PAMANTASAN NG LUNGSOD NG PASIG

Alcalde Jose Street, Kapasigan, Pasig City

COLLEGE OF NURSING

Case Study:

GROUP E
Janine Jordan
Gelia Lacson
Marichelle Laomoc
William Vincent Mabbayad
John Dean Macasaet
Mark Almond Montoya
 Carmela Obayan

INTRODUCTION
OVERVIEW
Cirrhosis is the irreversible replacement of a large amount of normal liver tissue with
nonfunctioning scar tissue. It develops because the liver is damaged. Attempts at
regenerating new liver cells are not effective.

• Alcoholism and hepatitis are the most common causes of cirrhosis.

• Symptoms, when they occur, include poor appetite, weight loss, and feeling weak,
sick, and tired.
• Many serious complications can occur, causing additional problems.
• The diagnosis is based on symptoms, a physical examination, blood tests, and
sometimes imaging tests or a biopsy.
• Stopping all alcohol intake is critical.

Liver damage, when repeated or sustained, can result in cirrhosis. In the United States,
the most common cause of cirrhosis is alcoholism—continued excessive intake of alcohol
for a long time. Viral hepatitis is a common cause: chronic hepatitis C in developed
countries, and chronic hepatitis B in many parts of Asia and Africa. Fatty liver
(nonalcoholic steatohepatitis) and other metabolic problems such as iron overload
(hemochromatosis) can also cause cirrhosis. Among Filipinos, the main cause of cirrhosis
is alcoholism. Other less significant causes of cirrhosis in the Philippines are chronic
hepatitis C and Chronic hepatitis B infection.
Cirrhosis is the third most common cause of death after heart disorders and cancer
among people aged 45 to 65. The scar tissue forms bands throughout the liver,
destroying the liver's internal structure and impairing the liver's ability to regenerate
itself or function. The liver is less able to do the following:

• Break down waste products made in the body

• Produce enough bile salts, which help the body absorb fats (in disorders of bile
excretion)
• Remove toxins
• Process (metabolize) drugs
• Produce proteins that help blood clot (clotting factors) and albumin for holding fluid
in blood vessels

The scar tissue also blocks blood flow through the portal vein (which carries blood from
the intestines to the liver). The result is high blood pressure in that vein (portal
hypertension). In addition, the scar tissue can block the flow of bile (a greenish yellow
digestive fluid produced by the liver) out of the liver.

SYMPTOMS
Many people with mild cirrhosis have no symptoms and appear to be well for years.
About one third never develop symptoms. Others are weak, feel sick and fatigued, have
a poor appetite, and lose weight. The tips of the fingers may enlarge (called clubbing). If
the flow of bile is chronically blocked, people develop jaundice , overall itchiness, and
small yellow skin bumps (nodules), especially around the eyelids. Because the damaged
liver cannot produce enough bile salts, absorption of fats and fat-soluble vitamins (A, D,
E, and K) is impaired. As a result, people may feel weak, have stools that are greasy and
foul-smelling (steatorrhea), and lose their appetite. Undernutrition and weight loss
commonly result from the impaired absorption of fats and vitamins and from loss of
appetite.
People with cirrhosis may have other symptoms due to severe liver failure or alcoholism:
• Muscles waste away (atrophy).
• The palms become red (called palmar erythema).
• The tendons of the hand shrink, causing the fingers to curl up (called Dupuytren's
contracture).
• Small spiderlike blood vessels appear in the skin.
• Salivary glands in the cheeks enlarge.
• The nerves outside the brain and spinal cord (peripheral nerves) malfunction
(causing neuropathy).
• Men have enlarged breasts (gynecomastia) and shrunken testes (testicular
atrophy) because the damaged liver cannot break down estrogens. Hair in the
armpits decreases.
• The spleen enlarges.
• Fluid inside the abdomen accumulates (ascites).
• The liver usually shrinks but sometimes enlarges.

COMPLICATIONS:
Advanced cirrhosis causes additional problems. The high blood pressure in the portal
veins can cause dilated, twisted veins to form at the lower end of the esophagus
(esophageal varices), in the stomach (gastric varices), or in the rectum (rectal varices).
People may vomit large amounts of blood if the esophageal or gastric varices bleed. High
blood pressure in the portal vein plus impaired liver function may lead to fluid
accumulation in the abdomen (ascites). Kidney failure may develop, and brain function
may deteriorate (causing hepatic encephalopathy).
Because vitamin D is poorly absorbed with impaired bile excretion, osteoporosis can
develop. Because vitamin K is poorly absorbed, people have a tendency to bleed easily.
The spleen, if enlarged, may trap blood cells and platelets, preventing them from
entering the bloodstream. Platelets (important for blood clotting) in the blood decrease,
making the tendency to bleed worse. Bleeding into the gastrointestinal tract will result in
anemia.
Liver cancer (hepatocellular carcinoma or hepatoma) can develop, particularly when
cirrhosis is due to chronic hepatitis B or hepatitis C or alcoholism.

DIAGNOSIS
Cirrhosis is usually diagnosed based on symptoms, results of the physical examination,
and a history of risk factors such as alcoholism. During the physical examination, a
doctor may feel a small, firm liver. Occasionally, the doctor feels small lumps (nodules)
on the surface of the liver or an enlarged spleen.

Blood tests to evaluate liver function are done. Results are often normal because these
tests are relatively insensitive and the liver has a tremendous reserve. The liver can
carry out essential functions even when its total activity is 85% below normal. A
complete blood cell count (CBC) is done to check for anemia and other blood
abnormalities. Blood tests may be done to check for hepatitis and other possible causes.
Ultrasonography or computed tomography (CT) can determine whether the liver is
shrunken or abnormally patterned, suggesting cirrhosis. Radionuclide scanning (using a
radioactive isotope) can show which areas of the liver are functioning and which are
scarred. If the diagnosis is still uncertain, a liver biopsy (removal of a tissue sample for
examination under a microscope) is done to confirm it. Biopsy and sometimes blood
tests can also help doctors determine the cause of cirrhosis.

If cirrhosis is confirmed, screening tests for liver cancer should be done every 6 to 12
months. Tests include blood tests to measure alpha-fetoprotein levels and
ultrasonography. Levels of alpha-fetoprotein (a protein normally produced by immature
liver cells in fetuses) increase when liver cancer develops.

PROGNOSIS AND TREATMENT

Cirrhosis is usually progressive. Stopping all alcohol intake halts further liver scarring but
cannot reverse damage already done. Continued alcohol use, even small amounts, leads
to progressive disease and serious complications. Once a major complication occurs—
such as vomiting of blood, accumulation of fluid in the abdominal cavity, or deterioration
in brain function—the outlook is grim.

No cure exists for cirrhosis. The liver will never again be normal. Cirrhosis is best
arrested at its earliest stages to stop any further injury. Treatment includes eliminating
the cause (such as alcohol) and treating complications as they develop. People need to
inform their doctor of all the drugs they are taking, including over-the-counter drugs and
dietary supplements, because the damaged liver may not be able to metabolize them. If
people need to take drugs that are metabolized by the liver, much smaller doses are
used to avoid further damage to the liver. In those with advanced cirrhosis, the diet
should be limited in protein and sodium, and supplemental vitamins should be taken.

Liver transplantation can be lifesaving for people with advanced cirrhosis. If they
continue to drink too much alcohol or if another cause cannot be altered, a transplanted
liver also eventually develops cirrhosis. Thus, liver transplantation is not done unless the
person has abstained from alcohol for at least 6 months.
ANATOMY
LIVER
The liver is the largest glandular organ of the body. It weighs about 3 lb (1.36 kg).
It is reddish brown in color and is divided into four lobes of unequal size and shape.
The liver lies on the right side of the abdominal cavity beneath the diaphragm .
Blood is carried to the liver via two large vessels called the hepatic artery and the
portal vein. The heptic artery carries oxygen-rich blood from the aorta (a major
vessel in the heart). The portal vein carries blood containing digested food from
the small intestine. These blood vessels subdivide in the liver repeatedly,
terminating in very small capillaries. Each capillary leads to a lobule. Liver tissue is
composed of thousands of lobules, and each lobule is made up of hepatic cells, the
basic metabolic cells of the liver.

Major Function
The various functions of the liver are carried out by the liver cells or hepatocytes.
Currently, there is no artificial organ or device capable of emulating all the
functions of the liver. Some functions can be emulated by liver dialysis, an
experimental treatment for liver failure.

Synthesis
 A large part of amino acid synthesis
 The liver performs several roles in carbohydrate metabolism:
 Gluconeogenesis (the synthesis of glucose from certain amino
acids, lactate or glycerol)
 Glycogenolysis (the breakdown of glycogen into glucose)
 Glycogenesis (the formation of glycogen from glucose)(muscle tissues
can also do this)
 The liver is responsible for the mainstay of protein metabolism, synthesis as
well as degradation
 The liver also performs several roles in lipid metabolism:
 Cholesterol synthesis
 Lipogenesis, the production of triglycerides (fats).
 The liver produces coagulation
factors I (fibrinogen), II (prothrombin), V, VII, IX, X and XI, as well as protein
C, protein S and antithrombin.
 In the first trimester fetus, the liver is the main site of red blood
cell production. By the 32nd week of gestation, the bone marrow has almost
completely taken over that task.
 The liver produces and excretes bile (a yellowish liquid) required for
emulsifying fats. Some of the bile drains directly into the duodenum, and
some is stored in the gallbladder.
 The liver also produces insulin-like growth factor 1 (IGF-1),
a polypeptide protein hormone that plays an important role in childhood
growth and continues to have anabolic effects in adults.
 The liver is a major site of thrombopoietin production. Thrombopoietin is
a glycoprotein hormone that regulates the production of platelets by
the bone marrow.
Breakdown
 The breakdown of insulin and other hormones
 The liver breaks down hemoglobin, creating metabolites that are added
to bile as pigment (bilirubin and biliverdin).
  The liver breaks down or modifies toxic substances (e.g., methylation) and
most medicinal products in a process called drug metabolism. This sometimes
results in toxication, when the metabolite is more toxic than its precursor.
Preferably, the toxins are conjugated to avail excretion in bile or urine.
 The liver converts ammonia to urea.

Other functions
 The liver stores a multitude of substances, including glucose (in the form
of glycogen), vitamin A (1–2 years' supply), vitamin D (1–4 months'
supply), vitamin B12 (1-3 years' supply),iron, and copper.
 The liver is responsible for immunological effects- the reticuloendothelial
system of the liver contains many immunologically active cells, acting as a
'sieve' for antigens carried to it via the portal system.
 The liver produces albumin, the major osmolar component of blood serum.
 The liver synthesizes angiotensinogen, a hormone that is responsible for
raising the blood pressure when activated by renin, an enzyme that is
released when the kidney senses low blood pressure.

HEPATIC PORTAL CIRCULATION

The liver is unusual in that it has a double blood supply; the right and left
hepatic arteries carry oxygenated blood to the liver, and the portal vein carries
venous blood from the GI tract to the liver.
The venous blood from the GI tract drains into the superior and inferior mesenteric
veins; these two vessels are then joined by the splenic vein just posterior to the
neck of the pancreas to form the portal vein. This then splits to form the right and
left branches, each supplying about half of the liver.
On entering the liver, the blood drains into the hepatic sinusoids, where it is
screened by specialized macrophages (Kupffer cells) to remove any pathogens
that manage to get past the GI defenses. The plasma is filtered through the
endothelial lining of the sinusoids and bathes the hepatocytes; these cells contain
vast numbers of enzymes capable of braking down and metabolizing most of what
has been absorbed.
The portal venous blood contains all of the products of digestion absorbed from the
GI tract, so all useful and non-useful products are processed in the liver before
being either released back into the hepatic veins which join the inferior vena cava
just inferior to the diaphragm, or stored in the liver for later use.
 THEORETICAL FRAMEWORK
This study used the Human-to-Human Relationship Model of Joyce Travelbee.
The group chose this theory for its applicability to patient’s condition.

HUMAN-TO-HUMAN RELATIONSHIP MODEL

According to this model, the nurse and the patient undergoes the following
series of the following interactional phases:

Original Encounter

This is described as the first impression by the nurse of the sick and vice-
versa. The nurse and the patient see each other in stereotype or in generalized
view like what happened in this situation. In the first encounter, the group thought
that the patient is really hard to talk to because he sometimes answers our
question which is not related to what we were asking.

Emerging Identities

This phase is described by the nurse and patient perceiving each other as
unique individuals. At this time, the link of relationship begins to form. As the
group continues to communicate with him, they implement the nursing
interventions in an individualized form and consider the patient’s distinctive needs.
The bit conversation started at this phase.

Empathy
 This phase is described as the ability to share person’s experience. The
result of the empathic process is the ability to expect the behavior of the individual
with who he or she empathized. In this part, the patient is giving his trust in a step
by step manner through communication of his experiences.

Sympathy

Sympathy happens when the nurse wants to lessen the cause of the
patient’s suffering. It goes beyond empathy. The nurse should use a disciplined
intellectual approach together with therapeutic use of self to make helpful nursing
actions. The group helped the patient to decrease his anxiety in independent
nursing interventions like the IV management and vital signs monitoring.

Rapport

It is defined as nursing interventions that lessen the patient’s suffering. The

nurse and the sick person are relating as human being to human being. The sick
person shows trust and confidence in the nurse. On the hospital stay of the
patient, he and the student nurses were able to build trusting relationship as they
both manifest good communication with one another.

NURSING HEALTH HISTORY

BIOGRAPHIC DATA
1. Name: Patient B
2. Address: Pasig City
3. Age: 61 y/o
4. Gender: Male
5. Marital Status: Single
6. Occupation: None
7. Religion: Protestant
8. Source of medical care: SSS (Social Security Service)

CHIEF COMPLAINT
 “Napansin kasi ng kapitbahay ko na lumalaki yung tiyan ko, eh tuloy tuloy
yung paglaki, halos dalawang linggo na. Kaya dinala na ko dito sa ospital,” as
verbalized by the client.

HEALTH HISTORY

A. History of Present Illness

2 weeks prior to admission, the client’s neighbor noticed the

insignificant enlargement of his abdomen. He didn’t seek any medical
consultation at first and ignored his condition. 1 week prior to admission, he
observed its continuous enlargement and he also noted feelings of fullness
and heaviness. He also felt pain on his abdomen at times. He was easily
fatigued and became restless, leading to the restriction of his physical
activities. Because of this, he seeked medical consultation at a clinic in Brgy.
Napico and there he was advised and prescribed to take furosemide which
he took for four days. When he noticed that his abdominal enlargement
hasn’t subsided and he became unresponsive to his medications, he finally
decided to seek medical consultation at Pasig City General Hospital last April
9, 2011.

B. Past History

Patient B has three previous hospitalizations. Last 2003, he was

hospitalized because of hernia and he undergone herniectomy. He also had
melena at the same year due to ulcer. Last 2007, he was again hospitalized
because of stroke. He has this same reason of being hospitalized last 2008
and he suffered right sided weakness. He also had allergy to Penicillin and
suffers from itchiness every time the drug was being taken or administered.

C. Family History of illness

The client has familial history of Diabetes Mellitus and Hypertension
from both sides of his parents. There were no history of Tuberculosis and
Asthma. He also had a brother who suffered from stroke 2 years ago. Patient
B was the first one on his family who suffered from liver cirrhosis and ascites.

PAIN ASSESSMENT

The client stated that he doesn’t feel any pain at the moment.
According to him, he just felt uncomfortable and irritable because of the
enlargement of his abdomen.

FUNCTIONAL HEALTH PATTERNS

1. Health Perception & Health Management Pattern

 The client’s general health is obviously disturbed because of the
presence of his illness and because of the physical changes that are
happening at the moment. But still, he perceives that his health will be
better in the future because of his hospitalization. He manages his health on
the hospital by cooperating with the nurses and doctors and also by doing
what they are saying. He knows that these things will help him get better.
According to him, he was an alcoholic since 20 years of age about 2-3
times per week and was able to consume at least 5 bottles per session. He
also stated that maybe because of aging, he just felt the need to stop
consuming alcohol and gradually lessen his intake to at least once a week
with only just one bottle per session on the next ten years. Nowadays, he
stated that he just drink occasionally and knows his limitation in drinking
alcohol. The client was also a smoker. He started smoking on his late thirty’s
and consumes 1 pack of cigarette per day. Today, he gradually lessen his
smoking and was able to consume only at least 5 sticks per day. He doesn’t
have regular check-up’s and only consults a doctor whenever an illness is
present.

2. Nutrition & Metabolic Pattern

Before hospitalization the patient’s usual diet is more on bread,

vegetables, fruits and fish and less on pork, meat and chicken. He can
usually consume ½ to 1 cup of rice every serving. According to him, he
voluntarily stopped eating these kinds of food because of their contribution
to his hypertension. He usually drinks 10 to 12 glasses of water per day. He
often drinks coffee and consumes 2 cups a day. He doesn’t like softdrinks
and juices. He doesn’t have any difficulty on eating but always experiences
feelings of fullness and heaviness prior to his confinement.
Now on his hospitalization, the doctor ordered his diet to be Diet As
Tolerated with Strict Aspiration Precautions because of his report that he
feels difficulty in breathing whenever he consumes foods. Presently at the
hospital, he eats bread and vegetables. He also consumes foods that are
available and the foods that are brought by his significant others. His intake
of water also decreases to at least 3-5 glasses of water a day. He also had an
IVF of D5NSS 1L x KVO at his right hand since his admission up to April 12,
2011. But it was shifted to an IVF of PNSS 1L x KVO since he undergone
blood transfusion also last April 12, 2011.

3. Elimination Pattern

Before hospitalization, the client usually urinates 5-6 times a day. His
urine was slightly yellowish in color. He has no difficulty in urinating and
experiences no pain whenever he feels the urge to urinate. His defecation
was at least 1-2 times a day with a brown, formed stool. But last April 10,
2011, a day after his hospitalization, his stool became soft, watery and light
brown in color.
Presently on his hospitalization, he was inserted with a foley catheter
attached to a urine bag. He eliminates urine at least 3000cc per day. His
urine is yellow in color. He defecates at least once a day, still with soft,
watery stool.
4. Activity & Exercise Pattern

Before hospitalization, the client does jogging and walking as his form
of exercise. But he said that he was not really fond of doing it. His usual
activities was quite sedentary. Since he doesn’t work anymore, he only stays
on their home and do some household chores with his nieces. He was fond of
reading newspapers as a form of leisure.
Presently, his activities became more sedentary. He was just on bed,
sleeping and resting. According to him, he feels very heavy and was easily
fatigued every time that he takes a walk. He also had a right sided weakness
since he got stroke last 2008. He still read newspapers and do chatting with
his significant other as his form of leisure. He can do activities like eating on
his own. But he needs assistance in regards to some of his activities like
bathing and walking. He also had an 02 via nasal cannula on his bedside with
a regulation of 2 lpm.

5. Sleep & Rest Pattern

Before hospitalization, his sleep pattern is usually 6-8 hours. His sleep
is continuous, he wakes up early and feels refreshed when he wakes up. He
do daytime naps whenever he feels tired of doing household tasks.
Presently, he stated that he has at least 5 hours of sleep, his sleep at
the hospital his interrupted that he almost wakes up every hour. He said that
he can’t sleep very well because of the hospital’s noise and environment. His
daytime naps are more often. He can rest since he doesn’t do much in the
hospital.

6. Cognitive-Perceptual Pattern

The client has no hearing difficulty before and during the

hospitalization. He doesn’t wear any hearing aids. But there is a visual
problem, he wears glasses since his late thirty’s and has a visual grade of 50
on both sides. There were still no memory changes.

7. Self - perception & Self-concept Pattern

The client has no changes in his self esteem and self confidence even
before and after the hospitalization. He is a positive thinker. He perceives his
self a strong man that can overcome any obstacle.

8. Role Relationship Pattern

There were changes in his role as an uncle and as a brother to his

nephews and his older brother before and after the hospitalization. Since he has
no wife and children, he dedicated hid life to take care of his nephews, giving
them the needs and assistance he can offer.

9. Sexuality - Reproductive Pattern

 Because of his hospitalization, his sexual life is not a priority for him. He is
not sexually active. He has no history of STD’s.

10. Coping Stress Tolerance Pattern

He knows that he is under a very stressful moment in his life right now
and he can’t do anything but to stay at the hospital and follow his therapeutic
regimens. He tries to adjust and cope well in his condition right now.

11. Value – Belief Pattern

The client is a Protestant. According to him, he always prays and never

forgets the Almighty God. Now that he was hospitalized, he still believes to his
faith and God is his inspiration and his strength especially on his current
condition. He believes that God will help him for his fast recovery.

PHYSICAL EXAMINATION
PRE-PHYSICAL EXAMINATION

04/12/11

I. Vital Signs:
Temperature: 36.5C V. Ears
Pulse Rate: 108 bpm  Negative discharge
Respiratory rate: 28 cpm  No hearing difficulties
BP:140/90mmHg
VI. Nose
II. General Appearance  Negative discharge
 Conscious and coherent  Septum in midline
 Tired and weak looking  With 02 of 2 lpm
 (+) right sided weakness
 (+) shortness of breath VII. Mouth
 (+) nausea  Dry lips
 Weight of 62 kg  Normal pinkish tongue
 Cracking lips
III. Skin
 Dry
 Dark brown in color
 No lesions VIII. Neck
 No palpable lymph nodes
IV. Eyes
 Icteric sclera IX. Chest and Lungs
 With eyeglasses with a visual  1:2 AP Ratio
grade of 50 on both eyes  (-) retractions
 (-) cough
  (-) wheezes
 (-) fremitus XII. Genitals
 (+) crackles  With foley catheter
attached to urine bag at
X. Heart 700cc level for 4 hours
 Precordim AP
 No murmurs XIII. Upper Extremities
 Tachycardic  With IVF at right hand of
D5NSS 1L x KVO
XI. Abdomen  No edema
 Semi soft abdomen  No deformities
 (+) hyperactive bowel  Strong, bounding pulse
sounds
 (+) Ascites XIV. Lower Extremities
 (+) Abdominal fluid wave  (+) bipedal edema
 Abdominal girth of 97  No deformities
cm.  No lesions

POST PHYSICAL EXAMINATION

04/14/11
I. Vital Signs:
Temperature: 37.7°C
Pulse rate: 100 bpm
Respiratory rate: 24 cpm
BP: 140/90 mmHg
II. General Survey:
 Conscious and coherent
 Tired and weak looking
 (+) difficulty of breathing
and use of accessory muscles
 (+) right sided weakness
 (+) shortness of breath
 Weight of 60 kg
 Coordinated facial
movements
 Sparse distribution of
black and white straight hair
V. Eyes
 Eye movements are
coordinated
 With fine eyebrows
 Icteric sclera
 With eyeglasses with a grade
of 50 on both sides
VI. Ears
 Negative discharge
 No hearing difficulties

III. Skin VII. Nose

 Dry and warm skin  No discharge
 Dark brown in color  Symmetrical
 No lesions  Septum in midline
 With O2 via nasal
IV. Head cannula of 4 lpm
 Symmetrical
  No deformities
VIII. Mouth  No lesions
 Dry lips
 Normal pinkish tongue
 Cracking lips

IX. Neck
 No palpable lymph nodes

X. Chest and Lungs

 1:2 AP Ratio
 (-) retractions
 (-) cough
 (-) wheezes
 (-) fremitus
 (+) crackles

XI. Axilla
 No tenderness
 No palpable lymph nodes
 No lesions

XII. Heart
 Precordium AP
 No murmurs

XIII. Abdomen
 Semi soft abdomen
 (+) hyperactive bowel sounds
 (+) Ascites
 (+) Abdominal fluid wave
 Abdominal girth of 96 cm

XIV. Genital
 With foley catheter attached
to urine bag at 700cc level for
4 hours

XV. Upper Extremities

 With IVF at right hand of PNSS
1L x KVO
 No edema
 No deformities
 Strong, bounding pulse

XVI. Lower Extremities

 (-) bipedal edema
 LABORATORY STUDIES
Blood Chemistry

April 7, 2011

RESULT NORMAL VALUES SIGNIFICANCE

This is due to hepato
54.9 cellular damage, thus
SGOT 8-46 U/L
HIGH liver may not functioning
well.
Indicates poor liver
29.7 function. Due to low
Albumin 35-52 g/L
LOW albumin, the patient also
manifested ascites.
0.86 Indicates poor diet and
A/G Ratio >1
LOW liver disease.

Complete Blood Count

April 9, 2011

RESULT NORMAL VALUES SIGNIFICANCE

Decreased levels may
94
Hemoglobin 135.0-180.0 g/L indicate anemia or
LOW
nutritional deficiency.
Decreased levels may
0.29
Hematocrit 0.40-0.54 g/L indicate anemia or
LOW
nutritional deficiency.
501
Platelet Count 150.0-400.0 g/L Indicates tissue damage.
HIGH
 0.77
Neutrophil 0.35-0.65 g/L May indicate infection.
HIGH

NORMAL VALUES SIGNIFICANCE

Prolonged or increase result
because the liver can’t able to
PT 69.6 (activity)
27.7-34.10 sec. synthesize clotting factors that is
PTT 36.8
why he is taking Vitamin K, to
correct coagulopathy.

Urinalysis
April 9, 2011
RESULT SIGNIFICANCE
Physical Yellow Normal urine color
Transparency Slightly turbid Normal.
ph pH 5 Normal pH.
Specific gravity is in normal range
1.020 which may indicate that the
Specific gravity
(1.010-1.025) kidneys function well in
concentrating the urine.

Clinical Chemistry
April 9, 2011
RESULT NORMAL VALUES SIGNIFICANCE
Sodium 125 135-145 mmol/L Low result is due to
LOW inability to excrete free
 water resulting from high
levels
of ADH and aldosterone.
86 Indicates tissue damage
AST 17-59 U/L
HIGH as a result of cirrhosis.
159 May indicate liver
ALKP 38-126 U/L
HIGH dysfunction.

Complete Blood Count

April 11, 2011
RESULT NORMAL VALUES SIGNIFICANCE
Decreased levels may
80.0
Hemoglobin 135.0-180.0 g/L indicate anemia or
LOW
nutritional deficiency.
Decreased levels may
0.25
Hematocrit 0.40-0.54 g/L indicate anemia or
LOW
nutritional deficiency.
Platelet Count ADEQUATE 150.0-400.0 g/L Normal.
0.80
Neutrophil 0.35-0.65 g/L May indicate infection.
HIGH

Fecalysis
April 11, 2011

RESULT INTERPRETATION
Color Yellow Diarrhea
Consistency Watery
Occult Blood Negative

Ultrasound
April 9, 2011

Impression:
• Findings in the liver suggests Hepatic Cirrhosis
• Massive ascites
• Sonographically normal common bile duct, gall bladder, pancreas, spleen, kidneys, and urinary
bladder

CLINICAL PATHWAY
Patient’s Name: Mardo Bracero Admission Date: April
9, 2011
Diagnosis: Ascites secondary to Liver Cirrhosis
 04/9/11 04/10/11 04/11/11
1st day 2nd day 3rdday

ASSESSMENT Emergency Room (9:36AM) Emergency Room (4:30AM) Male Medicine Ward

• Vital signs: • Conscious • Vital Signs

o BP 110/70 • Awake o BP 120/80
o RR 27 • Coherent o RR 28
o PR 91 • With ongoing PNSS 1L on o PR 96
o Temp. 37 right peripheral vein with o Temp 37.3
• (+) DOB regulation of KVO • Conscious
• (+) Crackles • Generalized weakness • Awake
• Abdominal distention noticed: • With O2 via nasal cannula • Coherent
100cm at 4 lpm • With ongoing D5NSS 1L x
• Globular abdomen; (+) fluid wave • (-) DOB KVO on right peripheral vein
• (+)Bipedal edema • (+) Crackles • Generalized weakness
• Weak looking • Hooked to O2 via nasal
• Dry lips Male Medicine Ward (10:30AM) cannula at 2-4 lpm
• (+)jaundice • Vital Signs • (+) DOB
• Pale conjunctiva o BP 110/80 • (+) Crackles
• Icteric sclera o RR 21 • (+) abdominal distention:
• With ongoing PNSS 1L on right o PR 86 97cm
peripheral vein with regulation of o Temp 36.8
KVO • (+) abdominal distention
• Weak and pale looking
• (-) DOB
• Hooked to O2 at 4lpm via
nasal cannula
• With ongoing D5NSS 1L on
right peripheral vein with
regulation of KVO

LABORATORY Emergency Room Emergency Room Male Medicine Ward

PROCEDURES
For the following laboratory studies: • For rpt 12 Lead ECG • FU: CXR results
• For rpt CBG • CBC results encoded
• CBC with platelet count • SF: Trop I • Fecalysis results encoded
• PT, PTT • SF: ABG
• Blood Typing NOTE:
• 12 Lead ECG NOTE: • CBC
• TROP I • TROP I - Hemoglobin 80
• ABG o <0.01ug/L (low)
• Na, K, BUN, Crea (normal) - Hematocrit 0.25
• Fecalysis (low)
Male Medicine Ward - Neutrophil 0.8
• AST, ALKP
• FU: CXR results (high)
• CXR
• For rpt CBC • Fecalysis
• CBG q 4
• SF: Fecalysis with occult - Color yellow
• TPAG - Consistency;
• UA blood
watery
• UTZ Whole abdomen - (-) occult blood
Variance
• Paracentesis
• Family Placement
NOTE:
(Financial Problem)
• CBC
- Hemoglobin 94 (low)
- Hematocrit .29 (low)
- Platelet 501 (high)
- Neutrophil 0.77 (high)
• PT, APTT
- PT 13.1
- APTT 36.8secs
(prolonged)
 04/12/11 04/13/11 04/11/11
4th day 5th day 3rdday

ASSESSMENT Male Medicine Ward Male Medicine Ward Male Medicine Ward

• Vital Signs • Vital Signs • Vital Signs

o BP 130/80 o BP 120/80 o BP 130/90
o RR 24 o RR 28 o RR 28
o PR 108 o PR 96 o PR 112
o Temp 36.1 o Temp 37.3 o Temp 37.2
• Conscious • Conscious • Conscious
• Awake • Awake • Awake
• Coherent • Coherent • Coherent
• With ongoing D5NSS 1L x • With ongoing PNSS 1L x • With ongoing PNSS 1L x
KVO on right peripheral vein KVO on right peripheral KVO on right peripheral vein
• Generalized weakeness vein • Generalized weakness
• Hooked to O2 via nasal • Generalized weakness • Hooked to O2 via nasal
cannula at 2-4 lpm • Hooked to O2 via nasal cannula at 2-4 lpm
• (+) Diarrhea cannula at 2-4 lpm • (+) abdominal distention:
• (+) DOB • (+)Diarrhea (BM 3x) 97cm
• (+) Crackles • (+) abdominal distention:
• (+) abdominal distention: 97cm
97cm
• (+) Fever at PM (temp 38.0)

LABORATORY Male Medicine Ward Male Medicine Ward Male Medicine Ward
PROCEDURES
• FU: CXR results • FU: CXR results • FU: CXR results

MEDICATIONS Male Medicine Ward Male Medicine Ward Male Medicine Ward

• D5NSS 1L x KVO • PNSS 1L x KVO • PNSS 1L x KVO

• O2 @ 2-4lpm via nasal cannula
• Furosemide 40mg TIV q 8hours
• Lactulose 30cc PO BID
• Lansoprazole 1 tab OD
• Aldactone 25mg 1 tab OD q
lunch
• Vitamin K 1 amp slow IV push q 8
x 3 days
NOTE:
• Check 10 R’s before, during and
after administration, note for any
unusual side effects.
• Explain to patient the indications
of drug to be given
11 Key Areas of Nursing Responsibility:
• Safe and Quality Nursing Care
• Research
• Personal and Professional
Development
Variance:
• Lactulose was hold because of
presence of diarrhea
• Spironolactone note taken
because of financial difficulties
• O2 @ 2-4lpm via nasal
cannula
• Furosemide 40mg TIV q
8hours
• Lactulose 30cc PO BID
• Lansoprazole 1 tab OD
• Aldactone 25mg 1 tab OD
q lunch
• Vitamin K 1 amp slow IV
push q 8 x 3 days
NOTE:
• Check 10 R’s before, during
and after administration,
note for any unusual side
effects.
• Explain to patient the
indications of drug to be
given
11 Key Areas of Nursing
Responsibility:
• Safe and Quality Nursing
Care
• Research
• Personal and Professional
Development
• O2 @ 2-4lpm via nasal
cannula
• Furosemide 40mg TIV q
8hours
• Hold Lactulose 30cc PO BID
• Lansoprazole 1 tab OD
• Aldactone 25mg 1 tab OD q
lunch
• Vitamin K 1 amp slow IV
push q 8 x 3 days
NOTE:
• Check 10 R’s before, during
and after administration,
note for any unusual side
effects.
• Explain to patient the
indications of drug to be
given
• Lactulose was hold because
of presence of diarrhea
11 Key Areas of Nursing
Responsibility:
• Safe and Quality Nursing
Care
• Research
• Personal and Professional
Development
 DRUG STUDY
DRUGS ACTION INDICATION ADVERSE CONTRAINDICATI NURSING
EFFECTS ON MANAGEMENT

Lactulose 30cc Cause an influx Constipation, Abdominal Patient who require Assess mental
BID of fluid in the salmonellosis. discomfort low lactose diet. condition
intestinal tract Treatment of associated Galactosemia or (clearing
by increasing the hepatic with intestinal deficiency confusion,
osmotic pressure encephalopat flatulence restlessness,
within the hy and cramps. irritability)
intestinal lumen. N/V Monitor possible
Lowers intestinal adverse
absorption of reaction. Monitor
ammonia Input and
Output
Lansoprazole Suppresses Treatment of Infrequently Hypersensitivity to Assess patient’s
OD gastric secretion duodenal rash, any ingredients of condition before
by inhibiting ulcer, gastric pruritus, this drugs. treatment ,
hydrogen/potassi ulcer, H. anemia, monitor for
um ATPase pylori leukopenia, possible drug
enzyme system associated leukopenia, induced adverse
located in the peptic ulcer, eosoniphilia, effect on the GI
secretory surface reflux constipation, system, monitor
of the parietal esophagitis. diarrhea, dry hepatic enzyme.
cells of the mouth,
stomach. interstitial
Classified as pneumonia.
 gastric acid
(proton pump)
pump inhibitor
since it blocks
the final step of
acid secretion.
Both basal and
stimulated
gastric acid
secretions are
inhibited
regardless of
stimulus.

Furosemide Inhibits the Hepatic Blurred Hypersensitivity, Assess pt’s

40mg TIV q8 reabsorption of Cirrhosis vision, alcohol underlying
Na & Cl from the dizziness, condition before
loop of Henle headache starting therapy,
and distal renal Hearing loss, monitor for
tubule. Increases tinnitus signs of
renal excretion Hypotension electrolyte
of H20, Na, Cl, imbalance,
Mg, K and Ca. assess for fluid
Effectiveness volume status
persists in
impaired renal
function.
Aldactone It helps to reduce Essential Acute renal Drowsiness, Assess fluid
25mg OD q the amount of hypertension, insufficiency, lethargy, mental status.
lunch water in the edematous anuria, confusion, Monitor Blood
body by acting disorders. hyperkalemi gynecomastia Pressure and
 on the kidneys to a pulse before and
increase the flow during
of urine without administration
excreting
potassium in the
urine. It can also
be used to help
increase the
level of
potassium in the
body when it is
too low.
Vitamin K 1 Synthetic analog Treatment Hypotension, Pronounced allergic Assess patient’s
amp TIV q8 x of vitamin K and cyanosis, diathesis. condition before
3days which is essential prevention of headache, therapy, assess
for hepatic hemorrhage dizziness, for bleeding,
synthesis of associated rash, pain, monitor Pro-time
blood clotting with vitamin K swelling, during
factors II, VII, IX deficiency. tenderness. treatment,
and X monitor for drug
induced adverse
reaction.

Omeprazole Supresses gastric Short –term Angina Hypersensitivity Assess other

40mg TIV secretion by treatment of Tachycardia Combination medication the
inhibiting active benign Palpitation treatment with patient is taking
hydrogen/potassi gastric ulcer Dizziness clarithromycin Taken before
um ATPase Headache should not be used meals
enzyme system in patient with Assess
in the gastric hepatic abdominal for
 parietal cell impairement pain

Amlodipine Inhibits calcium Hypertensive Flushing, Hypersensitivity; Use with caution

5mg TID ion from entering urgencies or palpitations, Blood pressure in CAD (can
the "slow emergencies tachycardia, <90mmHg cause increase
channels" or for blood peripheral in angina), CHF
select voltage- pressure edema, (can worsen
sensitive areas of increased heart failure
vascular smooth angina symptoms), and
muscle and Headache, pheochromocyto
myocardium dizziness, ma (limited
during somnolence, clinical
depolarization, paresthesia experience). Use
producing a Rash the I.V. form
relaxation of Nausea , dry cautiously in
coronary mouth patients with
vascular smooth Weakness, portal
muscle and myalgia hypertension
coronary Abnormal (can cause
vasodilation; EKG increase in
increases hepatic pressure
myocardial gradient).
oxygen delivery
in patients with
vasospastic
angina.
Paracetamol Decreases fever Decrease N/V, Hypersensitivity; Assess for fever
500mg PO by inhibiting the fever, drowsiness, intolerance to or pain, assess
effects of analgesic abd. Pain, tartrazine, alcohol, allergic reaction,
pyrogens on the hepatotoxicit table sugar, assess
hypothalamic y, rash saccharin hepatotoxicity,
heat regulating monitor liver or
centers and by a renal functions,
hypothalamic check I&O
action leading to
sweating and
vasodilataion.
Relieves pain by
inhibiting
prostaglandin
 synthesis at the
CNS but does not
have anti-
inflammatory
action because
of its minimal
effect on
peripheral
prostaglandin
symthesis.

Diphenhydrami Acts on blood It is used for Orthostatic Hypersensitivity to Assess

ne 25mg TIV vessels, GI, the hypertension histamine. respiratory
respiratory symptomatic , status, monitor
system by relief of bradycardia, input and
antagonizing the allergic extrasystoles output, monitor
effects of conditions , faintness, CBC in long-
histamine for H1- including drowsiness, term therapy,
receptor site; urticarial and dry mouth, assess nausea,
decreases angioedema, constipation, vomiting, bowel
allergic response rhinitis, and hypersensitiv sounds and
by blocking conjunctivitis ity reaction. abdominal pain.
histamine,; and in puritic
causes increase skin
heart rate, disorders.
vasodilation,
secretion;
significant CNS
depressant and
anticholinergis
properties.
 NURSING CARE PLAN
Name: Patient B (61 years old) Diagnosis: Ascites
secondary to Liver Cirrhosis
Date of Assessment: April 12, 2011 Date of Evaluation:
April 14, 2011
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION
SUBJECTIVE: Activity GOAL: After 3 days of nursing
SUBJECTIVE: Ineffective
intolerance(LevelGOAL: • • Monitor
Monitorclient’s vital signs,intervention the client had:
vital signs.
Client stated: breathing
III) related to After 3 days of nursing abdominal girth and After
 RR:3 24
daysbpm of
Client stated:ko lang sa
“Kakagaling pattern
imbalance After 3intervention
days of nursingthe client weight to provide
• Adjust activities to as nursing intervention
 HR: 100 bpm
“Nahihirapan nga akoko
banyo, pakiramdam related tooxygen
intervention
will bethe client
to will theWith
client
between able baseline
preventdata and evaluate 
overexertion. 02had:
inhalation of 4
huminga
pagod nadahil ang
pagod laki
ako at inability of
supply and be able to establish
demonstrate improve if Instruct
client’s condition
client to haveis  RR: 24 bpm
lpm via nasal cannula
ng tyan ko.”
hinihingal.” the
demand normal/effective respiratory
physical mobility as worsening.
complete bed rest.  HR: 100 bpm
 (+) easy fatigability
diaphragm
secondarytoto lowpattern.
evidenced by • Place client on moderate  With 02assistance
OBJECTIVE:  Observed
OBJECTIVE: move
hemoglobin and increased ability in • high
Teachback rest to facilitate
significant inhalation of other
4
from significant
downward
hematocrit count OBJECTIVES:
performing activities of movement of diaphragm
other to assist client lpm via nasal
while doing ADLs.
 Tachypnea,
 Inability to sit, secondary to After 8daily hours of nursing
living. thus improving respiratory
in performing cannula
Feeding: 0
stand RR: 28 cpm
or walk abdominal intervention, the client will effort.
activities of daily  (+) crackles
Bathing: 2
independently.
 Tachycardia distention be able to: • Increase
living. client’s oxygen to  (+) Ascites
Toileting: 2
: HR:
 Easy fatigability OBJECTIVES: 4 lpm. Bed
 (+) mobility:
abdominal2
108bpmof
 (+) shortness 1. Verbalize comfort
After 8 hours of • • Instruct
Teach client abouton NPO if Dressing:
fluid wave2
 With
breath afterO2activity during
nursingbreathing and
intervention, there is of
episodes
range motion.of Grooming:
 Abdominal 0
inhalation
 With O2 inhalation demonstrate
the client will be able dypsnea.
Provide passive ROM. General
girth: 96cms 3
mobility:
at 2(order
of 2 lpm lpm via
2-4 effortless
to: breathing
• Teach client about proper
lmp) nasal pattern.
• breathing
Facilitateexercises.
blood After 8 hours
After of nursing
8 hours of
 RR: 28cannula
cpm 1. Demonstrate
• Encourage
transfusion client
of 1 to
“u” have intervention,
nursing the client was
intervention,
(order 2. Identifytechniques
at least three
that
 HE: 108 bpm2-4 adequate
PRBC properlyrest periods
typed to ablethe to:client was able to:
lmp) measures how to
enable
 Hgb: 94 g/L (April reduce
and crossfatigue.
matched as
(+) use of increase respiratory
resumption of
11,2011) effort. activities.
ordered by
• Encourage physician
client o avoid 1. Demonstrate
1. Verbalize
accessory as(April
forming12, 2011)
foods because techniques
comfort thatduring
 Hct: 29% (April 11,
muscle this may increase enable resumption
breathing with of
2011) 2. Report
 (+) crackles • abdominal
Provide supplemental
distention. Also activities.
respiratory rate
 Slowed movement measurable
 (+) Ascites encourage
oxygen asclientprescribed.
to have of 24 cpm.
 Observed increase in
 (+) abdominal
assistance from normal
Regulate defecation
O2 habit. 2. Report measurable
activity
fluid wave other
significant inhalation
• Instruct to to
client 4 lpm.
limit fluid increase
2. Identify in activity
at least
tolerance.
 Abdominal
while doinggirth:
ADLs. intake to 1000 – 1500mL tolerance.
three measures
97cms
Feeding: 0 • daily
Administer
to lessen risk of how to
3. Demonstrate a
Bathing: 3 increasing
medications body’s
suchfluid
as 3. Demonstrate
increase a
decrease in
Toileting: 3 volume.
ferrous sulfate. decrease in
respiratory
physiological
Bed mobility: 3 • Assist client in the use of physiological
effort. signs of
signs of
Dressing: 3 relaxation technique to intolerance.
intolerance.
Grooming: 0 reduce fatigue.
General mobility: 3 • Teach client of deep
breathing exercises
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE: Fluid volume GOAL: • Monitor fluid intake and

Client stated: excess output. Weight and measure After 3 days of
“Nahihirapan nga ako (interstitial) After 3 days of nursing abdominal girth daily to nursing intervention
huminga dahil ang laki related to intervention the client will assess if condition is the client had:
ng tyan ko.” extravascular be able to stabilize fluid worsening.  RR: 24 bpm
fluid shifting volume as evidenced by • Instruct client to limit fluid  HR: 100 bpm
OBJECTIVE: secondary to balance input and output, intake to 1000 – 1500mL  (-) bipedal
 (+) Ascites increased normal vital signs, stable daily to lessen risk of edema
 (+) abdominal pressure in weight and free from signs increasing body’s fluid  Weight : 60kgs
fluid wave the portal of edema. volume.  BP: 130/80
 Abdominal girth: circulation • Instruct client to limit foods mmHg
96cms OBJECTIVES: high in sodium as  (+) strong
 Weight: 62 kgs After 8 hours of nursing prescribed by the physician bounding pulse
 (+) bipedal edema intervention, the client will because sodium attracts
be able to:  UO: 700cc/4
 (+) crackles water which may increase hours
 BP: 140/90 mmHg body’s fluid volume.
1. Demonstrate  (+) crackles
 HR: 108 bpm • Elevate edematous
behaviors to  SF: CBC, Na
 Strong, bounding extremities to and
monitor fluid status and K
pulse encourage changing
and reduce position to lessen edema
 With D5NSS 1L x recurrence of fluid After 8 hours of
and reduce tissue pressure
KVO excess. nursing intervention,
and risk for skin breakdown.
 With FC-UB the client was able to:
• Place client on moderate
 On DAT with sap 2. Verbalize  Demonstrate
high back rest to facilitate
 Input: 250 cc/4 understanding of behaviors to
movement of diaphragm
hours individual dietary monitor fluid
thus improving respiratory
 UO: 100 cc/4 and fluid status and
effort.
hours restrictions. reduce
• Encourage client to have recurrence of
 Hgb: 94 g/L (April adequate rest periods to
11, 2011) fluid excess.
reduce fatigue.
 Hct: 29% (April • Administer diuretics as
11, 2011)  Verbalize
prescribed. Note for blood understanding
 Na: 125 mmol/L pressure prior to of individual
administration. dietary and
fluid
restrictions.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE: Diarrhea GOAL: • Assess for rectal tenderness

Client stated: “Tatlong related to associated with episodes. After 3 days of
beses kada araw ako adverse After 3 days of nursing • Assess patient for any signs nursing intervention
dumudumi tapos effect of intervention the client will of electrolyte imbalance and the client verbalized
matubig.” medication be able to reestablish and dehydration. Monitor serum that his stool was still
Client reported urgency (lactulose) maintain normal pattern of sodium and potassium level. soft but lessen
on defecation. bowel functioning. • Regulate IVF fluid. frequency per day, at
• Monitor input and output. least once a day.
OBJECTIVE: OBJECTIVES:
• Obtain history of client if he
 (+) watery stool After 8 hours of nursing After 8 hours of
also experience diarrhea in
since 4/10/11 3 intervention, the client will nursing intervention,
drinking milk or other
times per day be able to: the client was able to:
dietary products that
 (+) hyperactive contain milk.
bowel sound 1. Identify the 1. Identify the
• Explain to the client that
 With medication causative factor of causative
diarrhea may be caused by
order of lactulose the diarrhea being factor of the
medication used (lactulose).
30 cc BID experienced. diarrhea being
• Encourage client to drink experienced.
 Fecalysis results non irritating liquids.
(-) for any 2. Verbalize
understanding • Encourage client on a BRAT 2. Verbalize
bacterial related
about the diet diet (banana, rice, apple understanding
etiology.
regimen. and tea) if not about the diet
contraindicated. regimen.
• Encourage client to limit
caffeine and high fiber food
and avoid milk.
• Teach client on relaxation
technique to avoid stress. It
increases risk of diarrhea.
• Hold lactulose as prescribed
by the physician.
 ASSESSMENT DIAGNOSIS PLANNING INTERVENTION EVALUATION

SUBJECTIVE: Risk for injury GOAL:

Client stated: “Nastroke related to • Teach significant others After 3 days of
na kasi ako noon right sided After 3 days of nursing about safety measures nursing intervention
naapektuhan ung weakness intervention the client will such as raising side the client was able to
kaliwang parte ng be able to participate in rails. participate in care
katawan ko.” care plan to lessen risk of plan to lessen risk of
injury. • Encourage significant injury.
OBJECTIVE: other to assist client in
 (+) right sided OBJECTIVES: performing ADLs. After 8 hours of
weakness After 8 hours of nursing nursing intervention,
 Observe intervention, the client will • Instruct significant the client was able to:
assistance from be able to: others to avoid living
significant others the patient alone. 1. Verbalize
in performing 1. Verbalize understanding
ADLs understanding of • Teach client about of individual
 Side rails were not individual factors passive ROM to increase factors that
raised that contribute to muscle activity of the contribute to
 Client was placed possibility of injury. affected side. possibility of
at the hallway of injury.
the hospital. 2. Demonstrate
• Transfer client at the
behaviors to reduce 2. Demonstrate
isolation ward once with
risk factors and behaviors to
available bed.
protect self from reduce risk
injury. factors and
• Encourage client to
protect self
avoid sudden standing
3. The significant other from injury.
to avoid orthostatic
will be able to help
hypotension.
in environmental 3. The significant
modification to other will be
enhance safety. able to help in
environmental
modification to
enhance
safety.