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Cirrhosis
Medical Nursing
Cirrhosis
Medical Nursing
Care Study
Submitted to: Tutor
Liver Cirrhosis
Acknowledgement
I express my heartfelt gratitude, sincere appreciation
and profound regards to the following people who, gave
guidance, strength, and encouragement in making this case
presentation possible. First of all, Thanks to God, for
granted us the knowledge and skills. To their family,
friends, and classmates, for their consideration and
unending support, emotionally, spiritually and financially.
To their clinical instructor, Madam. for guiding us in the
course of making this case presentation and giving them tips
on how to have a good presentation. Thanks to all Lectures
of Aquinas University and School of Nursing and all
medical personnel and staff members of Hospital Wattala,
A Ward, for sharing ideas, cooperating and giving full effort
in making the case presentation successful 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.
Contents:-
1. Objectives
To relieve Pain.
To promote Nutritional Level
To give Health Education.
Provide Comfort.
To prevent complication.
To maintain optimal fluid level.
Section 2
Introduction
2. Introduction
Secretion of bile
Storage of glycogen
Metabolism of fat
Deamination of amino acids
Production of the plasma protein
Storage of vitamins
Storage of irons
Production of clotting factors
Production of heat
Detoxification
Section 4
Patient Name
Age
Sex
Address
Civil Status
Religion
Contact No
BHT No
Ward & Room No
Consultant Name
Admission Date
: Mr.
: 58 years
: Male
:
: Divorced
: Buddhist
:
: 30848
:
:
:
Chief Complaint
Inadequate urine output since 3 days
Vomiting 4 times today
Vomits are water and light Brown color content.
Swelling in Abdomen and Scrotum since 10 days
Generalized swelling in the abdomen and Scrotum, Tenderness
when palpating the abdomen and Scrotum.
Poor oral Feeding 10 days (Loss of Appetite)
Medication History
Metformin 850mg bd
Furosemide 40mg nocte
Spironolactone 25mg bd
Tolbutamide 500mg bd
Atrovastatin 10mg nocte
Family History
Social History
Living arrangement
Divorced and lives alone
Residence
Resides in an apartment, No identified harmful
environmental exposure.
Occupation
Retired Bank Manager
Tobacco, Alcohol and other Drug Use
One pack per day smoking history until 2010, 20 years of
Alcohol use until 2012 June.
Diet and Exercise
Patient maintains a low sodium diet and gets moderate
exercise.
Education
He is a University Graduate
Temperature
Pulse Rate
Respiratory Rate
Blood Pressure
Pain
Height
Weight
MBI
98.5 F/Axilla
81/bpm
24/bpm
120/80mmHg
6/10 in pain Scale
174cm
78kg
General Appearance
Patient is appropriately groomed for the environment, is oriented for Place,
Time, and Person, and in No apparent Distress. He appears jaundiced and
underweight.
Head
Head is regular shape, with no apparent lesion, Masses, or Foreign bodies.
Scalp shows no evidence of skin condition or infestation, and exhibited no
tenderness on palpation.
Eyes
Lids are normal, No evidence of discharge, Ptosis or edema.
Direct and consensual reactivity of light.
Visual fields are normal
Left 6/6, Right 6/6
External ears and nose are of symmetric regular shape and size.
No scars, lesions, masses or foreign bodies.
No tenderness to palpation of ears and nose.
Nasal mucosa is moist and pink with no discharge.
No allergic Rhinitis.
No Ear discharge.
Sense of smell is good.
Mouth/Dental
Lips, Teeth, and gums all appear healthy with no lesions and ulceration.
Oral mucosa, tonsils, and palate appear healthy. No appear masses, lesions,
foreign bodies or other abnormalities.
Sense of taste is good.
Loss of Appetite in 10 days.
Neck
Neck is symmetric with no any lesions or ulceration.
There is no tenderness to palpation.
Skin
Skin appears is yellow color and there are no apparent rashes lesions or
ulcers.
Face
No scars in the face.
No wrinkles and patient facial appearance is normal.
Respiratory System
Cardiovascular System
No chest pain.
Patient has a 4 years history of hypertension, patient on treatment, regular
check up and using drugs such as Spironolactone and Frusemide.
Nails are Normal.
No cyanosis
CRFT (capillary refilling time) 2 seconds.
No oedema in the body and other extremities.
Extremities are Warm.
Abdomen
Abdominal walls shows/ appearing distended and round.
Pain in the right upper quadrant of the abdomen, this pain is on and off
occurring an exertion.
Abdominal girth is 65cm.
Umbilicus is protruded.
Tenderness to palpation of Abdomen.
Nutritional Assessment
Elimination
Bladder
No Incontinence
4days history of Urinary Retention.
No Hematuria.
No Burning Sensation during pass Urine.
Bowel
No Constipation/diarrhea.
Patient taking Lactulose 30cc use in Ward.
No Malena
No difficulty passing Stool.
Neurological Assessment
No Syncope
No Confusion
Headache on the Morning
No Convulsive signs.
Musculoskeletal Assessment
No Numbness
No Myalgia
No Fracture/injury
Patient complain of Difficulty in Walking because abdominal distention, and
Dyspnoea on exertion.
Psychiatric Assessment
Patient Alert, and Oriented to Time, Place, and Person.
Patient Anxiety because of Disease Condition.
Drug Treatment
Section 5
Cirrhosis
5.1. Cirrhosis
Cirrhosis is a complication of many liver diseases that is characterized by
abnormal structure and function of the liver.
The diseases that lead to cirrhosis do so because they injure and kill liver cells,
and the inflammation and repair that is associated with the dying liver cells
causes scar tissue to form.
The liver cells that do not die multiple in an attempt to replace the cells that
have died. This results in clusters of newly formed liver cells (regenerative
nodules) within the scar tissue.
There are many causes of cirrhosis; they include chemicals, viruses, toxic
metals and autoimmune liver disease in which the bodys immune system
attacks the liver.
5.2. Etiology
Alcohol
Is a very common cause of cirrhosis. The development of cirrhosis
depends upon the amount and regularity of alcohol intake. Chronic, high level
of alcohol consumption injures liver cells. Alcohol cause a range of liver
diseases; from simple and uncomplicated fatty liver, to the more serious fatty
liver with inflammation, to cirrhosis.
Chronic viral hepatitis
Is a condition where hepatitis B or hepatitis C virus infects the liver for
years. Most patients with viral hepatitis will not develop chronic hepatitis and
cirrhosis. For example, the majority of the patients infected with hepatitis A
recover completely within weeks, without developing chronic infection.
Inherited (genetic) disorders
Result in accumulation in toxic substance in the liver which lead to tissue
damage and cirrhosis. Examples include the abnormal accumulation of the iron
(hemochromatosis) or copper (wilsons disease). In hemochromatosis, patients
inherit a tendency to absorb an excessive amount of iron from food. Over time iron
accumulation in different organs throughout the body causes cirrhosis, arthritis,
heart muscle damage leading to heart failure, and testicular dysfunction causing
loss of sexual drive. Over time copper accumulates in the liver, eyes, and brain.
Cirrhosis, tremor, psychiatric disturbances and other neurological difficulties
occur, if the condition is not treated.
Autoimmune hepatitis
Is a liver disease caused by a an abnormality of the immune system that is
found more commonly in women. The abnormal immune activity in autoimmune
hepatitis causes progressive inflammation and distruction of liver cells
(hepatocytes), leading ultimately to cirrhosis.
Primary biliary cirrhosis (PBC)
Is a liver disease caused by an abnormality of the immune system that is
found predominantly in women. The abnormal immunity in PBC causes
chronic inflammation and destruction of the small bile ducts within the liver. In
PBC, the destruction of the small bile ducts blocks the normal flow of the bile
into the intestine. As the inflammation continues to destroy more of the bile
ducts, it also spread to destroy nearby liver cells. As the destruction of the
hepatocytes proceeds, scar tissue (fibrosis) forms and spreads throughout the
areas of destruction.
Non alcoholic fatty liver disease (NAFLD)
Refers to a wide spectrum of liver diseases that, like alcoholic liver
disease, ranges from simple steatosis, to nonalcoholic steatohepatitis (NASH),
to cirrhosis. All stages of NAFLD have in common the accumulation of fat in
liver cells. NAFLD is associated with the metabolic syndrome and diabetes
mellitus type 2. Obesity is the most important cause of insulin resistance,
metabolic syndrome, and type 2 diabetes mellitus.
5.3. Pathophysiology
Normal liver
Columns of hepatocytes 12
cells thick radiate from the portal
tracts (PT) to the central veins. The
portal tract contains a normal intra
lobular bile duct branch of the
hepatic artery and portal venous
radical
A cirrhotic liver
Many people with cirrhosis have no symptoms during the early phases of the
disease. Symptoms are caused by either of 2 problems:
Gradual failure of the liver to carry out its natural functions.
Distortion of the livers usual shape and size because of scarring.
The most common symptoms of cirrhosis are as follows:
Signs and Symptoms may not appear until complications of cirrhosis set in.
Many people do not know they have cirrhosis until they have a complication:
Jaundice Yellowing of the skin and eyes from deposition of bilirubin in
these tissues. Bilirubin is a product of the breakdown of old blood cells
in the liver.
Fever
Diarrhea
Itching from deposition in the skin of products of the breakdown of
bile.
Abdominal pain and Ascitis from enlargement of the liver or formation
of gallstones.
Weight gain from fluid retention
Swelling in ankles and legs (Edema) from fluid retention
Difficulty breathing from fluid retention
Sensitivity to medications due to impairment of the livers ability to
filter medications from blood.
Confusion, Delirium, Personality changes, or Hallucinations
(Encephalopathy) from buildup of drugs or toxins in the blood, which
then affect the brain.
Extreme sleepiness, Difficulty awakening, or Coma other symptoms of
Encephalopathy
Bleeding from Gums or Nose Due to impaired production of the
Clotting Factors.
livers, abnormally nodular livers, enlarged spleens, and fluid in the abdomen,
which suggest cirrhosis.
Advanced cirrhosis leads to a reduced level of albumin in the blood and
reduced blood clotting factors due to the loss of the liver's ability to produce
these proteins. Thus, reduced levels of albumin in the blood or abnormal
bleeding suggest cirrhosis.
Abnormal elevation of liver enzymes in the blood (such as ALT and AST) that
are obtained routinely as part of yearly health examinations suggests
inflammation or injury to the liver from many causes as well as cirrhosis.
Patients with elevated levels of iron in their blood may have hemochromatosis,
a genetic disease of the liver in which iron is handled abnormally and which
leads to cirrhosis.
Auto-antibodies (antinuclear antibody, anti-smooth muscle antibody and antimitochondrial antibody) sometimes are detected in the blood and may be a clue
to the presence of autoimmune hepatitis or primary biliary cirrhosis, both of
which can lead to cirrhosis.
Liver cancer (hepatocellular carcinoma) may be detected by CT and MRI
scans or ultrasound of the abdomen. Liver cancer most commonly develops in
individuals with underlying cirrhosis.
If there is an accumulation of fluid in the abdomen, a sample of the fluid can be
removed using a long needle. The fluid then can be examined and tested. The
results of testing may suggest the presence of cirrhosis as the cause of the fluid.
5.6. Management
Treatment of cirrhosis includes
1). Preventing further damage to the liver.
2) .Treating the complications of cirrhosis.
3). Preventing liver cancer or detecting it early.
4). Liver transplantation.
Propranolol (Inderal)
A beta blocker is effective in lowering pressure in the portal vein
and is used to prevent initial bleeding and rebleeding from varices in
patients with cirrhosis.
Octreotide (Sandostatin)
Also decreases portal vein pressure and has been used to treat
variceal bleeding.
During upper endoscopy (EGD)
Sclerotherapy or band ligation can be performed to obliterate
varices and stop active bleeding and prevent rebleeding.
Transjugular intrahepatic portosystemic shunt (TIPS)
Is a non-surgical, radiolotic procedure to decrease the pressure
in the portal vein. TIPS are performed by a radiologist who inserts a
stent (tube) through a neck vein, down the inferior vena cava and into
the hepatic vein within the liver. The stent then is placed so that one end
is in the high pressure portal vein and the other end is in the low
pressure hepatic vein. This tube shunts blood around the liver and by so
doing lowers the pressure in the portal vein and varices and prevents
bleeding from the varices.
A surgical operation to create a shunt (passage)
From the high-pressure portal vein to veins with lower pressure
can lower blood flow and pressure in the portal vein and prevent varices
from bleeding.
Hepatic encephalopathy.
Patients with an abnormal sleep cycle, impaired thinking, odd behavior,
or other signs of hepatic encephalopathy usually should be treated with a low
protein diet and oral lactulose. Dietary protein is restricted because it is a
source of toxic compounds that cause hepatic encephalopathy. Lactulose,
which is a liquid, traps toxic compounds in the colon so they cannot be
absorbed into the blood stream, and causes encephalopathy. (Lactulose is a
laxative and the adequacy of treatment can be judged by loosening or
increasing frequency of stools).
Hypersplenism.
The filtration of blood by an enlarged spleen usually results in only mild
reductions of red blood cells (anemia), white blood cells (leukopenia) and
platelets (thrombocytopenia) that do not require treatment. Severe anemia,
however, may require blood transfusions or treatment with erythropoietin
hormone that stimulate the production of red blood cells.
No approved medication is available yet to increase the number of
platelets. As a necessary precaution, patients with low platelets should not use
aspirin or other no steroidal anti-inflammatory drugs (NSAIDS) since these
drugs can hinder the function of platelets. If a low number of platelets are
associated with significant bleeding, transfusions of platelets usually should be
given. Surgical removal of the spleen (splenectomy) should be avoided, if
possible, due to the risk of excessive bleeding during the operation.
Spontaneous bacterial peritonitis (SBP).
Patients suspected of having spontaneous bacterial peritonitis usually
will undergo paracentesis. Fluid that is removed is examined for white blood
cells and cultured for bacteria. Blood and urine samples also are often
obtained for culturing because many patients with spontaneous bacterial
peritonitis also will have infection in their blood and urine. In the infection may
have begun in the blood and the urine and spread to the ascitic fluid to cause
spontaneous bacterial peritonitis. Most patients with spontaneous bacterial
peritonitis are hospitalized and treated with intravenous antibiotics such as
cefotaxime.
Patients with cirrhosis who are hospitalized for bleeding varices have a
high risk of developing spontaneous bacterial peritonitis and should be
started on antibiotics early during the hospitalization to prevent
spontaneous bacterial peritonitis.
Patients with low protein levels in the ascitic fluid (Ascitic fluid with low
levels of protein is more likely to become infected.)
4. Liver transplantation
Cirrhosis is irreversible. Many patients' liver function will gradually
worsen despite treatment and complications of cirrhosis will increase and
become difficult to treat. Therefore, when cirrhosis is far advanced, liver
transplantation often is the only option for treatment. Recent advances in
surgical transplantation and medications to prevent infection and rejection of
the transplanted liver have greatly improved survival after transplantation.
1.
As cirrhosis of the liver becomes severe, signals are sent to the kidneys to retain salt
and water in the body. The excess salt and water first accumulates in the tissue
beneath the skin of the ankles and legs because of the effect of gravity when standing
or sitting. This accumulation of fluid is called edema or pitting edema. As cirrhosis
worsens and more salt and water are retained, fluid also may accumulate in the
abdominal cavity between the abdominal wall and the abdominal organs. This
accumulation of fluid (called ascites) causes swelling of the abdomen, abdominal
discomfort, and increased weight.
2.
Fluid in the abdominal cavity (ascites) is the perfect place for bacteria to grow.
Normally, the abdominal cavity contains a very small amount of fluid that is able to
resist infection well, and bacteria that enter the abdomen (usually from the intestine)
are killed or find their way into the portal vein and to the liver where they are killed.
In cirrhosis, the fluid that collects in the abdomen is unable to resist infection
normally. In addition, more bacteria find their way from the intestine into the ascites.
Therefore, infection within the abdomen and the ascites, referred to as spontaneous
bacterial peritonitis or SBP, is likely to occur. SBP is a life- threatening complication.
Some patients with SBP have no symptoms, while others have fever, chills, abdominal
pain and tenderness, diarrhea, and worsening ascites.
3.
In the cirrhotic liver, the scar tissue blocks the flow of blood returning to the heart
from the intestines and raises the pressure in the portal vein (portal hypertension).
When pressure in the portal vein becomes high enough, it causes blood to flow around
the liver through veins with lower pressure to reach the heart. The most common veins
through which blood bypasses the liver are the veins lining the lower part of the
esophagus and the upper part of the stomach.
As a result of the increased flow of blood and the resulting increase in pressure, the
veins in the lower esophagus and upper stomach expand and then are referred to as
esophageal and gastric varices.
4.
Hepatic encephalopathy
Some of the protein in food that escapes digestion and absorption is used by bacteria
that are normally present in the intestine. While using the protein for their own
purposes, the bacteria make substances that they release into the intestine. These
substances then can be absorbed into the body. Some of these substances, for example,
ammonia, can have toxic effects on the brain. Ordinarily, these toxic substances are
carried from the intestine in the portal vein to the liver where they are removed from
the blood and detoxified.
When the toxic substances accumulate sufficiently in the blood, the function of the
brain is impaired, a condition called hepatic encephalopathy. Sleeping during the day
rather than at night (reversal of the normal sleep pattern) is among the earliest
symptoms of hepatic encephalopathy. Other symptoms include irritability, inability to
concentrate or perform calculations, loss of memory, confusion, or depressed levels of
consciousness. Ultimately, severe hepatic encephalopathy causes coma and death.
5.
Hepatorenal syndrome
Patients with worsening cirrhosis can develop hepatorenal syndrome. This syndrome
is a serious complication in which the function of the kidneys is reduced. It is a
functional problem in the kidneys, meaning there is no physical damage to the
kidneys. Instead, the reduced function is due to changes in the way the blood flows
through the kidneys themselves. The hepatorenal syndrome is defined as progressive
failure of the kidneys to clear substances from the blood and produce adequate
amounts of urine while other important functions of the kidney, such as retention of
salt, are maintained.
6.
Hepatopulmonary syndrome
Hypersplenism
The spleen normally acts as a filter to remove older red blood cells, white blood cells,
and platelets (small particles that are important for the clotting of blood.). The blood
that drains from the spleen joins the blood in the portal vein from the intestines. As the
pressure in the portal vein rises in cirrhosis, it increasingly blocks the flow of blood
from the spleen. The blood "backs-up," accumulating in the spleen, and the spleen
swells in size, a condition referred to as splenomegaly. Sometimes, the spleen is so
enlarged that it causes abdominal pain.
8.
Cirrhosis due to any cause increases the risk of primary liver cancer (hepatocellular
carcinoma). Primary refers to the fact that the tumor originates in the liver. A
secondary liver cancer is one that originates elsewhere in the body and spreads
(metastasizes) to the liver.
The most common symptoms and signs of primary liver cancer are abdominal pain
and swelling, an enlarged liver, weight loss, and fever. In addition, liver cancers can
produce and release a number of substances, including ones that cause an increased
in red blood cell count (erythrocytosis), low blood sugar (hypoglycemia), and high
blood calcium (hypercalcemia ).
Section 6
Discharge Goals:1.
2.
3.
4.
7.1.
Nursing Assessment
Monitor for signs and symptoms.
Fatigue
Weight loss, abdominal pain, and distention
Pruritus (severe itching of skin)
Confusion or difficulty thinking (due to the build-up of waste
products in the blood and brain that the liver is unable to get rid of).
Gastrointestinal bleeding (enlarged veins [varices] develop and
burst, causing vomiting and passing of blood in bowel movements)
Ascites (bloating or swelling due to fluid build-up in abdomen and
legs)
Jaundice (yellowing of skin) and icterus (yellowing of the eyes)
Petechiae (round, pinpoint, and red-purple lesions), ecchymosis
(large yellow and purple blue bruises), nose bleeds, hematemesis,
melena (decreased synthesis of prothrombin and deteriorating
hepatic function)
Palmar erythema (redness and warmth of the palms of the hands)
Spider angiomas (red lesions vascular in nature with branches
radiating onthe nose, cheeks, upper thorax, and shoulders)
Dependent peripheral edema of extremities and sacrum
Personality and mentation changes, emotional lability, euphoria,
and sometimes depression.
Asterixis (liver flapping tremor) is a coarse tremor characterized by
rapid,nonrhythmic extension and flexion of the wrists and fingers
Fetor hepaticus (liver breath) is a fruity or musty odor.
Assess/Monitor
ACTIVITY/REST
Weakness
Fatigue, exhaustion
CIRCULATION
History of or recent onset of heart failure (HF), pericarditis, rheumatic heart
disease, or cancer, causing liver impairment leading to failure
Easy bruising, nosebleeds, bleeding gums
ELIMINATION
Flatulence
Diarrhea or constipation
Gradual abdominal enlargement
FOOD/FLUID
Anorexia
Food intolerance, ingestion
Nausea, vomiting
Hematemesis
NEUROSENSORY
Significant other (SO)/family may report personality changes, depressed
mentation
PAIN/DISCOMFORT
Abdominal tenderness and right upper quandrant (RUQ) pain
Severe itching
Pins-and-needles sensation, burning pain in extremities (peripheral
neuropathy)
RESPIRATION
Dyspnea
SAFETY
Itching, dryness of the skin (pruritus)
SEXUALITY
Menstrual disorders (women)
Impotence (men)
TEACHING/LEARNING
7.2.
Nursing Diagnosis
7.3.
Nursing Interventions
IDEAL
Assess for any significant findings on the abdominal size -to provide
a basis of proper and comfortable positioning
Assess for any discomfort related to pain at the right side of the
body- to provide a basis of proper and comfortable positioning.
Monitor intake and output closely (hourly)- to monitor any
improvement or worsening of patients condition
Regulate IVF to ordered flow rate- to prevent overload and under
load of fluid intake.
Provide side rails. - to promote patients safety
Encourage the client to urinate if feeling of voiding is present.- to
alleviate urinary distention
Educated the client and the SO about the significance of urination.to provide information about the significance of voiding in relation
to its underlying condition
Bedside care done-to promote comfort and safety of the clients
condition.
Position the patient in a Fowlers or Semi Fowlers position with
pillows - Relieves pressure on diaphragm. -Observe for
manifestations like crackles or increased respiration.- Identifies fluid
in the lungs
Monitor vital signs every 2 hours- to identify any changes in
patients health status.
Encourage the client to inhale and exhale exercise. - To alleviate
breathing difficulty.
Use light, cool clothing which promotes evaporation. Keep clothing
and bed dry. - Minimizes irritation and itching
Keeping the environment cool.- Minimizes itching
Avoid activities that promote sweating. Minimizes itching
Keep nails short and smooth.- Prevents breaking skin integrity when
scratching
Reposition patient every 2 hour.- Relieves pressure over bony
prominences
Dependent:
Medications were given as prescribed, lactulose 30 ml,
metronidazole 200mg 1 tab TID via NGT. To alleviate clients
condition as prescribed by the physician.- to promote wellness and
alleviate the existing problem.
Instructed the So to maintain Nothing Per Orem Diet (NPO) as
recommended given since Gastrointestinal function are impaired due
to abdominal distention.- to reduce gastric irritation.
Administer Oxygen as ordered. - To alleviate breathing difficulty and
assist the need of air by the client.
Thank you.
9. References
Saladin: Anatomy & Physiology: The Unity of Form and Function, Third
Edition, the McGrawHillCompanies
Marilynn E. Doenges, APRN, BC-Retired, Mary Frances Moorhouse, Alice C.
Murr (2010) Nursing Care Plans
Danielle Platt & Mary Moss, Adult Medical and Surgical Nursing
David A. Warrell (Editor), Timothy M. Cox (Editor), John D. Firth (Editor),
Edward J., J R., M.D. Benz, Oxford Textbook of Medicine 4th edition (March
2003), By Oxford Press.
Nicki R. Colledge, Brian R. Walker, Stuart H. Ralston,(2010), Davidsons
Principles and Practice of Medicine, An imprint of Elsevier Limited.
Sondra G. Ferguson, Tracey Goldsmith, Constance J. Hirnle, Carol Ann
Barnett Lammon, Sandra Smith Pennington, Frank Romanelli.(2006), The
Clinical drug Therapy Rationales for Nursing Practice.
Mr. R
30848
A
Date
Time
18/02/2013
On
admission
19/02/2013
20/02/2013
21/02/2013
22/02/2013
Temperature
Pulse
Respiration
BP
94.6 F/Axilla
99.2/Axilla
100.4/Axilla
98.6/Axilla
99.8/Axilla
80/bpm
86/bpm
88/bpm
94/bpm
86/bpm
22/bpm
24/bpm
26/bpm
24/bpm
22/bpm
130/70mmHg
10am
02pm
06pm
10pm
130/70 mmHg
02am
06am
10am
02pm
06pm
10pm
96.4/Axilla
95.4/Axilla
94.8/Axilla
96.4/Axilla
98.6/Axilla
80/bpm
84/bpm
82/bpm
82/bpm
86/bpm
22/bpm
24/bpm
28/bpm
26/bpm
24/bpm
120/85 mmHg
130/80 mmHg
120/80 mmHg
02am
06am
10am
02pm
06pm
10pm
98.9/Axilla
99.1/Axilla
98.2/Axilla
98.6/Axilla
92.4/Axilla
98.2/Axilla
84/bpm
88/bpm
84/bpm
86/bpm
82/bpm
80/bpm
22/bpm
26/bpm
24/bpm
20/bpm
24/bpm
20/bpm
02am
06am
10am
02pm
06pm
10pm
92.4/Axilla
98.6/Axilla
96.6/Axilla
98.4/Axilla
97.8/Axilla
88/bpm
94/bpm
84/bpm
86/bpm
82/bpm
22/bpm
26/bpm
24/bpm
20/bpm
24/bpm
02am
06am
10am
02pm
06pm
10pm
98.8/Axilla
98.9/Axilla
101/Axilla
99/Axilla
98.2/Axilla
84/bpm
80/bpm
88/bpm
86/bpm
82/bpm
24/bpm
26/bpm
26/bpm
24/bpm
20/bpm
Remarks
120/80mmHg
130/80 mmHg
120/80 mmHg
96% on air
98% on air
130/80 mmHg
135/65 mmHg
99% on air
130/90 mmHg
120/80 mmHg
120/85 mmHg
99% with O2
98% with O2
99% with O2
96%with O2
120/80 mmHg
130/80 mmHg
140/70 mmHg
98% on air
96% on air
Date
Mr. R
30848
A
Time
Oral
IV Fluids
NG Feed
Total
Urine
Other
Total
18/2/2014 1pm-7pm
120ml 300ml
420ml
200ml
200ml
7pm-7am
140ml 600ml
1260ml 250ml
450ml
19/2/2014 Time
Oral
IV Fluids
NG Feed
Total
Urine
Other
Total
7am-1pm
180ml 300ml
480ml
150ml
150ml
1pm-7pm
200ml 300ml
980ml
170ml
330ml
7pm-7am
300ml 600ml
1880ml 200ml
530ml
20/2/2014 Time
Oral
IV Fluids
NG Feed
Total
Urine
Other
Total
7am-1pm
250ml 300ml
550ml
180ml
180ml
1pm-7pm
200ml 300ml
1050ml 200ml
380ml
7pm-7am
200ml 600ml
2050ml 300ml
680ml
200ml
Mr. R
30848
A
21/2/2014 Time
Oral
IV Fluids
NG Feed
Total
Urine
Other
Total
7am-1pm
100ml 120ml
300ml
420ml
200ml
200ml
1pm-7pm
50ml
120ml
300ml
890ml
250ml
450ml
240ml
200ml
1330ml 270ml
720ml
NG Feed
Total
Urine
7pm-7am
22/2/2014 Time
Oral
IV Fluids
Other
Total
7am-1pm
100ml 120ml
200ml
420ml
350ml
350ml
1pm-7pm
100ml 120ml
200ml
840ml
300ml
650ml
7pm-7am
50ml
200ml
1330ml 350ml
240ml
1000ml
Diabetic Chart
Patient Name:
BHT No:
Ward/Room No:
Mr. R
30848
A
Date
Time
RBS Value
Medication
18/02/2014
6am
180 mg/dl
19/02/2014
6am
125 mg/dl
12nn
110 mg/dl
6pm
117 mg/dl
6am
132 mg/dl
12nn
128 mg/dl
6pm
118 mg/dl
6am
96 mg/dl
12nn
84 mg/dl
6pm
70 mg/dl
6am
90 mg/dl
12nn
84 mg/dl
6pm
99 mg/dl
6am
120 mg/dl
20/02/2014
21/02/2014
22/02/2014
23/02/2014
Investigations
N
o
Investigation Name
1.
2.
Normal
Value
18/02/
2013
4000-11000 cumm
40-75%
20-40%
2-8%
1-6%
0-3%
4-6%
11.5-15.5g/dl
36-46%
83-101FL
27.5-32Pg
31.5-35g/dl
11.6-14.8%
150,000-450,000cumm
8000 cumm
68%
20%
6%
4%
2%
6%
12.7g/dl
40%
88.1FL
32.4Pg
24.5g/dl
10.9%
198,0000cumm
Serum Electrolytes
Sodium (Na+)
Potassium (K+)
Chloride (Cl-)
137-145mmol/L
3.5-5.1mmol/L
98-105mmol/L
19/02/
2013
20/02/
2013
21/02/
2013
6500 cumm
57%
38%
6%
5%
0%
4.25%
12.8g/dl
37.5%
88.1FL
29.8Pg
33.8g/dl
14.9%
257,000cumm
141 mmol/L
3.5 mmol/L
99 mmol/L
22/02/
2013
7800 cumm
64%
38%
6%
0%
0%
2.95%
10.4g/dl
30.5%
10.3FL
35.2Pg
34.1g/dl
18.8%
234,000cumm
136 mmol/L
3.2 mmol/L
98 mmol/L
3.
Serum Creatinine
Male 0.5-1.5mg/dl
Female 0.6-1.2mg/dl
1.1mg/dl
0.9mg/dl
1.1mg/dl
4.
CRP
0-6 mg/L
48.5mg/L
42.5mg/L
34.2mg/L
5.
Liver Profile
Total Protein
Albumin
Globulin
A/G Ratio
Total Bilirubin
Alkaline Phosphatese
ALT/SGPT
AST/SGOT
GAMMA GT
6.4-8.2g/dl
3.4-5.0g/dl
2.5-3.5g/dl
1:1
0.2-1.2g/dl
50-136U/L
30-65U/L
15-37U/L
15-85U/L
7.7 g/dl
3.1 g/dl
5.2 g/dl
1.1
10.58 g/dl
75 U/L
32 U/L
18 U/L
49 U/L
7.6 g/dl
2.5 g/dl
5.1 g/dl
0.5
13.78 g/dl
122 U/L
33 U/L
60 U/L
40 U/L
7.8 g/dl
2.2 g/dl
5.8 g/dl
1.1
10.2 g/dl
120 U/L
34 U/L
54 U/L
76 U/L
Renal Profile
Sodium
Potassium
Chloride
Urea
S. Creatinine
Calcium
Phosphorus
Uric acid
137-145mmol/L
3.5-5.1mmol/L
98-105mmol/L
5-40mg/dl
0.5-1.5mg.dl
8.5-10.1mg/dl
2.5-4.5mg/dl
3.5-8.35mg/dl
6.
134 mmol/L
4.7 mmol/L
96 mmol/L
23.54 mg/dl
0.8 mg/dl
8.9 mg/dl
3.3 mg/dl
2.8 mg/dl
28.4mg/L
7.2 g/dl
3.0 g/dl
5.4 g/dl
0.5
9.4 g/dl
122 U/L
38 U/L
42 U/L
80 U/L
7.
ESR
8.
Lipid Profile
Total Cholesterol
Triglyceride
HDL
LDL
VLDL
CHOL/HDL ratio
9.
Prothrombin Time
Control
INR
28mm
>200mg/dl
>150mg/dl
>40mg/dl
>129mg/dl
212 mg/dl
132 mg/dl
43 mg/dl
142.6 mg/dl
26.40
4.9
39seconds
13seconds
3.1
24mm
22mm
215 mg/dl
126 mg/dl
56 mg/dl
140 mg/dl
25.5
4.7
36seconds
15seconds
2.8
Medication Chart
No
Drug Name
1.
Generic Name
Route
Levofloxacin
Oral
Drugs
Levofloxacin
Levaquin
Classification
Antibiotic
(Fluoroquinolone)
Side Effects
Nursing Considerations
Action
IV
Trade Name
Contra Indications
Indications
Bacterial
infection of the
Skin, Sinuses,
Kidneys, Liver,
Bladder or
Prostate.
Bronchitis
Pneumonia
Anthrax or plaque
Hypersensitivity
of Levofloxacin
Pregnancy
Breast feeding
Diarrhea
Abdominal
pain/cramps
Agitation
Confusion
Fever
Redness &
Swelling of
skin
Burning on
the skin
Skin rash
itching
Hypersensitivity of
Levofloxacin
History of muscle
disorders
(myasthenia
gravis)
No
2.
Drug Name
Generic Name
Route
Indications
Trade Name
Classification
Proton Pump
inhibitor
Side Effects
Nursing Considerations
Action
Oral
IV Drug Suppress gastric acid
Pantaprazole
production
Pantacid
Pantodac
Contra Indications
Sahort term
treatment of
erosive
oesophagitis
associated with
GERD
Duodenal Ulcer
Prophylaxis of
NSAID associated
gastric or
duodenal ulcer
Hypersensitivity
of Pantaprazole.
Allergic
reactions
Constipation
Dry mouth
myalgia
Thrombocyt
openia
Generalized
oedema
Depression
Vertigo
pruritis
Drug Name
3.
Route
Generic Name
Metranidazol Oral
drug,
e
Injec,
Classification
Antimicrobial
Drug
Side Effects
Nursing Considerations
Action
High action against
anaerobic bacteria and
protozoa to killing
Trade Name
Flagyle
Metranidazol
e
Contra Indications
Indications
Anaerobic
infection
Leg ulcers &
Pressure sores
Bacterial
vaginosis
Pelvic
inflammatory
disease
Acute ulcerative
gingivitis
Acute oral
infections
Surgical
prophylaxis
Hepatic
impairment
Hepatic
encephalopathy
Pregnancy
Breast feeding
Nausea,
Vomiting
Taste
disturbance
Oral
mucositis
Drowsiness
Dizziness
Headache
Ataxia
Psychotic
disorders
Thrombocyt
openia
Myalgia
Visual
disturbance
Pruritis
Erythema
Drug Name
4
Route
Generic Name
Metformin
Hydrochlorid
e
Classification
Biguanides
Side Effects
Nursing Considerations
Action
Oral
Drugs
Trade Name
Glycomet
Metformin
Glymet
Contra Indications
Indications
Diabetes Mellitus
Poly Cystic Ovary
syndrome
Renal impairment
Ketoacidosis
Sepsis
Respiratory
failure
Hepatic
impairment
Pregnancy
Breast feeding
Anorexia
Nausea,
vomiting
Diarrhea
Abdominal
pain
Metallic
taste
Lactic
acidosis
Erythema
Pruritis
Urticaria
Decrease Vit
B12
absorption
Drug Name
5.
Route
Generic Name
Frusemide
Trade Name
Lasix
Frusemide
Side Effects
Nursing Considerations
Action
Oral,
inje
Indications
Classification
Loop Diuretic
Contra Indications
Oedema
Oliguria due to
renal failure
Pulmonary
oedema
Chronic heart
failure
Liver cirrhosis
Renal failure
Anuria
Hyponatrem
ia
Hypokalemi
a
Hypomagnes
imia
Hypochlorae
mic
alkalosia
Increase
calcium
exertion
Hypotension
GI
disturbance
Hyperglyce
mia
pancreatitis
Administer in
night
Educate patient
about polyuria
Drug Name
6.
Route
Generic Name
Spiranolacto
ne
Trade Name
Classification
Potassium
sparing
Diuretics
Aldosterone
Antagonists
Side Effects
Nursing Considerations
Action
Oral
drug
Antagonizing the
Aldosterone
Indications
Aldactone
Spiranolacto
ne
Contra Indications
Oedema
Ascitis in cirrhosis
Malignant
Cirrhosis
Nephritic
Syndrome
CHF
Primary
hyperaldoesteroni
sm
Hyperglycemia
Hyponatremia
Addisons disease
GI
disturbances
Impotence
Gynaecomes
tia
Menstrual
irregulation
s
Lethargy
Headache
Confusion
Rashes
Hyperkalemi
a
Hyponatrem
ia
Osteomalaci
a
As with potassium
sparing diuretics,
potassium
supplements must
not be given with
aldosterone
antagonists.
Monitor serum
Electrolyte level.
Assess for GI
disturbances.
Drug Name
7.
Generic Name
Tolbutamide
Trade Name
Route
Oral
drug
Indications
Sulphonylure
as
Side Effects
Nursing Considerations
Action
Tolbutamide
Classification
Contra Indications
Type 2 Diabetes
Mellitus
Headache
Tinnitus
Nausea,
Vomiting
Diarrhea
Hypoglycemi
a
Fever
Jaundice
Photosensiti
vity
Thrombocyt
openia
Agranulocyt
osis
Anemia
Drug Name
8.
Route
Generic Name
Atorvastatin
Trade Name
Atorva
Atacor
Atrovastatin
Classification
Statin
Contra Indications
Side Effects
Nursing Considerations
Action
Oral
drug
Indications
Primary hyper
cholesterolaemia
Heterozygous
familial hyper
cholesterolaemia
Homozygous
familial hyper
cholesterolaemia
Prevention of
cardiovascular
events in patient
with Type 2 DM.
Pregnancy
Breast Feeding
Chest pain
Angina
Insomnia
Dizziness
Hypoaesthes
ia
Arthralgia
Back pain
Headache
Altered liver
function test
Abdominal
pain
Flatulence
Constipation
Nausea &
vomiting
Hypersensiti
ve reaction.
Nursing Assessment
20/02/2013,
Wednesday, 8.30am.
Subjective Data
Mr W A P Ranjith,
58years
Verbalized I have
1. Abdominal Distention
and Generalized
swelling of Abdomen
and Scrotum since two
weeks
2. Abdominal Pain
Right Upper Quadrent
site, On & Off type pain,
Pain on Exertion, and No
Radiation in other site.
Nursing diagnosis
Goal
1. Pain related to
Abdominal Distention
Reduce the
Pain
Planning
Nursing Intervention
3. Provide comfort
measures such as mouth
care, back care and
repositioning.
4. Encourage the patient to
use of the relaxation
technique.
5. Monitor Vital Signs.
6. Provide Diversitional
Activities.
7. Administer Analgesics as
Prescribed.
8. Administer IV fluids as
Prescribed.
Evaluation
After Nursing
interventions
patient
verbalized feel
comfortable.
5. Decreased level of
Urine output since 3
days
9. Administer Analgesics As
Prescribed.
Morphine SC
Objective Data
1. Patient General
Appearance is good.
Maintain
Effective
breathing
Pattern
1. Monitored Respiratory
rate, depth and effort.
5. Encourage patient
frequent repositioning.
6. Encourage patient to
deep breathing and
coughing exercises.
After Nursing
interventions
patient
breathing
pattern is normal
Tenderness when
palpating abdomen.
9. abdominal Girth of the
Patient is 60cm
10. Decreased Urinary
output, today 150ml in
7am to 1pm.
10 Administer Supplement
O2 therapy.
3. Imbalanced
Nutrition less than
body Requirements
related to Anorexia,
Nausea and Vomiting.
Maintain
normal
Nutrition
level
After nursing
patent get
normal diet
WBC 6500cumm
RBC 4.25%
Hb% 12.8g/dl
PCV 37.5%
Plt Count 257,000
cumm
* Renal Profile
Na+ 134mmol/L
K+4.7mmol/L
Cl- 96mmol/L
Urea 23.54mg/dl
S. Creatinine 0.8mg/dl
Ca + 8.9mg/dl
Uric acid 2.8mg/dl
5. Restricted intake of
caffeine and gas producing
or spicy and excessive hot or
cold foods.
6. Provided mouth care for
before meals.
7. Administered Nutritional
Foods such as Soup, juice
and Milk.
8. Administered Iv fluids
Hartmann 50cc/hr as
prescribed.
9. Monitor and Charted Vital
Signs.
10. Monitor and charted
intake and output chart.
Maintain
normal
optimal
body fluids
After Nursing
interventions
reduced vomiting
and patient have
normal Vital
Signs
9. Encourage patient to
frequently try to passing
urine.
10. Educate warn the
patient for risk of fluid
collection in the body and
its complications.
9. Administered Prescribed
medication, such as Antacid
(Pantocid 40mg), Diuretics
( Lasix 40mg, &
Spironolactone).
Maintain
skin
integrity in
normal
level
6. Encourage patient to
regular schedule while on
bed or chair and active or
passive range of motion
exercises.
7. Elevated patient
edematous leg part to
reduce edema.
8. Changed bed linen, kept
linen dry and free from
wrinkles.
9. Frequently change
position for prevent bed
sores.
10. Encouraged patient for
personal hygiene and
perineal care following
urination and bowel
opening.
Nursing Assessment
21/02/2013 7.30am
Thursday
Subject Data
Mr. W A P Ranjith
Verbalized I have
1. Vomiting 3times in
morning its red color
with mixed watery.
Nursing Diagnosis
1. Risk for bleeding
related to development
of esophageal varices
it evidenced by
vomiting with blood.
Goal
Planning
Maintain
1. Assess for signs and
homeostasis
symptoms of GI bleeding.
with absence of
GI bleeding
2. Reassure the patient &
assess Vomitus for blood
stain.
3. Provide psychology
support.
2. Difficulty breathing
since morning 6am
3. Abdominal distention
and Discomfort
Nursing Interventions
8. Encourage patient to
increase oral intake.
Evaluation
After nursing
intervention
reduced
vomiting
mouth.
Objective Data
10. Monitor & Maintain
intake and output chart.
1. Patient General
Appearance ill looking.
2. Patient Restlessness.
3. Skin color is yellow
color and poor skin
turgor
12. Administer
medication as prescribed
such as Antiemetic &
Vitamins.
9. Administered prescribed IV
Fluid in 20ml/hr.
10. Administered Prescribed
stat dose Antiemetic
Doperidone 10mg stat.
11. Administered prescribed
stool softeners Lactulose 30cc
tds.
Maintain
optimal body
fluid.
Slightly leg
Edema
reduced
urine flow.
6. Assess NG tube
position and administer
Fluid prescribed time
interval.
7. Encourage patient to
take rest.
9. Monitor Serum
Electrolyte level as
needed
* CRP 34.2mg/L
3. Altered breathing
pattern related to
decreased lung
expansion and
accumulated secretion
it shows defaulting
Maintain
normal
breathing
pattern
2. Provide psychological
support.
2. Provided psychological
support and talked with
patient friendly.
3. Position the patient in semi
fowlers position to reduce
difficulty breathing and
abdominal distention.
6. Assess patient
respiratory pattern for
using accessory muscle
for respiration.
7. Maintain a calm
attitude environment.
8. Encourage patient
deep breathing exercises.
After
Nursing
interventions
patient
breathing
pattern is
normal it
shown
normal
respiratory
rate and
depth.
prescribed.
11. Administer
Medication as prescribed.
4. Disturbed body
image related to
altered physical
appearance.
Understanding
changes &
acceptance of
self in the
present
situation.
2. Provide psychological
support.
4. Explain relationship
between nature of
disease and symptoms.
4. Explained relationship
between nature of disease
and symptoms.
Patient
normally
adjusted his
condition.
with change in
appearance, suggest
suitable clothing.
8. Introduce counselor
for Divert patient
worried mind.
9. Keep and observation
of patient in out of bed.
10. Educate the patient
about effect of Alcohol
consumption.
5. Acute confusion
related to disease
condition.
Maintain usual
level of
Consciousness
changes in appearance,
suggested suitable clothing.
9. Introduced Psychological
Counselor to divert patient
and family worried mind.
10. Kept and Observed
patient out of bed.
11. Educated patient for
effect of Alcohol and Smoking
consumption.
Patient
diverted in
his disease
condition
and satisfied
his nature of
disease.
8. Administer IV fluids
and Nutritional food
supplements.
9. Provide continuity of
care for morning care,
evening care and mouth
care.
Assessment
Nursing Diagnosis
Goal
Planning
Nursing Interventions
22/02/2013,
02.00pm
1. Hyperthermia
related to infective
process
Maintain
normal body
temperature
1. Monitor QHT
Subjective Data
2. Nausea
3. Tiredness due to
3days
4. Loss of Appetite due
to 10 days
Objective Data
1. Patient general
appearance is lethargy
and weakness.
2. Patient Conscious,
Rationale, and Alert to
8. Administer Antibiotic as
prescribed.
7. Administered Slight cool
orange juice.
9. Administer Cool drink.
8. Raised patient bed rails to
10. Raise the bed side rails prevent falling.
of all time.
Evaluation
After nursing
interventions
patient body
temperature
was reduced
in
98.5F/axilla
5. No Allergies.
14. Educate the patient
for signs for Hypothermia.
2. Imbalanced
Nutrition less than
body requirement
related to Loss of
appetite and Nausea
Maintain
normal body
nutrition level
4. Administer Nutritional
supplements and IV fluid
as prescribed.
4. Administer IV fluid as
prescribed.
Patient
satisfied
about
nursing care
13. Paracentesis
procedure done on
yesterday night, 500ml
peritoneal fluid
removed.
14. Patient feel
comfortably of without
abdominal distention.
Abdominal girth 45cm
15. Urinary Catheter
removed today
morning, no bleeding
from urethra after
removing catheter.
16. Patient urinary
sensation +.
17. Reduced patient
Scrotal edema.
18. Morning Bowel
opened normally, Dark
green color and no
blood stain.
19. No headache and
3. Anxiety related to
disease condition
Reduce Anxiety
2. Provide psychological
support.
2. Provided psychological
support to the patient to
reduce the anxiety.
3. Communicate with
friendly and kindly.
4. Change the patient
position frequently.
5. Encourage the patient
for deep breathing and
exercises.
6. Educate simple
relaxation techniques.
7. Introduce the hospital
staff and environment for
the patient.
Patient
satisfied and
gained some
knowledge
about his
disease
condition
Confusion signs.
* FBC
WBC 7800cumm
RBC 2.95%
Hb% 10.4g/dl
PCV 30.5%
Plt count
234,000cumm
*CRP 28.4mg/L
*Liver Profile
Total Protein 7.2g/dl
4. Deficient knowledge
regarding disease
condition, treatment,
and prognosis.
Increase
patient
knowledge
regarding
Patient
satisfied and
gained some
knowledge
Albumin 3.0g/dl
Globulin 5.4g/dl
A/G ratio 0.5
Alkaline Phospata
122U/L
ALT(SGPT) 38U/L
AST(SGOT) 42U/L
disease
condition
treatment methods.
modalities.
about his
disease
condition.
Assessment
Nursing Diagnosis
Goal
Planning
Nursing Interventions
Evaluation
23/02/2013 9.30am
Deficient Knowledge
regarding self and
Home care activities.
Educate self
and home care
interventions.
Patient
satisfied
the nursing
care.
Patient was
Discharged at 8am
Subjective Data
Mr. Ranjith 58yrs male
patient verbalized "I
am"
3. Follow up Care.
3. A low sodium diet helps relieve
that fluid retention problem.
1. Feeling good.
2. Loss of Appetite and
loss of food taste
sensation.
Objective Data
1. Patient general
appearance is good.
2. Patient conscious ,
rationale and Alert to
Time, Place and Person.
3. Patient happy mood
in his discharge.
4. Skin color is normal
and no itching and
rashes.
7. No Extremities
edema.
8. IV cannula removed
and no bleeding in
cannula site.
home settings.
9.Patient discharge with
NG tube.
10.Urine output is good
and patient urine pass
with sensation.
11. Morning Bowel
opened without
lactulose.
12. Patient ambulate
morning without
restlessness and
discomfort.
13. Vital Signs
Temperature
98.6F/Axilla
Pulse 84/bpm
Respiration 24/bpm
BP 120/85mmHg