Biographic Data:

Patient J.P, 65 years old, Male, Filipino, Married, Roman Catholic, Working as a jeepney driver and presently residing in Caloocan City was admitted at our institution last February 11, 2012.

Chief Complaint:
Generalized body weakness

History of Present Illness:

Patient was apparently well 1 month PTA patient was noted yellowish discoloration of the skin and eyes on the patient. He was brought to Ospital ng Maynila, after 4 days of symptoms wherein he was admitted for 2 nights. Laboratories done were urinalysis, CBC, HBT-UTZ revealing diffuse parenchymal Liver disease and bile sludge. Patient was sent home with Silymarin and Lactulose. 3 week PTA, patient sought consult with AP to regression symptoms with associated generalized body weakness and loss of appetite. Diagnostic were done such as chest X-ray revealing pneumonitis urinalysis with trace albumin, CBC with low hemoglobin of 10.9 Medications prescribed such as Senokot, Diphenhydramine 25mg/tab, Cefuroxime 500mg/tab, Polynerve 500mg OD, Iberet FA, Ascorbic Acid and Ciprofloxacin 500mg/tab BID. 1 week PTA with the above symptoms, there was noted edema on both feet, associated with on and off fever. At this time patient was noted by the relatives to have increasing sleeping time during the day. Symptoms progress which prompted patient to seek consult hence this admission.

Past Medical History:

(-) Hypertension (-) DM (-) Allergies (+) previous Hospitalization

Family History:
(+) DM-Mother (+) Asthma

Personal and Social history:

Non smoker Chronic alcohol drinker for 30 years, usually hard drinks amounting to 34L/day

Physical Exam upon Admission:

V/S BP= 90/60, HR=78bpm, RR=18BPM, T=36.1 (+) generalized jaundice Yellowish conjunctiva, pallor oral mucosa tongue (+) Spider Angiomata

PHYSICAL EXAMINATION:
Physical examination upon admission:
Globular abdomen, (+) visible veins or peristalsis, fluid wave or bruit, tense and glistering Dull (+) direct/rebound tenderness abdominal girth=88cm (+) grade 3 bipedal pitting edema.

Physical Assessment: PHYSICAL ASSESSMENT Date Assisted February 13,2012

Vital Signs Blood Pressure Heart Rate Respiratory Rate Temperature Weight Height

NORMAL

ACTUAL FINDING

INTERPRETATION

120/80mmHg

90/60mmHg

Decrease BP due to anemia Within normal limit Within normal limit Within normal limit BMI= 18.86 Underweight

60-100bpm 16-20cpm 36-37.5C 70-83 kgs

78 beat per minute 18cpm 36.1 C 63kgs. 56 ft

PHYSICAL ASSESSMENT Mouth

NORMAL Uniform pink color

ACTUAL FINDING pale oral mucosa with foul odor

INTERPRETATION
Associated with anemia, fetor hepaticus may be associated with liver disease For ostorized feeding Yellowish discolorations signifies liver disease,

Nose Upper Extremities Skin

with NGT Varies from light to Jaundiced and warm deep brown, from to touch in both ruddy pink to light extremities, pink, from yellow over tones to olive. Smooth coordinated movements No visible vascular pattern Flapping of both hands, Noted visible veins, tense and glistening

Muscles Hand Abdomen Inspection

Asterexis early sign of hepatic encephalopathy Visible veins pattern is associated with liver disease,tense glistening may indicate ascites and edema

Silver white striae

Presence of purplish striae

Purplish striae or spider Angiomas associated with liver disease

Auscultation

Audible bowel sound

Abdominal girth 103cm high pitch,loud, rushing sounds

Hyperactive sound associated with the use of laxatives.

Percussion

Dullness is only in full bladder and at the liver and spleen area

Dullness at the entire part

Large dull area associated with presence of fluid

Palpation

No tenderness

Reported rebound tenderness when palpation

Indicate peritoneal inflammation

Elimination Urine

Amber or clear and aromatic, amounting to 30cc per hour No deformities no swelling All five toes bend downward

Lower extremities Legs Plantar Reflex

Cola colored, amounting to 400500 drained every 8 hours, with foul odor Noted grade 3 bipedal edema All five toes spread outward and the big toes moves upward Capillary refill delayed at 6 sec.

Indication of bilirubin excretion

Indication of fluid retention Associated with neurologic function

Toenails

Prompt return of pink or usual color general less than 4 seconds 14-15 normal

May indicate circulatory impairment

Glasgow Coma Scale

GCS =12-13

Near normal, with disoriented to time and date

GORDONS FUNCTIONAL HEALTH PATTERNS

HEALTH PATTERN NUTRITIONAL PATTERN PATIENT PARAMETERS Parameters: Eating habits, appraisal of appetite, weight loss or gain change in skin, hair or nails. Observation: Tone,texture,coloring of skin and mucus membrane, proportion of height and weight texture of hair, condition of scalp, nails gums and teeth. PATIENT DATA

ANATOMY

PATHOPHYSIOLOGY OF HEPATIC ENCEPHALOPATHY

GI Tract Produces AMMONIA Ammonia Enters Portal Circulation

Unable to Metabolized by Liver

Increase AMMONIA

Enters the Brain

Excites Peripheral Benzodiazepine Type Receptors

Neuro Steroid Synthesis

Stimulates GABA Neurotransmitters

Depression of CNS

Ammonia Inhibits Transmission & Synaptic Regulation

S/Sx:
Mental Changes Motor Disturbance Alteration in Mood & Sleep Restlessness & Insomnia @ Night Difficulty to Awaken at Day Disoriented to Time & Date

Progress

Complication:

DEATH

Generalized Jaundice Ascites Peripheral Edema Plantar Reflex- Abnormal Asterixis Fetor Hepaticus (breathe)

PATHOPHYSIOLOGY OF LIVER CIRRHOSIS

Risk Factor:
Modifiable: *Alcohol consumption *chemicals * Malnutrition * Bacterial Dse. Non-modifiable *Gender: Men>Women *Age: 40-60 to 63 y/o

Destroy Liver Cells

Replace by Scar Tissue

Liver is contracting

Hobnail Liver Appearance

Obstruction of Hepatic Portal Vessel Occurs because Blood Not Allow Circulation Freely

Glucoromide Conjugation

Pressure of Hepatic Portal Vessel

Damming of blood in GIT

No Conversion of B2 B1

Venous Congestion

Accumulation of Fluid in Peritoneal Cavity

B2

Edema

Ascites

S/sx: Weakness, Fatigue

COMPLICATION: Hepatic Encephalopathy

MEDICATION
Drugs Action Indication Side Effect Nursing Implication

Brand Name: aminoleban Generic Name

An enteral formula containing amino acids, carbohydrates, fats, vitamins and minerals as a dietary

Nutritional supplement for patient with chronic liver impairment.

occasional nausea and vomiting, hypersensitivity reactions, occasional fever, chills,

>Assess patients condition before starting the therapy. >Be alert to adverse reactions. >Monitor patient temperature. >If GI reaction occur monitor patient hydration.

Contraindication: headache and severe renal disorder, abnormal amino acid metabolism and other than hepatic disorder. vascular pain

Classification: supplement parenteral nutrition especially for patients with liver impairment.

Drugs Brand Name: kalium Durule Generic Name: Potassium Chloride Classification: electrolyte

Action Replacement of potassium and maintain potassium level.

Indication Prevention and correction of potassium deficiency

Side Effect Rash, vomiting, diarrhea, hyperkalemia

Nursing Implication >Take drugs with meals or with food and a full glass of water to decrease GI upset. >Do not chew or crush tablets, swallow tablets whole

Contraindication : patient with oliguria, GI disorders, hyperkalemia, heat cramps

>You may find wax matrix capsules in the stool. It is not absorbed in the GI tract. >Report tingling of the hands and feet, unusual tiredness or weakness, feeling of heaviness in the legs, severe nausea, vomiting, abdominal pain, black or tarry stools, pain at IV injection site.

Drugs Brand Name: ursofalk Generic Name: Ursodeoxycholic acid

Action Alters composition of bile, increasing concentrations of itself and decreasing amounts of toxic bile acids. It also increases

Indication Used in the treatment of chronic liver disease in which the flow of the bile has stopped for some reason Contraindication Acute inflammation of the gall bladder or biliary tract. Hypersensitivity to bile acids or any excipient of the formulation

Side Effect Diarrhea, allergic reactions, nausea and vomiting, sleep disturbance

Nursing Implication >Administer with food to increase drug dissolution. >If patient inadvertently takes too much, diarrhea will most likely result and may warrant systemic treatment.

Classification: Naturally occurring bile acid. Bile salt replinisher

bile flow

Drugs Brand Name: tazidime Generic Name: ceftazidime

Action Use to treat against a broad range of gram (- ,+) bacteria It inhibits synthesis of bacterial cell

Indication Cns infection

Side Effect Urticaria, kidney damage, loss of liver function

Nursing Implication >Assess for liver and renal dysfunction >Culture infection >Have vit. K available in hypoprothrombinemia

Contraindica tion: Contraindicated to patient with allergies to penicillins, cephalosphorin

occurs >Discontinue if hypersensitivity occurs

Classification: Antibiotic 3
rd

wall, causing cell death

gen

cephalosphorin

Drugs Brand Name: Duphalac Generic Name: lactulose

Action Inhibits bacterial DNA gyrase thus preventing replication in susceptible bacteria.

Indication Used to reduce the amount of ammonia in the blood of patient with liver disease. It works by drawing ammonia form the blood into the colon where it is removed from the body

Side Effect Diarrhea, gas, nausea Stop and report: stomach pain or cramps and vomiting

Nursing Implication >Assess condition before therapy and reassess regularly thereafter to monitor drug effectiveness >Monitor pt. for any adverse reactions >Regularly assess mental condition >Monitor I&O

Classification: Gastrointestinal agent Hyperosmotic laxative

Contraindication: Patient who require a low lactose diet

Drugs Brand Name: Acifre, omepron Generic Name: omeprazole

Action It inhibits transport of hydrogen ions into gastric lumen also it increases the gastric ph and

Indication Treatment of gastric ulcer In combination with appropriate antibiotics

Side Effect Headache, dizziness, diarrhea, abdominal pain, nausea and vomiting, URI infection, back pain, rash, cough

Nursing Implication >Give before meals >Do not crush or chew tablet, swallow whole >Evaluate for therapeutic response like relief of GI symptoms >Report headache

Classifigastic: Gastric acid pump inhibitor

reduces gastric acid formation Contraindication: Known hypersensitivity with omeprazole

LABORATORY
February 12,2012 Result Leukocytes Erythrocyte 16.88 3.35 Remarks High Low Normal Values 5.0-10.0 M-4.6-6.2 Interpretation Infection Abnormal loss of RBC

Hemoglobin Hematocrit Thrombocyte Neutrophil Lymphocyte

9.9 29.00 227 87.800 4.500

Low Low Low High Low

M-12.0-17.0 40.0-54.0 M-150-450 50.00-70.00 20.0-40.0

Anemia Anemia

Infection Use of corticosteroid and other immunosuppressive drugs.

Monocyte Eosinophil

5.800 1.400 Result Remarks

0.0-7.0 0.00-5.000 Normal Values 0.000-1.000 High 11-14 Liver disease; damage, Vitamin k deficiency, obstruction of bile duct. Interpretation

Basophil PT patient

0.500 27.2

PT control BUN

12.5 95 mg/dl

High High

11-14 9-20 Renal impairment is detected by an increase in both BUN and cretinine

Creatinine SGOT(AST) SGPT(ALT)

8.04 mg/dl 776. U/L 199. U/L Result

High High High Remarks High High

0.66-1.25 17-59 21-72 Normal Values 0.2-1.3 0-0.4 0-1.1 Interpretation Jaundice Jaundice Liver cell damge

Total Bilirubin Direct Bilirubin Indirect Bilirubin ammonia Alkaline phosphatase HBSAg Albumin

42 mg/dl 41.5 mg/dl 0.5 mg/dl 62 Umol/L 418.00 Non-reactive 2.6 mg/dl Result

high High

9-30 100.00-290.00 IU/L

Liver disease Liver disease

low Remarks Low Low Remarks

1.5-2.5 Normal Values 11-14 70-130 Normal Values

Edema Interpretation

PT INR PT Activity

2.68 20 Result

Interpretation

sodium Potassium

129 mmol/L 3.3 mmol/L

Low Low

137-145 3.5-1.5

Hyponatremia Hypokalemia

ABG RESULTS
Result Remarks Normal Values Interpretation

Ph

7.34

Low

7.35-7.45

Acidosis

PCO2

26 mmhg

High

22-26

Normal

PO2

100 mmhg

High

80-100

normal

HCO3

15 mmol/L

low

35-35

Acidosis

***Metabolic Acidosis.

NURSING CARE PLAN

ASSESSMENT Subjective: pumapayat na ako as verbalized by the patient. Objective: Weight on admission = 63kg. Weight upon assessment = 59kg. DIAGNOSIS Imbalanced nutrition: Less body requirements r/t inability to as manifested by loss of weight Long Term: After 4 days of nursing intervention, the patient will be free from signs of malnutrition . Auscultate bowel sounds. No characteristics of stool (color, amount, & frequency). Determine psychological factors/perform psychological assessment. PLANNING Short Term: After 24 hours of nursing intervention, the patient will display laboratory values. INTERVENTION Independent: Discuss eating habit, including food preferences and intolerances. Assess disease effects and use of laxatives. That may be affecting appetite, food intake or absorption. To assess body image and congruency with reality. Long Term: After 4 days of nursing intervention, the goal was partially met, patient is not totally free from signs of malnutrition. To appeal to clients likes and dislikes. Short Term: After 24 hours of nursing intervention, goal was partially met; the patient display laboratory results close within the normal values. RATIONALE EVALUATION

absorb nutrients normalization of

Review indicative laboratory data including liver functions and electrolytes. Note age, body

Helps determine nutritional needs

build, strength, activity/rest level. >Promote pleasant and relaxing environment. >Develop stress reduction teaching. >Weigh regularly. Dependent: >Administer drug as ordered (amminoleban) >Assist in treating underlying causative factors including malabsorption. Collaborative: >Consult dietician To enhance intake. To monitor effectiveness of efforts. Implement interdisciplinary team management.

ASSESSMENT Objective: -Peripheral Edema -(+3) Bipedal Edema -ascites -Takes 2 3 L/day of liquids (Prior to admission)

DIAGNOSIS Fluid Volume Excess related to excessive fluid intake as evidenced by (+3) bipedal edema and ascites

PLANNING Short Term Goal: >After 2 hours of nursing interventions, the patient will be able to verbalize or at least understand the dietary and fluid restrictions

INTERVENTION INDEPENDENT: >Record intake and output every 1 to 8 hours depending on res-ponse to interventions and on patient acuity

RATIONALE >Indicates effectiveness of treatment and adequacy of fluid

EVALUATION Short Term Goal: After 2 hours of nursing interventions, the patient was able to verbalized and understand the dietary and fluid restrictions. The goal was met.

Long Term Goal: After 8 hours of nursing interventions, the client will be able to have a balanced I & O, stable weight and free signs of edema

>Measure and record abdominal girth and weight daily >Elevate edematous extremities, change position frequently >Place in semi fowlers position, as appropriate

>Monitors change in ascites formation and accumulation >To reduce tissue pressure and risk of skin breakdown >To facilitate movement of diaphragm, thus improving respiratory effort

Long Term goal: After 8 hours of nursing interventions the client was able to had a balanced I & O, stable weight and free signs of edema. The goal was partially met.

>Explain rationale for sodium and fluid restrictions DEPENDENT: >Restrict sodium and fluid intake if prescribed >Administer diuretics, potassium and protein

>Promotes patients understanding of restriction and cooperation with it. >Minimizes formation of ascites and edema >Promotes

supplements as prescribed. COLLABORATIVE: >Assist with possible procedures, if indicated. >Consult a dietician, as needed

excretion of fluid through the kidneys and maintenance of normal fluid and electrolyte balance

DISCHARGE PLAN
Medicine:
Advise patient to take his medicine religiously. >Lactulose 30 cc, once a day. >Omeprazole 20mg/tab once a day and take this 30 minutes before meal. >Ceftazidime 500mg/tab twice a day (8am - 8pm) >Amminozelam 50g (1sachet) once a day.

Exercise:
>Encourage alternating periods of rest and ambulation. *Have at least 1 hr. ambulation in AM and 1 hr. in PM with specific time of 15-20 mins. Interval every ambulation and gradually increasing of hours every 3 days. >Maintain some periods of bed rest with legs elevated to mobilize edema and ascites.

Treatment:
>Ensure follow up and self-care. >Advise patient and family to monitor sign and symptoms and to follow the treatment regimen. >Ensure dietary restriction especially in food with high in protein and alcohol. > Provide written instruction

Health teaching /Hygiene:

>Stress the necessity of giving up alcohol completely. >Provide written dietary instruction. >Emphasize the importance of rest, a sensible lifestyle and adequate well balanced diet. >Encourage frequent skin care, bathing, and massage with emollient lotions. >Advice patient to keep fingernails short. >Encourage oral hygiene before meals.

Others Patient referral:

>Emphasize importance of follow-up check-up after 1 week. Diet: >Encourage patient to eat high calorie, moderate protein meals and to have supplementary feedings. >Suggest small frequent feedings and attractive meals in an aesthetically pleasing setting at meal time.

Spiritual:
>Emphasize the importance of having a strong faith with God. >Advise relatives or significant others to provide a moral support. >Emphasize the positive effect of prayer.