused by contraction of skeletal and smooth muscles. 

Prepare the body: remove all tubes and position the body

R: To make the body look comfortable and natural for family viewing. 

Place the body in a plastic or fabric shroud and put a tag on it.

R: To prepare the body for transport to the morgue. 

Return the deceased’s possession to the family such as jewelries, eyeglasses, clothing and all personal items.



Offer to people



Help the family with decision making regarding funeral home, transportation, and the removal of the deceased’s belongings.

R: The family needs help since they are on the process of grieving. 

Demonstrate comion in providing information and to families.

R: This will inform the family of your genuine concern for them

PROGNOSIS

Criteria Onset of Illness

Poor

Fair

Good

Justification We rated it poor since the



patient started manifesting symptoms that are associated with liver cirrhosis since December 2009. On January 23, 2010, 13 days prior to his ission, the patient experienced headache, chest pain, dull abdominal pain, felt nauseated and dizzy.. Duration of

Occurrence of



Illness

manifestations related to liver cirrhosis has been observed to start since December 2009. It is also poor since liver cirrhosis is a chronic disease. Hospital days until our last with the patient are 6 days.

Attitude and



As verbalized by his wife,

willingness to

the patient is taking

take

medications but sometimes

medications

with skipped doses because he neglects to take and due to forgetfulness.

Age



The patient is 73 years old and we rated it as poor since geriatric patients have deteriorating body systems that hinder recovery. The wear and tear theory suggests that as a person ages, he or she is more prone to illness and resistance and the ability to heal is getting weaker.

Precipitating



We rated it poor since his

and

age and race predisposes

predisposing

him in developing the

factors

disease. Moreover, his chronic alcoholism precipitates the development of the disease. Longtime alcohol beverage drinking is

the most common factor that triggers liver cirrhosis. Environment

The ward has poor



ventilation, crowded and noisy. With this, it is not favorable for recovery. Family



Family is fair. They give time in giving care to the patient but cannot provide all the needs especially the medications and mechanical ventilator because of financial inadequacy.

Basis for Prognosis: Poor = 1

Fair = 2

Good = 3

Range of prognosis: 0-1.50 = poor 1.51-2.0 = fair 2.0-2.5 = good

Result: POOR: Precipitating and predisposing factors, Age, Duration of Illness, Onset of Illness, Environment FAIR: Attitude and willingness to take medications and Family GOOD: None

Computation: Good: 3 x 0 = 0 Fair: 2 x 2 = 4 Poor: 1 x 5 = 5 Total: 9/7 = 1.28 (POOR PROGNOSIS)

RECOMMENDATION Every rotation we have is a learning course and practice to develop our skills and hearts as caregivers. In this rotation, the 3rd group of BSN-3H, cultured a lot of knowledge in this experience; experience that will serve as our guide and basis for improvement. In relation with improvement, the group had come up with recommendations, which we think, would have made the exposure a lot better. To our client’s family: One of the most important factors of recovery for a certain illness is the participation of the patient himself. However, our client has suffered a disease wherein he has gone seriously affected both physically and emotionally and even his consciousness and responsiveness have been depleted. The family’s involvement in the treatment of the patient is very essential and highly needed. The family should know all the basic facts and information about the patient’s illness because them, more than anybody else are expected not just to care but also to accept his condition with utmost understanding. Being aware of the illness itself and its treatment will elicit awareness and would definitely pave the way to the prevention and alleviation of any ailment that any of the family may possibly have. To the family , the death of a love one is not the end of every one’s life. His death should serve a lesson and be a step towards taking good care of one’s body.

To the Student Nurses: In line with this case study, the group would like to encourage all student nurses to get more involved in the promotion of health in our country. We are to provide health services to the greater population in a way that it is more generalized. We must impart to those who are in need, our knowledge regarding health and on how they could maintain a healthy lifestyle. We must apply to them the skills that we have learned by rendering them a quality- based service. We must also teach the patients as well as the significant others on the alternative means of promoting health and on how to prevent the possible occurrence of a disease. Empathy must always be shown not just to the patient but also to the significant others. Student nurses must also be sensitive to the feelings and emotions not just of the patient but also to the significant others especially in experiences of death and finite separation. To the medical world:

We would like to encourage the medical practitioners or the of the health care team that they should have to be more committed or comionate in their chosen profession. They must have to cater the health needs of the people of different kinds without putting levels of discrimination on them. Their job is not that easy but they must have to be very careful because they are already dealing here with the life of a person. They must have to extend their hands not only in the physical means but also in a holistic way of giving or providing care to individuals, families and the population groups especially in significant others who may have lost love ones.. They are tasked to render

their services in order to achieve the good health condition of the citizens of the country because the health of the nation lies in the health of the populace.

REFERENCES

BLACKWELL’S DICTIONARY OF NURSING 5TH EDITION, 2004 BROWN, K.S (2003) DEVELOPMENTAL THEORY: UNDERSTANDING THE AGES. RETRIEVED FROM HTTP://WWW.HAVERFORD.EDU/PSYCH/DDAVIS/P109G ERIKSON.STAGES.HTML. RETRIEVED ON FEBRUARY

12, 2010.

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