1

Table of Contents

Introduction

Biographical DataHealth History

Past

Present

Functional Health Patterns

Genogram

Psychopathophysiology

Physical Assessment and Review of System

Normal Anatomy …

Diagnostic and Laboratory Results

Pharmacotherapy

Prognosis

Bibliography
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Introduction

Cirrhosis is a condition in which the liver slowly deteriorates and malfunctions

due to chronic injury. Scar tissue replaces healthy liver tissue, partially blocking the flow

of blood through the liver. Scarring also impairs the liver’s ability to control infections;

remove bacteria and toxins from the blood process; nutrients, hormones, and drugs make

proteins that regulate blood clotting; and produce bile to help absorb fats—including

cholesterol—and fat-soluble vitamins.

A healthy liver is able to regenerate most of its own cells when they become

damaged. With end-stage cirrhosis, the liver can no longer effectively replace damaged

cells. A healthy liver is necessary for survival.

Many people with cirrhosis have no symptoms in the early stages of the disease.

As the disease progresses, symptoms may include weakness, fatigue, loss of appetite,

nausea, vomiting, weight loss, abdominal pain and bloating, itching, and spiderlike blood

vessels on the skin.

Liver cirrhosis was the 12th leading cause of death in the United States in the year

2001, accounting for roughly 27,000 deaths, according to the Centers for Disease Control

and Prevention. More than half of those deaths may be related to alcohol use and/or

abuse, according to the National Institute on Alcohol Abuse and Alcoholism. Clearly

drinking can be harmful to the liver; moreover, a study in the June 2004 issue of

Alcoholism: Clinical and Experimental Research has found that drinking patterns may

also contribute to liver damage, and this effect may vary by gender.Cirrhosis has various

causes. In the United States, heavy alcohol consumption and chronic hepatitis C have
 3

been the most common causes of cirrhosis. Obesity is becoming a common cause of

cirrhosis, either as the sole cause or in combination with alcohol, hepatitis C, or both.

Many people with cirrhosis have more than one cause of liver damage.

Treatment for cirrhosis depends on the cause of the disease and whether

complications are present. The goals of treatment are to slow the progression of scar

tissue in the liver and prevent or treat the complications of the disease. Hospitalization

may be necessary for cirrhosis with complications.

 4

Biographical Data

Name: “Boy Bungot”

Room #: Male Ward 6

Age: 42 years old

Civil Status: Married

Occupation: Farmer

Address: P-5 Kianggat Dangcagan 8719 Bukidnon

Birthday: March 24, 1967

Sex: Male

Weight: 60.5 kg

Height: 5’5”

Nationality: Filipino

Religious Affiliation: Roman Catholic

Highest Educational attainment: 2nd year High school

Usual health care provider: Health Center

Date of confinement: February 01, 2010

Source of history information: Patient and patient’s wife, chart

Attending Physician: Dr. Chuvaness

Chief Complaints: Jaundice

Impression/ Diagnosis: R/I Liver Cirrhosis, Colelithiasis

 5

Health History

Past History

Patient is not allergic to dust, foods and contact with any substances. He did not

experience childhood illnesses except for mild fever and headaches. He said he had not

experienced measles, chicken pox and other illnesses.

He started drinking alcohol when he was still in his elementary years, particularly

Grade 5 at the age of 12. He verbalized, he could consume 2 bottles of tuba for every

session, usually when he gets his allowance for school (this is occasional). As verbalized

by patient, he received complete immunization but forgot the types of vaccines.

1980, he met an accident which caused dislocation to his wrist bone. Since one of

his relative is a quack doctor, he was treated with banana trunk that is used as a splint for

his wrist. He was not hospitalized this time.

1982, he stop schooling because of financial constraints and due to the fact that he

always cut classes because he would go out to drink with his friends.

On the year 1985, they transferred their residence from rural to urban area. This

time, instead of drinking tuba, he changed to Tanduay. He can consume 2 bottles of long

neck for 3 sessions per week with his 3 friends. This time, he works as a driver of a

motorcycle. Every time he has extra money, he would buy alcohol and drink with his

friends.

1990-1992, He stopped from driving and became a security guard. Every time he

gets his salary, he would go out with his friends and drink. Despite of this, he did not

experienced sickness except from hang over.

 6

1997, He start farming and stopped from his work as a security guard. Every day

he always feels tired because of work. Every time he feels tired, he took Alaxan 1 tab.

2000, he often times experienced headache, backache and hang over during the

day from his nightly session of drinking with his friends and sometimes fever and cough.

He said he would just take OTC like Biogesic, Lincocin, and Alaxan whenever he felt

pain and weakness. He said that he would rather take those medications than going to the

hospital for admission because the medications only cost 7 pesos.

At 2005-2007, he did not have any sickness as claimed by patient. He cannot

remember if he had any illness this time but was sure he was not hospitalized.

February 12, 2007, he met another motor accident which caused minor laceration

on his upper lips. He was brought to Kibawe Hospital and his wound was sutured. He still

did not go for admission.

April, 2008, patient had night alcohol session. The next day, he went to the farm

without his breakfast and he collapse with duration of 10 minutes only. He said he was

dizzy that time and his head is aching and believe he was “hang over” from that night

session. After that incident, his wife did not allow him to go to the farm again.

September 25, 2008, patient experienced pain in urination with scanty amount.

Temp- taken PCM. Not relieved. Epigastric pain and feeling of fullness. This prompted

him to go for check-up at Kibawe Hospital and was diagnosed of UTI. He did not want to

be admitted so he was prescribed by the doctor these medications: Sambong 3x a day,

Cotrimoxazole 2x, taken for 1 week. Aside from UTI, he was also diagnosed of Liver

Cirrhosis through ultrasound. His doctor wanted to let him stay at the hospital so that he

can be observed for further signs & symptoms but he refused. The doctor prescribed him

essentiale forte, Multivitamins, Aluminum chuvah, and antibiotics. Advised to reduce

 7

alcohol consumption and increased fluid intake. Wala siya nisunod sa doctor kay feeling

niya ok ra siya.

September 1, 2009, his son met an accident which caused him so many problems

especially about financial reasons. This time he always drinks alcohol to forget his

problems. According to him, he could consume 2-3 long neck of Tanduay every day. His

wife said he will get wild whenever she will not give him money to buy alcohol.

Present History

January 19, 2010, patient noticed yellowish discoloration of the skin but he did

not mind it. 2 days after, he noticed that his lower extremities were becoming edematous

and according to his wife, it’s not that severe. His wife wanted to bring him to the

hospital but he refused because he said he can still manage himself. He did not do

anything to manage the condition of his skin. He thought it will just be relieved. After a

week, on the 26th day of January, he experienced having itchiness any part of his body.

He said he only applied ointment to manage the itchiness. It was relieved but only for a

short time then the itchiness would again occur. So every time he feels itchy, he would

apply ointment. On the 28th, he noticed his eyes were becoming yellowish but still he did

not mind it. 31st of January, he said he had eaten pork for lunch. He said he consumed a

lot of it. At around 4 o’clock, he experienced localized, dull epigastric pain at right upper

quadrant with a scale of 6/10. This was not relieved even through defecation or positional

changes. His wife let him drunk rice water or “lawot” to lessen his epigastric pain but

still this was not relieve. This time he cannot sleep because of pain even his wife applied

ointment on his abdomen. The next morning, his pain increases to 8/10 associated with
 8

shortness of breath. According to his wife, he was so restless and his wife encouraged

him to go to the hospital. At around 10 am, his pain increases to 10/10 that he said he

could not bear it any more. This prompted him to go to Maramag Bukidnon Provincial

Hospital for proper management. At the ER, he was examined by a doctor with orders of

full low-fat diet and requested diagnostic test such as CBC, U/A, Creatinine, SGPT,

ultrasound, HBSAg, and CXR-PA. His vital signs in the ER revealed: BP-120/80 mmHg,

RR- 22 cpm, HR- 75 bpm, T- 36.2°C, Weight-60.5 kg. IVF was inserted D5LR 1L @ 20

gtts/min and was given the following medications: Metronidazole 500 mg IVTT q 8h;

Ceftazidine 1gm IVTT q 12h; essentiale forte 1 cap TID; Omeprazole 40g OD;

Spinorolactone 500g 1 tab OD; Lactulose 10 cc TID.

During the week’s duty, patient had LBM with 4 episodes of Bowel Movement

every day for 2 days which consists of watery stool in moderate amount.
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FUNCTIONAL HEALTH PATTERN

Health Perception – Health Management

The patient usually described his health as good but since he is on the hospital as

of now he described his health as fair. For his daily practices he would usually brush his

teeth three times a day, however, when he would get drunk he would forget to do this. He

drinks 3-4 glasses of water a day only but he drinks a lot of alcohol. Patient verbalized

that every time he gets his salary, everyday he would buy one long neck of Tanduay a

day for four days consecutively. For his leisure activities, he would just watch and

hangout with his friends and drinks alcohol with them. Also, he would visit his mother’s

house and his siblings to chitchat with them and he takes nap every afternoon. His work

already served as his exercise for him going to the farm every morning to pick some

weeds and taking care of the animals such as cow, chicken and pig. He works under the

sun from six to nine in the morning and four to six in the afternoon wearing only a bonnet

as his sun protection. The patient does not smoke cigarettes nor take any illegal drugs.

However, he is alcoholic since grade five in elementary up to the present before he would

start to feel sick. Their knowledge of safety practices was that they didn’t have fire

protection in their house but they are aware that in case of fire they would have to turn off

their shellane and pour water on the ceiling. Their water is from a manual water pump.

The patient owns a motorcycle and wears a helmet every time he rode on it. Moreover,

they also have a poison control. They kept it in a place where there children could not

reach it.

Furthermore, for the patient’s family history, the cause of death of his

grandparents were hypertension. His mother has lung problem and is also hypertensive.
 10

In regards to his father, he does not know due to the fact that his father has many siblings,

he could no longer recall it. For his siblings, his older brother has hepatitis A and also

suffered UTI. His sister died because of fatigue as what the patient verbalized. As for

their health practices, he verbalized that they don’t have health practices as long as their

family have something to eat, and able to feed their children. However, their children

have completed their immunization when his children were young.

For patient’s health perception especially regarding his health right now, he was

aware now of his problem and expects to be able to recover from it. He hoped that

throughout his hospitalization they would be able to help him recover from his illness.

Nutritional – Metabolic Health

Patient’s usual food intake is meat especially beef and pork. Usually he took four

spoonful of his meal only as what he described. He only eats breakfast and throughout

that day he would drink alcohol and get drunk. His usual fluid intake were 3-4 glasses a

day of water and the rest were alcohol and that’s usually one long neck a day and so on

with the following day. He never experienced indigestion or anything. He has no food

restriction. The only thing he does not like to eat was fish and when asked he simply

verbalized that he just don’t like it. For the last six months, he weight has changed when

illness started. He doesn’t have any problems with his ability to eat. It was just he drinks

a lot of alcohol than eating his meals.

Elimination

Two years ago, patient experienced dysuria and oliguria because of UTI.

Normally he would urinate more or less four times a day. Also, he has no problem in

defecation. He defecates twice a day.

Activity – Exercise
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His usual activities of daily living were to go to his farm at 6-9 in the morning to

work there and take care of the animals and continued his work at 4-6 in the afternoon.

Going to the farm and working there already served as his exercise. There was no

limitation in his activity. He can do everything when he was still healthy, however, when

he started to not feeling well, he stopped working at the farm and just stayed home and

took a nap. Also, he visits his siblings place and his mother’s place in his leisure time.

Sometimes, he goes to his friends and drink alcohol but that only happens once a month

and every 15 days they sold rubbers and the money they get from that he would buy four

bottles of long neck and can consume one long neck a day. Aside from that, every three

months after harvesting coconut, the money they earned from it, he would buy four

bottles of long neck alcohol and only him will drink one a long neck a day.

Sleep – Rest

Patient verbalized that his usual sleep pattern was, he sleeps after PBB show and

wakes up at around 5 in the morning. He does not use any drugs to aid him with his

sleeping. No problems in falling asleep whatsoever.

Cognitive – Perceptual

No problems in his sensory perception except that he has troubles reading small

letters. He verbalized that he is near – sighted and when asked if he wears eye glasses he

stated that he does not have one. Furthermore, he has no problems with his hearing. He

can hear well as well as he can read and write. Also, two years ago, he collapsed due to

being drunk.

Self – perception
 12

Patient’s most concern right now is his health. He verbalized that no matter what

happen he would give up drinking and eating pork as long as his health will recover. That

is his present goal.

Role Relationship

They speak Bisaya at home. His wife and he would always argue on his alcohol

intake. He lives together with is wife and his children. Both his wife and him does the

decision making and in disciplining their children. However, he had fights with is

relatives concerning the land they own. He was not afraid of anyone but he verbalized

that the only thing he was afraid of was “wakwak”.

Sexuality

He verbalized that before he got sick he was sexually active but he started to have

the illness he was no longer active. He verbalized also that in the middle of the night he

would try to stimulate his wife even though his penis would no longer erect.

Coping Stress Management

His coping management was drinking alcohol. There was some instances where

one of his children got in to a motor accident and due to some problems regarding the

hospital expenses, his coping was still to drink alcohol so that he can forget and take his

mind off from his problems.

Value – Belief System

He believes in God and through God he can find strength in Him.

 PATERNAL MATERNAL

”Nerbyo
Alcoholi
s”
c
Deceas Fatigu
ed
Hypertensi Smok
48 42 33 31
Lung
disease Patien
Liver UTI
cirrhosis
 Laboratory and Diagnostic Test Results

Ultrasound

The liver is enlarged and exhibit tissue alteration. The intrahepatic ducts are not

dilated. No focal lesions noted.

The gallbladder is normal in size and configuration. There are multiple tiny

echogenic foci seen within its lumen. No wall thickening.

The pancreas and extrahepatic ducts are obscured. No focal lesions noted here.

No enlarged lymph nodes or mass appreciated in the vicinity of the abdominal

aorta.

The spleen is enlarged. Splenic index in 1,777 cm3. No focal lesions noted.

Splenic hilum is unremarkable.

Both kidneys exhibit hypoechoic parenchyma relative to the liver and spleen. The

central echocomplexes are normal. The pelvocalyceal system and ureters are not dilated.

No focal lesions and calculi appreciated.

The urinary bladder is adequately filled showing regular contour and smooth

walls. No abnormal echoes or calculi no intraluminally.

The prostate gland is enlarged having an approximate weight of 22 grams. Few

calcifications appreciated here.

Impressions:

Liver Cirrhosis

Hepatospleenomegaly

Microcholecystolithiasis

Obscured extrahepatic ducts and pancreas

Prostate gland enlargement grade I by ultrasound criteria with concretions

 No free intraperitoneal fluid demonstrated

Sonographically normal intrahepatic ducts, kidneys, and urinary bladder

Urinalysis

Color: yellow Ketones: (++)

Transparency: hazy Specific Gravity: 1.015

Reaction: 6.5 Sugar: Negative

Albumin: negative

Pus Cells: 10-15

RBCs: 0-3

Diagnostic Normal Values Result Interpretation

February 01, 2010
Hemoglobin 13-18 gm 9.0 Anemia & fluid retention
Hematocrit 42-51 vol % 29 Anemia & hemodilutions
White Blood Cells 5,000-10,000/cumm 18,400 Infection
Platelet Count 150,000-450,000 324,000 Normal
Segmenters 56-65 78
Lymphocytes 25-35 22
Alkaline Phosphate 80-308 u/l 19.9 Protein deficiency
SGOT (ASAT) Up to 37 u/l 80.0 Hemolytic anemia,
metastasis hepatic tumors,
alcohol withdrawal
syndrome, fatty liver
SGPT (ALAT) Up to 42 u/l 48 Acute hepatocellular injury
Pharmacotherapy

Brand name: Flagyl

Generic name: Metronidazole

General action: Antiprotozoal, Antibacterial, amebicide

Indication:

Treatment for amebic hepatic abcess, also for trichomoniasis and bacterial infections

caused by anaerobic microorganism.

Mechanism of action:

Chemical Effect: Direct-acting trichomonacide and amebecide that works at both

intestinal and extraintestinal sites.

Therapeutic Effect: Hinders the growth of selected organisms, including most anaerobic

bacteria and protozoa.

Contraindication:

Contraindicated with hypersensitivity, hepatic disease and candidiasis.

Adverse Reaction:

CNS: headache, dizziness, insomnia, anxiety

G.I: unpleasant metallic taste, nausea, vomiting, diarrhea

G.U: dysuria, incontinence, darkening of the urine

Adverse Reactions:

Convulsive seizure; peripheral neuropathy; rash; pruritus. GI discomfort, anorexia,

nausea and furred tounge, dry mouth, and unpleasant metallic taste, headache, less

frequently vomiting, diarrhea, weakness, dizziness and darkening of the urine.

Leucopenia, peripheral neuropathy, skin irritation, burning sensation.

Drug- drug Interaction:

Decrease effectiveness with barbiturates. Psychosis happen if taken with disulfiram also

increases bleeding tendencies with oral anticoagulant.

Route/dosage

750 mg/TID p.o for 5-10 days

Nursing consideration:

➢ Take full course of drug with food if G.I upset occurs.

 ➢ Do not drink alcohol severe reaction may occur.

➢ Urine may be darker in color than usual and this is expected.

➢ You may experience this side effects: dry mouth with metallic taste, nausea and

vomiting, diarrhea.

➢ Report severe G.I upset, dizziness, unusual fatigue or weakness, fever and chills.

[Gilliam, S. 2006. Nurses Drug Guide. LWW: Philadelphia. 7th ed. pp.853-855]

[2008. PPD’s Nursing Drug Guide 2nd ed. Malan Press: Philippines. pp.144-145]

[Karch, A.2005. Nursing Drug Guide. LWW: Philadelphia. pp. 796-797]

Brand Name: Prilosec

Generic Name: Omeprazole

General Action: Antisecretory agent, Proton pump inhibitor

Indication: For active duodenal ulcer. First line treatment for heartburn or GERD .Also

for gastric ulcer.

Mechanism of action:

Gastric acid pump inhibitor: suppresses gastric acid secretion by specific inhibition of the

hydrogen-potassium ATPase enzyme system at the secretory surface at the gastic parietal

cells; blocks the final step of acid production

Contraindication:

>Hypersensitivity

Drug-drug interaction:
Increase serum levels and potential increase in toxicity of benzodiazepines; if this

combination are used, monitor pt. very closely.

Adverse Reaction:

CNS: headache, dizziness, insomnia, anxiety

Derma: rashes, inflammation, urticaria, pruritus, dry skin.

G.I: diarrhea, abdominal pain, constipation, dry mouth, tounge atrophy.

Resp: cough and epistaxis

Nursing Consideration:

➢ Take the drug before meals. Do not chew or crush the tablet.

➢ Have regular medical check-up

➢ Report severe headache, worsening of symptoms, fevere and chills.

[Karch, A.2005. Nursing Drug Guide. LWW: Philadelphia. pp.897-898]

Brand Name: Lasix, Apo-furosemide

Generic Name: Furosemide

General Action: Loop diuretic

Indication: for edema associated with cirrhosis, hypertension and renal disease

Mechanism of Action: Inhibits the reabsorption of sodium and chloride from the

ascending limb of the loop of Henle leading to the sodium rich diuresis.

Contraindindication: Contraindicated with allergy to furosemide

Drug-drug Interaction: Increase the risk of cardiac arrhythmias with digitalis

glycosides, decrease absorption of furosimide with phenytoin

Adverse Reaction:
CNS: dizziness, vertigo, weakness, headache, drowsiness, tinnitus,

CV: orthostatic hypotension, thrombophlebitis, cardiac arrythmias

Derma: photosensitivity, pruritus, urticaria

G.I: nausea, anorexia, vomiting, constipation, diarrhea

G.U: polyuria, nocturia, glycosuria

Nursing Consideration:

➢ Take the drug early so increased urination will not disturb sleep.

➢ Take with food to prevent G.I upset.

➢ Weigh yourself on a regular basis at the same time same clothing.

➢ Report loss/gain of more than 3lbs. in one day.

[Karch, A.2005. Nursing Drug Guide. LWW: Philadelphia. pp. 557-558]

Brand Name: Aldactone

Generic Name: Spironolcatone

General Action: Potassium sparing aldosterone antagonist

Indication: Treatment for edema associated with hepatic cirrhosis, CHF, nephritis

syndrome also for hypokalemia

Mechanism of Action: Competitively blocks the effect of aldosterone in the renal tubule,

causing loss of sodium and water and retention of potassium.

Contraindication: Contraindicated with allergy to spironolactone, hyperkalemia and

renal disease

Drug-drug Interaction: Increase hyperkalemia with potassium supplements, ACE

inhibitors, diet in rich of potassium.

Adverse Reaction:
CNS: Dizziness, headache, drowsiness, fatigue, confusion

Derma: rash, urticaria,

G.I: prompting diarrhea, dry mouth, thirst, vomiting

G.U: impotence, irregular menses, amenorrhea

Nursing Consideration:

➢ Take the drug early so increased urination will not disturb sleep.

➢ Take with food to prevent G.I upset.

➢ Weigh yourself on a regular basis at the same time same clothing.

➢ Report loss/gain of more than 3lbs. in one day.

➢ Avoid foods that are rich in potassium

[Karch, A.2005. Nursing Drug Guide. LWW: Philadelphia. pp. 1093-1094]

Brand Name:

Generic Name: Essential Forte

General Action: Cholelitholytics and Hepatic Protector

Indication: For cirrhosis, acute or chronic hepatitis, necrosis of the liver cells

Mechanism of Action:

The active ingredients of the preparation are essential phospholipides. In normal

conditions the body synthesizes all the needed for the liver phospholipides and in cases of

liver impairment the function of the liver can be improved by adding to the diet such

substances. The deficiency of phospholipides leads to impairment of liver cell wall

function. The deficiency of phospholipides also leads to impairment of fat metabolism

and thus hepatic steatosis.

Essenciale works by improving the above mentioned effects, promotes cell membrane

regeneration, reactivates different enzyme systems and receptors, increases the

detoxification ability of the liver and through that mechanism normalizes liver function.

Contraindication:

• Hypersensitivity to any components of the preparation

• Newborns and prematurely born children

Drug-drug Interaction:

It is important to tell your doctor or pharmacist what medicines you are already taking,

including those bought without a prescription and herbal medicines, before you start

treatment with Essentiale. Similarly, check with your doctor or pharmacist before taking

any new medication while taking this one, to ensure that the combination is safe.

Adverse Reaction:

CNS:

CV:

Derma: Rashes

G.I: Diarrhea, Abdominal pain, nausea,

G.U:

Musculoskeletal:

Resp:

Brand Name: Ceptaz, Fortaz

Generic Name: Ceftazidime

General Action: Antibiotic (cephalosporin third generation)

Indication: Treatment for UTI, also for treatment of E.coli

Mechanism of Action: Bactericidal: Inhibits synthesis of bacterial cell wall, causing cell

death.

Contraindication: Contraindicated with allergy to cephalosporins or penicillin.

Drug-drug Interaction: Increased nephrotoxicity with aminoglycosides, increased

bleedings effects with oral anticoagulants.

Adverse Reaction:

CNS: Headache, dizziness, lethargy, paresthesias.

GI: Nausea, vomiting, diarrhea, anorexia, abdominal pain, flatulence,

GU: Nephrotoxicity.

Hematologic: Decreased WBC, decreased platelets, decreased hematocrit.

Nursing Consideration:

➢ Avoid alcohol while taking this drugs and for 3days after, because severe

reactions often occur.

➢ You may experience these side effects: Stomach upset or diarrhea.

➢ Report severe diarrhea, difficulty breathing, unusual tiredness or faigue, pain at

injection site.

[Karch, A. 2005. Nursing Drug Guide. LWW: Philadelphia. pp. 256-257]

Nursing Diagnosis: Imbalance Nutrition: Less than body requirements r/t abdominal distention & discomfort, anorexia
NANDA: Intake of nutrients insufficient to meet the metabolic needs
Cause Analysis: Nutritional status can be affected by disease or injury states; physical factors; social factors; or psychological factors.
-Gulanick & Myers. Nursing Care Plans:Nursing Diagnosis & Interventions 6th Ed. (2007) p. 134-135
Assessment NIC with Intervention Rationale Outcome Expected
NIC: Nutrition Therapy NOC: Nutritional Status
Subjective: ASSESSMENT:
-reports of weight loss from -Weighed daily. Instruct to -Weight is a good indicator of UNMET As Evidenced By
60kg to 58kg weigh @ least weekly @ home both nutritional status & fluid -no weight gain
-reports feeling of fullness balance. Short-termed weight
-verbalized anorexia fluctuations tend to reflect fluid
balance, while longer term
changes in weight one more
Objective: reflective of nutritional status.
-weight (Lemone NCP, p.723)
Feb. 2, 2010 -Assessed dietary intake & -Identifies deficits in nutritional
-60kgs. nutritional status through diet intake & adequacy of
Feb. 3, 2010 hx & diary & laboratory data nutritional state. (Smeltzer,
-58kgs. p.1323)
-poor skin turgor COMFORT MEASURES:
-decreased skin mobility -Encouraged in between snacks -A small meal is more
-scaly skin appealing. Between meal
- dry cracked lips snacks help maintain adequate
-bipedal pitting edema grade 2 calorie & nutrient intake.
present (Lemone, NCP p.323)
-jaundice (+) sclerae, skin
-ascites (+) -Provided diet high in -Provides calorie for energy
Abdominal girth: carbohydrates with protein sparing protein for healing
Feb. 2, 2010 intake consistent with liver
-39 inches function.
Feb. 3, 2010
-38 inches -Elevated head of bed during -Reduces discomfort from
meals/place on comfortable abdominal distention &
position decreased sense of fullness
produced by pressure of

-Provided oral hygiene before
meals. Pleasant environment
for meals @ meal time
-Offered small more frequent
meals 6x a day
-Provided attractive meals & an
aesthetically pleasing setting at
meal time
-Sodium intake is restricted to
under 2g/day, and fluids are
restricted as necessary to
reduce ascites and generalized
edema.
-Unless serum ammonia levels
are high, a palatable diet with
adequate calories and protein is
recommended. If hepatic
encephalopathy is acute,
protein may initially be
eliminated generally is
restricted to 60g/day.
TEACHINGS:
-Assisted patient in identifying
low-sodium foods
abdominal contents & ascites
on the stomach. (Smeltzer, Med
Surg.p.1323)
-Promotes positive
environment & increased
appetite, reduces unpleasant
taste. (Smeltzer, Med
Surg.p.1323)
-Decreases feeling of fullness,
bloating. (Smeltzer, Med
Surg.p.1323)
-Promotes appetite & sense of
well-being
-Fluids are often limited to
1500 ml/day. Fluid needs are
calculated based on response to
diuretic therapy, urine output,
and serum electrolyte values.
(Lemone and Burke, Medical
Surgical p.717)
-When encephalopathy resolves
and serum ammonia levels
stabilize, protein intake is
allowed as tolerated. The diet is
high in calories and includes
moderate fat intake to promote
healing. (Lemone and Burke,
Medical Surgical p.717)
-Reduces edema & ascites
 -Taught to eliminate alcohol formation. (Smelter, Med
Surg.1323)

-Eliminates “empty calories”

and further damage from
alcohol. (Smeltzer, Med
Surg.p.1324)
Care Plan Evaluation: The care plan needs more time to meet the goal of the intervention.
Nursing Diagnosis: Ineffective Breathing Pattern r/t increase intra-abdominal pressure on the diaphragm & reduced lung capacity 2⁰
Ascites
NANDA: Inspiration and or expiration that does not provide adequate ventilation
Cause Analysis: Ascites is the accumulation of fluid in the peritoneal cavity. Thus, causing pressure to the diaphragm that would
eventually restrict lung expansions interfering with efficient gas exchange & leading to hypoxia. –Lemone, p.562-
Assessment NIC with Intervention Rationale Outcome Expected
NIC: Airway Management NOC: Respiratory Status
Subjective: ASSESSMENT: ventilation
-reports of dyspnea & SOB -Monitored respiratory status -Ascites may cause pressure &
especially when on supine for changes in rate & depth, use increase the effort of breathing. -Partially met AEB:
position & is alleviated when pt of accessory muscles, & Depending on the severity &
is on sitting or fowler’s position increased work of breathing, amount of ascetic fluid, the depth Experiences improved
nasal flaring, & symmetric of the respirations may vary, & respiratory status
-reports of abdominal pain expansion chest expansion may be decreased
P-upon movement (Comer, S (2005) Delmar’s Still reports of minimal
Q-dull Critical Care Nursing Care plans, dyspnea
R-non radiating 2nd Ed. Thomson Delmar
S-6/10 Learning: Singapore, p.223) Exhibits normal respiratory
T-intermittent rate with no adventitious
-Monitored for presence of -Liver failure may result in sounds
Objective: cough and character of sputum abnormal coagulation, which in
-RR turn can result in bloody Exhibits full thoracic
Feb. 1, 2010 secretions. Atelectasis from excursion without shallow
- 2 am-26 cpm, decreased chest excursion may respiration
- 6 am-31 cpm, occur & result in infection
Feb. 2, 2010 (Comer, S (2005) Delmar’s Experiences absences of
nd
- 10 pm-30 cpm, Critical Care Plans, 2 Ed. confusion or cyanosis
- 2 am-34 cpm, Thomson Delmar Learning:
- 6 am-30 cpm, Singapore, p.224)
Feb 3, 2010
- 10 pm-29 cpm, - Auscultated lung fields for -Breath sounds may be decreased
- 2 am-30 cpm.) adventitious breath sounds or because of decreased chest
-use of accessory muscles rubs expansion from increasing ascites
-nasal flaring (Comer, S (2005) Delmar’s
-chest excursion=15cm Critical Care Plans, 2nd Ed.
-diaphragmatic excursion=5cm Thomson Delmar Learning:
-cough (-) Singapore, p. 224)
-clear breath sounds in all lung
fields -Assessed for thoracic or upper -These can result to shallow
-fluid wave (+) abdominal pain breathing (NCP by Gulanic, p.30)
-abdominal girth, ascites
present -Inquired about precipitating -Knowledge of this factors is
Feb. 2, 2010 and alleviating factors useful in planning interventions to
-39 inches prevent or manage future episodes
Feb. 3, 2010 of dyspnea (Gulanick,NCPp. 39)
-38 inches COMFORT MEASURES:
-shifting dullness (+) -Encouraged deep breathing & -Improves lung expansion &
-LOC pt is awake coughing exercises helps to remove secretions.
-oriented to time, person & (Comer, S (2005) Delmar’s
place Critical Care Plans, 2nd Ed.
Thomson Delmar Learning:
Singapore, p.224)
-Elevated head of bed to at -Reduces abdominal pressure on
least 30 degrees the diaphragm & permits fuller
thoracic excursion & lung
expansion. (Smeltzer, 1330)
-Conserved patient’s strength -Reduces metabolic & oxygen
by providing rest periods & requirements. (Smeltzer, Med
assisting with activities Surg. 1330)
-Used pain management like -This allows for pain relief & the
(divertional activities, guided ability to deep breathe. (Gulanick
imagery) as appropriate NCP, p.31)

TEACHINGS:
-Explained all procedures -This decreases patient’s anxiety.
before performing (Gulanick, NCP p. 31)

-Explained effects of wearing -Free movement of the chest wall

 restrictive clothing & abdomen is necessary for
optional breathing. (Gulanick,
-Taught pt. to pace activities & NCP p. 31)
to avoid unnecessary tasks -Energy conserving methods
when dyspneic reduces fatigue, dyspnea &
oxygen consumption.
(GulanickNCP, p. 31)
Care Plan Evaluation: Care Plan Evaluation: The care plan was effective because it enables the patient to verbalize his concerns on the
cause of the change in his appearance.
Nursing Diagnosis: Disturbed body image r/t changes in general appearance (Ascites, jaundice, peripheral edema)
NANDA: Confusion in mental picture of one’s physical self
Cause Analysis: Throughout the life span, body image changes as a matter of development, growth, maturation, changes related to
childbearing and pregnancy, changes that occur as a result of aging and changes that occur or are imposed as a result of injury or
illness.
-Gulanick & Myers. Nursing Care Plans:Nursing Diagnosis & Interventions 6th Ed. (2007) p. 21-
Assessment NIC with Intervention Rationale Outcome Expected
NIC: Body Image/Role NOC: Psychosocial
Subjective: Enhancement Adjustment: Life change
-Patient verbalized the changes
on his appearance especially ASSESSMENT:
the color of his eyes, and -Assessed changes in -Provides information for PARTIALLY MET As
presence of spider like blood appearance & the meaning assessing impact of changes in Evidenced By
vessels in the abdomen these changes have for patient appearance, sexual function, & -verbalized concerns related to
-Putting of lip gloss in the lips & family role on the patient & family. changes in appearance, life, and
(Smeltzer, p. 1327) lifestyle
Objective: -maintained good grooming
-weight -Assessed patient’s family’s -Permits encouragement of and hygiene
Feb. 2, 2010 previous coping strategies those coping strategies that are -verbalized that some of
-60 kgs. familiar to patient & have been previous lifestyle practices
Feb. 3, 2010 effective in the past. (Smeltzer, have been harmful
-58 kgs. p. 1327)
-ascites (+) COMFORT MEASURES:
Abdominal girth -Encouraged patient to -Enables patient to identify &
Feb. 2, 2010 verbalize reactions & feelings express concerns, encourages
-39 inches about these changes patient & significant others to
Feb. 3,2010 share these concerns.
-38 inches (Smeltzer, p. 1327)
-jaundice (+) – skin & sclerae
-bipedal pitting edema grade 2 -Assisted & encourage patient -Encourage patient to continue
present to maximize appearance & safe roles & functions while
-dry, cracked lips
-scaly skin
-poor skin turgor
-decreased skin mobility
- spider angioma present
Care Plan Evaluation: The care plan was effective because it enables the patient to verbalize his concerns on the cause of the change in
his appearance.
explore alternatives to previous
role function
-Assisted patient in identifying
short-term goals
-Encourage & assist patient in
decision making about care
-Identified with patient
resources to provide additional
support
encouraging exploration of
alternatives. (Smeltzer, p.
1327)
-Accomplishing these goals
serves as positive
reinforcement & increased self-
esteem. (Smeltzer, 1327)
-Promote patient’s control of
life & improves sense of well-
being & self-esteem. (Smeltzer,
p. 1327)
-Assist patient in identifying
resources & accepting
assistance from others when
indicated. (Smeltzer, p. 1327)
Nursing Diagnosis: Fluid Volume Excess: Third Space fluid shift r/t decreased production of albumin
NANDA: It is increased isotonic fluid retention
Cause Analysis: Cirrhosis of the liver impairs aldosterone metabolism & alters renal perfusion, leading to increase salt & water
retention.
–Porth p.866
Assessment NIC with Intervention Rationale Outcome Expected
Subjective: NIC: Fluid/Electrolyte NOC: Fluid Balance
-patient verbalized an increased Management
in the abdominal girth and PARTIALLY MET As
presence of fluid in the stomach ASSESSMENT: Evidenced By:
and edema on the peripheral -Recorded intake & output of -Indicates effectiveness of tx & -Exhibited no rapid increase in
-Usual weight as reported was 1-8hrs depending on response adequacy of fluid intake. weight
68 kg. to interventions to interventions (Smelter,Med-Surg 1332) -consumed diet low in sodium
& on patient activity. and within prescribed fluid
restriction
Objective: -Measured & record abdominal -Monitors changes in ascites -exhibited decreasing
-presence of dullness upon girth & weight daily. formation & fluid abdominal girth
percussion accumulation. (Smeltzer,Med-
-fluid wave upon palpation Surg p.. 1332)
-Bipedal pitting edema grade 2
present -Monitored electrolytes, hgb, & -Diuretics may cause
-Weight from Feb 2, 2010 60kg Hct electrolyte imbalances,
to 58kg (Feb 3, 2010) shunting may cause
-Abdominal girth from (Feb hemodilution. (Black & Hawks,
2. ) 38cm to (Feb 3. )37cm Med SURG. p. 1357)
-decreased skin mobility
-Assessed urine specific gravity -Specific gravity measures the
RR concentration of urine, an
Feb. 1, 2010: indicator of hydration.
2 am-26 cpm (LeMone NCP, p. 722)
6 am-31 cpm -Monitored albumin/protein -Protein molecules act as
levels “magnets” that help maintain
body fluid in correct
Feb. 2, 2010: compartments, low protein
10 pm-30 cpm level allows shift of fluid to
2 am-34 cpm extravascular space. (Gulanick,
6am-30 cpm p. 676)

-Checked abdomen for dullness -Fluid in the Peritoneal cavity

Feb. 3, 2010: on percussion may produce a dull sound on
10 pm- 29 cpm percussion. (gullanick NCP p.
2 am- 30 cpm 676)

Labs.: -Assessed for signs of portal -Portal hypertension is high

Hgb. 9.0 indicates fluid
retention
Hct. 29 indicates hemodilution
Urine Specific Grav. 1.015
Urine Albumin: Negative
(-) signs of UGIB
hypertension hx of upper GI
bleeding & spider nevi
-Assessed breathing patterns
blood pressure within vascular
bed, which is usually a high
flow, low-resistance vascular
system. As cirrhosis progresses,
normally distensible
-Ascites may limit excursion of
the diaphragm on inspiration.
The patient may hypoventilate
in a supine position

COMFORT MEASURES:
-Restricted sodium & fluid -Minimizes formation of ascites
intake if prescribed & edema. (Smelter, )

-Implemented measures to -Edema causes skin to

prevent skin breakdown breakdown faster. (Black &
Hawk, p. 1353)
-Prepare patient for - Paracentesis will temporarily
paracentesis. decrease amount of ascites
 present. (Smeltzer, Med-Surg
p.1328)

NIC 2 : Medication -Inhibits the reabsorption of

administration sodium and chloride from the
-Spironolactone 500mg 1tab ascending limb of the loop of
OD Henle leading to the sodium
rich diuresis.(Davis Drug
Guide p.771)

-Lasix, Apo-furosemide 40mg - Competitively blocks the

IVTT effect of aldosterone in the
renal tubule, causing loss of
sodium and water and retention
of potassium.(Davis Drug
Guide p.771)

Assessment:
-monitor I&O ratios and daily
weight throughout therapy.
TEACHINGS:
-Explained rationale for sodium -Minimizes formation af ascites
& fluid restriction.
-Advised to consume pure egg
white.
-Promotes patient’s
understanding of restriction &
cooperation with it. (Smeltzer,
Med-Surg p.1328)
and edema. (Smeltzer, Med-
Surg p.1328)
-Increases plasma oncotic
pressure. (Smeltzer, Med-Surg
p.1318)

Care Plan Evaluation: The care plan was very effective because it really helps the patient especially in monitoring his fluid volume
however it still needs more time in the implementation of the care plan.
Nursing Diagnosis: Risk for ineffective protection: bleeding r/t altered clotting mechanisms
NANDA: Decrease in the ability to guard self from internal or external threats such as injury or bleeding
Cause Analysis: In hepatic dysfunction, the production of blood clotting factors by the liver is reduced, leading to an increased
incidence of bruising, epistaxis, bleeding from wounds, and GI bleeding. Decreased production of several clotting factors may be
partially due to deficient absorption of Vit. K from the GI tract. This probably is caused by me inability to liver cells to use Vit. K to
make prothrombin. (Smeltzer p. 1307)
Assessment NIC with Intervention Rationale Outcome Expected
Subjective: NIC: Bleeding precautions NOC: Cognitive Orientation
ASSESSMENT: Partially met as evidence by:
-Monitored for V/s; report -Identifies onset of problem
tachycardia or hypotension. and potential trend. (Delmar the patient would identify at
-Monitor coagulation studies NCPpp.221) least 3 reasons for precautions
and platelet. Report abnormal with the use of his medications.
result.

-Observed each stool for color, -Increases serum ammonia may Partially Met as evidenced
consistency and amount indicate increasing by:
encephalopathy. (Delmar would not exhibit absence of
NCPpp.221) restlessness and other
Objective: -Observed for hemorrhagic -Rapid wrist flapping when indicators of hemorrhage and
Protime Control 11.5 secs. manifestations. Ecchymosis, arms are raised in from the shock.
INR= 2.6 epistaxis, petechiae, and body with hands dorsiflexed
Feb. 2 2010 bleeding gums. may indicate presence of
BP:10 PM 100/80 mmHg encephalopathy. (Delmar
2 AM 110/80 mmHg NCPpp.222)
6 Am 100/60 mmHg - observed for symptoms of -Provides initial baseline from
Feb 3, 2010 anxiety, epigastric fullness, which to gauge deterioration in
10 PM 110/70 mmHg weakness and restlessness status. As encephalopathy
2 Am 110/70 mmHg worsen, pt. LOC and ability to
6 Am 100/70 mmHg cooperate diminish to the point
RR : Feb 1, 2010 of coma. (Delmar NCP pp.
2 am 26 cpm COMFORT MEASURES: 222)
6 am 31 cpm -Instituted bleeding precautions
Feb 2 * prevent constipation -Reduces source of ammonia
10 Pm 30 cpm *avoid injections; if needed, (Smeltzer Med.-Surg.p.1328)
2 AM 34 cpm use small gauge needle and -Promotes consumption of
6 AM 30 cpm apply gentle measure adequate carbohydrates for
Feb. 3, 2010 * energy requirements (Smeltzer
10Pm 29 cpm -Provided frequent, small Med Surg p.1328)
Feb 4, 2010 feedings of carbohydrates. -minimizes risk for further
2 am 30 cpm increase in the metabolic
requirements. (Smeltzer, Med
No BM since Admission -Protected from infections. Surg. p. 1328)
Hemorrhagic manifestations: -minimizes shivering, which
(-) ecchymosis would increase in metabolic
(-) petechiae requirements (Smeltzer, Med
(-) bleeding gums -Keep environment warm Surg p. 1329)
(-) anxiety and draft-free. -minimizes pt’s activity and
(+) epigastric fullness metabolic requirements
(+) restlessness -Limit visitors. (Smeltzer Med Surg, p. 1329)
(-) weakness -provides stimulation to the
patient and opportunity for
serving the patient’s level of
-Awake at intervals (q2-4H) consciousness. ( Smeltzer Med
to assess cognitive status. Surg, p. 1329)
 -If possible, have pt. write a
name each day and do simple
mathematic calculation.
Care Plan Evaluation:
The Care of plan needs more time to meet the goal of intervention.
-as hepatic failure progresses,
the ability to write becomes
more difficulty and writing
becomes illegible @ pre-coma
stage inability to perform
mental calculations may
indicate worsening failure.
(Delmar NCP p. 221)